Oral Health Care in Care Homes

According to NICE (the National Institute for Health and Care Excellence), over 50% of elderly adults living in a care home setting have tooth decay. If we compare this to those who don’t live in a care home setting, the figure is 40%. This tells us that there is an issue with oral health care in care homes. Good oral health is essential for quality of life.

When oral health is poor, older people can suffer pain, which means they might not eat or drink properly. Because of this, older adults can be malnourished.

Besides eating, oral health problems can prevent medication from being taken. What’s more, there has even been a link found between aspiration pneumonia and poor oral health, especially in care homes. It is crucial, therefore, that we work on promoting oral health care in residential settings for older adults. In this article, we’ll go over what we mean by oral health care and how to promote good oral health in care homes.

What is oral health care?

When we talk about oral health care, we’re referring to the entire mouth and teeth and how they’re looked after. People who live in care homes have a higher risk of having oral health problems. This can be due to a number of reasons.

These include:

• Long-term medical conditions that make attending dental appointments harder.
• Medical conditions that make holding and using a toothbrush more difficult.
• Medication causes a dry mouth and reduces saliva production.
• Older people who have their natural teeth have a greater need for complex care (when compared to those with dentures).

A person’s quality of life can be significantly impacted by their oral health. Maintaining oral health is a significant part of a person’s health and wellbeing. When a person has poor oral health, they can be in pain. This can prevent them from eating or even drinking, which can lead to dehydration and malnutrition. Poor oral health also limits a person’s ability to take required medicines.

Additionally, many common health problems like arthritis, diabetes, smoking and cancer have oral health side effects, as do medicines taken to treat these conditions.

With poor oral health, people are at risk of developing mouth conditions and diseases. Risks include cavities, periodontal disease, gingivitis, receding gums, dry mouth, and even oral cancer.

Cavities

Dental cavities – or tooth decay – is tooth damage caused by bacteria in the mouth. The bacteria produce acids that attack surface enamel. This leads to cavities or holes in the tooth. If it isn’t treated, it causes pain and infection. You can even lose teeth as a result.

Periodontal disease

Periodontal disease causes tooth loss, but it is a preventable disease. This condition is a disease of the bone structure and gums surrounding the teeth. It is caused by bacterial build-up and tartar that isn’t removed from brushing.

Periodontal disease can go undetected and is painless – at least during its initial years from onset. Commonly, it only gets diagnosed when it begins to cause problems. For the elderly, who often struggle to floss or brush regularly, carers need to make sure that they maintain good oral hygiene and have regular trips to a dental hygienist to remove plaque and bacteria.

Gingivitis

A build-up of plaque and bacteria also causes gingivitis. Gingivitis is often commonly referred to as ‘gum disease’. It is caused by poor oral hygiene and is common in those with reduced eyesight or mobility who are unable to properly brush or care for their teeth.

Gingivitis is swelling and inflammation of the gums. The gums might be painful or bleed when the teeth are brushed. If untreated, it can cause the formation of pockets to appear between the gum and tooth root, which gives rise to the ideal conditions for infections and harmful bacteria to grow. Gingivitis often precedes periodontal disease.

Receding gums

Ageing gums and teeth are inevitable in old age. As a person’s gums age, they begin to lose their elasticity, which means they recede. Though receding gums are not a huge problem in themselves, they do cause extra sensitivity in the elderly and so it is often recommended to use sensitive oral hygiene products.

When the root of the tooth is exposed by receding gums, it is more porous and softer than the visible part of the tooth, which makes it more susceptible to decay and cavities.

Dry mouth

Dry mouth, also called xerostomia, is often a side effect of medication that many elderly people take. However, this condition is very treatable.

When a person has a dry mouth, they have a higher risk of forming cavities. For good oral hygiene, you need a healthy amount of saliva. This is because it has anti-bacterial properties that will fight off bacteria and plaque in the mouth. With a lack of saliva, the mouth is a better breeding ground for bacteria and diseases to spread.

Oral cancer

Your risk of oral cancer increases as you age and is found more often in those over the age of 50. It is also the sixth most common cancer. If a person is or has been a regular drinker or smoker, their risk will be higher.

Care homes with elderly residents should ensure patients have regular check-ups at the dentist as early-stage oral cancer is much more treatable.

Is oral health in care homes important?

When people live in a care home, they often require additional support to maintain their oral health. NICE (the National Institute for Health and Care Excellence) recommends that all older people have support with cleaning their teeth or dentures each day.

On admission to the care home, all service users should have a thorough assessment of their oral health, and this should be kept in their individual care plan.

Given that care home residents often have complex care needs, it comes as no surprise that they will find managing their own oral health difficult. When people are unable to practise good oral hygiene, they have a higher risk of developing problems like oral diseases and conditions.

Examples of conditions that indicate more help is needed

Depending on a person’s individual needs, some require more help than others with their oral hygiene. Here are some common medical conditions that affect a person’s ability to care for their teeth.

Arthritis

Stiffness and pain from arthritis often make flossing and brushing more difficult. Furthermore, if a patient is suffering from jaw pain or jaw problems, they might not manage to maintain an open mouth in the dentist’s chair.

A study from 2008 published in the Journal of Periodontology, showed that people who had rheumatoid arthritis were nearly eight times more likely to have periodontal disease.

When people have arthritis, they’re more likely to also have a dry mouth, mouth sores and gingivitis.

Dementia

It’s not surprising that people who have dementia will find oral hygiene difficult. Problems with memory might mean forgetting to brush teeth or forgetting how to brush teeth. It’s also common to not be able to express tooth pain, which can mean that problems go untreated.

Improvement is needed

Oral health care in care homes needs urgent improvement. The Faculty of Dental Surgery has made several recommendations:

• Health professionals like healthcare staff, nursing staff, pharmacists and doctors should have oral health training.
• Social care providers need to make sure their staff have received appropriate training and that service users have an individual oral health care plan.
• People who are in care homes (as well as their carers and families) should have access to advice on how to ensure good oral health.
• Oral health professionals, regulators, care providers, local authorities and health services should be working on strategies to improve dental service access for care home residents.
• Care homes and hospitals should ensure they have an oral health care policy in place.
• Inspections of care homes should assess the oral health care standards.

Even though these recommendations already exist, more information is still needed to comprehend the scale of the problem of elderly oral health in care homes.

How to promote oral health care in care homes?

For anyone working in a health and social care setting, it’s important to be aware of the importance of oral health care.

Employers are responsible for providing adequate training and all employees should be able to answer ‘yes’ to the following questions:

• Do I know how oral health can potentially affect dignity, and general health and wellbeing?
• Do I know the possible impact of untreated mouth infections or dental pain on a person’s general health and wellbeing when they can’t articulate their distress or pain?
• Am I aware of when and how to assess and reassess a person’s oral health?
• Am I aware of the daily procedures of delivering oral health care?
• Am I aware of the procedures to report any oral health care concerns?
• Do I understand how to deal with a person’s changing circumstances and needs?
• Do I know how important denture marking is and how I can arrange it (with permission)?

It’s essential that all service users have the oral health care they deserve. Care homes should be person-centred, which means that all individuals need encouragement and support in practising good oral hygiene.

Promoting good oral hygiene and care in care homes

Anyone who works in a health and social care setting has a duty to promote good oral hygiene and support those they care for to look after their oral health.

Care home health and care workers should help individuals to maintain their oral hygiene by:

• Ensuring all surfaces of the teeth as well as the gum line, are brushed thoroughly for two minutes twice each day.
• Ensuring the toothpaste contains an adequate amount of fluoride and that the excess is spat out after finishing brushing.
• Ensuring that flossing happens daily.
• Ensuring that mouthwash is used to remove any particles of food after the teeth have been brushed and flossed.
• Ensuring service users eat a healthy diet and don’t over-indulge in sugary drinks or foods.
• Ensuring that toothbrushes are replaced every 3-4 months or earlier when needed.
• Ensuring service users have regular dental appointments for check-ups and visits to the hygienist.
• Ensuring that patients avoid using tobacco.

Is oral health care a part of a person’s care plan?

In a care home setting, support and assessments in oral health can prevent service users from problems like disturbed sleep, pain and other health issues that are caused by poor oral health. Simple adjustments and changes to a patient’s routine each day can change things massively for the better.

Just like health care workers support movement through manual handling, they can support service users in oral care by ensuring they:

• Support or prompt individuals to brush their teeth twice a day using a fluoride toothpaste.
• Support or prompt individuals to use toothpaste.
• Support or prompt individuals to clean dentures.
• Use the toothbrush and dental hygiene products as per the service user’s wishes.

It’s also important for staff to know how to assess oral health. This is made easier by the regular completion of oral health assessments as this helps monitor for changes. It’s also useful when service users move between settings.

Having procedures around oral health in care plans is essential.

Should staff have training in oral health care?

According to a 2019 Care Quality Commission review, 47% of care homes that were inspected said staff weren’t given any specific oral health care training.

Though the NICE guidelines don’t state that training in oral health is a requirement, it is recommended that managers of care homes make sure their staff know when and how to deliver oral care. They should also know how to respond to a service user’s changing circumstances and needs.

The UK Health Security Agency has training available for carers that is available to download.

How to achieve and maintain good oral hygiene in care homes

Providers of health and social care need to train staff appropriately on oral care and oral health. They should also make sure that their service has a policy on oral care. This policy should ensure that oral health is included as a part of any initial health assessments when a new service user arrives at the setting.

The UK Health Security Agency has a care homes assessment tool in its library that has been published by PHE (Public Health England). What’s more, each individual’s health care plan should always include a section on oral health. There is also a published oral health policy quality assurance checklist available.

Any oral care policy also needs to state how often resident oral health should be reassessed and how health care staff will support service users with their daily oral hygiene.

Providing preventative measures, including advice to service users, their carers and families, is essential to ensuring continued good oral health and hygiene.

Oral health care plan

An oral health care plan is an individual plan that is used to assess service users and provide details of support needed with regards to their oral health and hygiene.

The plan will cover what care home staff should be checking, what they should be supporting, and how they should be supporting service users. It should be a working document that is reviewed frequently.

It is recommended that oral health care plans form an integral part of an individual’s overall health care plan. It should be used in such a way that it can identify needs for further investigation as and when they occur.

To begin an oral health care plan for a new service user, the individual should answer questions like:

• How do you normally manage oral care?
• What help do you need with oral care?
• What aids do you use, e.g., the type of toothbrush (manual or electric), floss, mouthwash, etc.?
• Do you use dentures? If yes, do they have a mark with your name on? If they don’t, would you like them marking?
• When was your last visit to the dentist and who was the dentist that you saw?
• If you currently don’t have a dentist, would you like us to help find you one?

With a baseline assessment done on arrival and an oral health care plan drawn up, there should be regular dates for review implemented.

At the time of being reviewed, a service user should also have their oral health reassessed.

This should include checks of the following:

• The presence of dental pain.
• Natural teeth.
• Dentures.
• Gums and other tissues.
• The tongue.
• Saliva.
• Oral cleanliness.

Conclusion

To summarise, oral health care is an integral part of maintaining the health and dignity of service users in care homes. Oral health should be considered in an individual’s care plan and there should be an oral health care plan for each service user.

Though NICE guidelines don’t specify that staff need specific training on oral care, they are expected to ensure they meet the oral care needs of the service users in their care. By promoting oral health care, service users in care homes will lead happier and healthier lives.