Mouth Care Matters
Mouth CareMattersMouth CareMattersA guide for hospital healthcareprofessionalsDeveloping peoplefor health andhealthcarewww.hee.nhs.uk
Version controlVersion:V12Date ratified:11 November 2016Name and title of authorMili Doshi, Consultant in special care dentistryDate issued11 November 2016Review dateNovember 2017 2016 Mouth Care Matters
Contents
A guide for health care professionals1Introduction 1.17Dental decay (caries) 30What is Mouth Care Matters in hospitals? 77.1What is dental decay (caries)? 311.2The Mouth Care Matters training programme 87.2Signs of dental decay 311.3Who is Mouth Care Matters training for? 87.3Symptoms of dental decay 31Mouth Care Matters team 7.4Causes of dental decay 317.5Prevention of dental decay 32Management of dental decay in hospitalisedpatients 321.4682Why do we need Mouth Care Matterstraining? 107.62.1What is the impact of hospitalisationon oral health? 118Diet and oral health 332.2We are a changing population 118.1Effects of sugar in teeth 342.3Our mouths are changing 118.2Safe snacks 342.4We are taking more medication 118.3Sugar and medication 342.5What are the barriers to providing good mouthcare in hospitals? 119Fluoride 352.6References 129.1What is fluoride? 363Why is oral health important forhospitalised patients? 9.2How does fluoride work? 36149.3How much fluoride is enough? 363.1Definition of oral health 159.4References 363.2Oral hygiene and oral health 1510Tooth surface loss 373.3References 1510.1What is tooth surface loss? 384Oral health and general health 1710.2Signs of tooth surface loss 384.1Oral health links to systemic disease 1810.3Symptoms of tooth surface loss 384.2Hospital-acquired infections linkedto poor oral hygiene 10.4Tooth erosion 3810.5Management of tooth erosion in hospitalisedpatients 3810.6Tooth abrasion 3910.7Management of tooth abrasion in hospitalisedpatients 3910.8Tooth attrition 4010.9Management of tooth attrition in hospitalisedpatients 4011Periodontal (gum) disease 4111.1Definition of periodontal (gum) disease 4211.2Causes of gum disease 434.319Links to general health andsystemic disease 194.4References 195A healthy mouth 215.1Why ‘Mouth Care Matters’ and not‘Dental Care Matters’? 225.2What does a healthy mouth look like? 225.3What could an unhealthy mouth look like? 235.4When to seek medical/dental advice 245.5References 2411.3Signs of gum disease 436Dry mouth (xerostomia) 2511.4Symptoms of gum disease 436.1What is a dry mouth? 2611.5Management of gum disease in hospital 436.2What are the functions of saliva? 266.3What are the signs and symptoms ofa dry mouth? 12Oral thrush (candida/fungal infection) 442612.1What is oral thrush? 456.4What are the causes of a dry mouth? 2612.2Causes of oral thrush 456.5What is the impact of a dry mouth onhospitalised patients? 12.3Signs of oral thrush 452612.4Symptoms of oral thrush 456.6Prevention 2712.56.7Management of a dry mouth for hospitalisedpatients Management of oral thrush in hospitalisedpatients 462712.6Antifungal medication 4612.7References 466.8Saliva substitutes/moisturising agents 286.9Mouth audit at East Surrey Hospital 296.10References 29
Contents13Angular cheilitis 4713.1What is angular cheilitis? 4819Having the ‘right tools’ for mouth careand assessment on the wards 67Pen torches 6813.2Causes of angular cheilitis 4819.113.3Signs of angular cheilitis 4819.2Toothbrushes 6819.3Toothpastes 7013.4Symptoms of angular cheilitis 4813.5Management of angular cheilitis in hospitalpatients 19.4Foam swabs 704819.5Finger guard 72Mouth ulcers 4919.6Prescribed/on the advice of a dentist/doctor 72References 72731414.1What is a mouth ulcer? 5019.714.2Causes of mouth ulcers 502014.3Signs of a mouth ulcer 50Recording mouth care for hospitalisedpatients – The Mouth Care Pack 14.4Symptoms of a mouth ulcer 5020.1Why do we need to record mouth care? 7420.2The tool - Mouth Care Pack 7420.3Guide for completing the MouthCare Pack 7420.4Completing the mouth care screening sheet 7520.5Notes on the mouth care screening sheet 7520.6Level of support 7520.7Mouth care assessment (middle pages of themouth care pack) 7714.5Management of mouth ulcers in hospital 5115Excessive drooling 5315.1Why do some patients drool? 5415.2Signs of drooling 5415.3Symptoms of drooling 5415.4Management of drooling inhospitalised patients 5416Mucositis 5520.8Daily recording sheet 7916.1What is mucositis? 5620.9References 7916.2Signs of mucositis 5616.3Symptoms of mucositis 5621Assisting patients with mouth care 8116.4Management of mucositis inhospitalised patients 21.156How to distinguish between independent anddependent patients? 8221.2Different types of assistance 8217Oral cancer 5721.3Cross infection control 8317.1What is oral cancer? 5821.4Key messages in steps 8417.2What are the signs and symptoms oforal cancer? 5822Denture care 8522.1Changes in denture demographics 8622.2Types of dentures 8622.3Importance of denture hygiene 8722.4Denture fixative 8722.5Removing and replacing dentures in the mouth 8722.6Lost dentures 8722.7Cleaning dentures 8822.8The denture sunflower 9023Dental referrals 9123.1Urgent and non-urgent referrals 9217.3Management of suspected oral cancerin hospital 5818Patients with increased oral health riskfactors 5918.1Why are some patients more at risk from mouthcare problems? 60Signs of mouth related problems in vulnerablepatients 6018.3Dementia and oral health 6018.4Mental Capacity Act 6118.5Learning disabilities and oral health 6218.6Mental health conditions and oral health 622418.7Intensive care – ventilated patientsand oral health Drugs that cause dry mouth(xerostomia) 936225MOUTHS 95Head and neck cancer treatment andoral health 25.1What is MOUTHS? 9663Stroke, dysphagia and oral health 6326Contact 9718.218.818.918.10 Physical disability and oral health 6318.11 End of life care and oral health 6418.12 References 64
1IntroductionKey messages MCM is a training initiative to improvethe oral health of hospitalised patients MCM training comes in various formats MCM training is not just for nurses but arange of health care professionals
Introduction1.1What is Mouth Care Matters in hospitals?Mouth Care Matters (MCM) is a training initiative aimedat improving the oral health (health of the mouth) ofhospitalised adult patients in Kent, Surrey and Sussex.This guide complements the Mouth Care Matterstraining that is currently being delivered in hospitals. Theinformation to the best of our knowledge, is up-to-dateand evidence-based.The programme was developed and piloted at East SurreyHospital, an acute hospital with approximately 650 beds.From a comprehensive review of the current literature, webelieve the findings at East Surrey Hospital, with regards tomouth care, are representative of hospitals up and downthe country. For this reason this guide includes findingsfrom focus groups, clinical audits, patient cases and directAbout ‘Mouth Care Matters’ postersobservations of mouth care being carried out on patientson the wards.Mouth Care Matters is based on four key themes, hospitalstaff require the: Knowledge of the importance of mouth care andgood oral health and the links to general healthand well-being Skills gained through training on how to carry outmouth care and assessment of the mouth ‘Tools’ needed to provide good mouth care Support when necessary from doctors/dentists/mouth care teamPoster to help identify a healthy & unhealthy mouth7
A guide for health care professionals1.2The Mouth Care Matters trainingprogrammeFactoring in time for additional training for busy healthcare professionals can be difficult, therefore MCM trainingcomes in various formats and includes:1.4Mouth Care Matters teamAs part of the Mouth Care Matters training programme,Surrey and Sussex Health Care Trust recruited a mouth careteam. This team is responsible for: Ward-based training Small group classroom teaching sessions Classroom training Ward-based, hands-on training Sessions tailored to specific groups, for examplethe speech and language team, palliative care,chemotherapy, oncology, doctors, dieticians andpharmaceutical teamSupporting staff and carers with mouth care inchallenging situations Liaising when urgent dental referrals are neededduring an inpatient stay Signposting patients to appropriate dental serviceson discharge Supporting the hospital with mouth care policiesand audit Mouth Care Matter promotional and socialmedia work E-Learning MCM guide MCM resources (posters, newsletters etc.) MCM website1.3Who is Mouth Care Matters training for?Mouth Care Matters supports the need for every hospitalto have a dedicated mouth care lead.MCM is not only about training the nursing staff in ahospital; oral health promotion is also important forother health care professionals involved in the care ofhospitalised patients including doctors, speech andlanguage therapists, dieticians, occupational therapists andpharmacists. Working together we can form a more holisticapproach to patient care, including mouth care.Roles of health care professionals in mouth careHealth Care ProfessionalRoles in mouth care and oral health may include:DoctorsDiagnosing and prescribing for oral conditions such as ulcers and oral thrushNursing staffCarrying out mouth care assessments and assisting or providing mouth careSpeech and language therapist (SALT)Providing mouth care advice for high risk dysphagia patientsDietetics teamNutritional advice taking into account oral healthOccupational therapists (OT)Helping to advise and/or create aids for toothbrushes for patients withphysical disabilitiesPharmacistsAdvising patients/carers on drug related oral problems including dry mouthPhysiotherapistsRole can involve looking in the mouth and make other teams aware of poororal conditions8
IntroductionDiagram to illustrate the Mouth Care Matters team as part of inpatient careDoctorsNursingMouth Care cupationalTherapy9
2Why do weneed MouthCare Matterstraining?Key messages Oral health has been found to deterioratein hospitalised patients Some patient groups will have anincreased risk of developing problems withtheir mouths There are a number of barriers that mayprevent nursing staff from providing/assisting with mouth care
Why do we need Mouth Care Matters training?2.1What is the impact of hospitalisationon oral health?There is evidence that hospitalisation is associated witha deterioration in oral health of patients (Terezakis et al.,2011). This in turn has been linked to: An increase in hospital-acquired infections (seesection 4.2) Poor nutritional intake Longer hospital stays Increased care costsPoor oral health is strongly associated with malnutritionand this in turn can affect a patient’s recovery (Gil-Montoyaet al., 2008), increasing time in hospital.There are certain groups of patients that will be more atrisk of developing mouth related problems due to eitherone or a combination of medical, cognitive or physicaldisabilities (see section 18).Table to show patient groups with increased oral healthrisk factors:DementiaOxygen therapyFrail elderlyVentilated patientsLearning disabilitiesImmunocompromisedPalliative careHead & neck radiationChemotherapyPoor mobilityDeliriumStrokeMental healthPhysical disability2.2We are a changing populationWe are an ageing population; it is predicted by 2020,around 20% of the population of the United Kingdom willbe aged 65 or older (ADHS, 2009). As people get olderthey are at a greater risk of developing medical, physical orcognitive problems and may need more help with personalcare, including mouth care.2.3Our mouths are changingAs people are now living longer, they are also retainingtheir teeth for longer. In 1968, 37% of the population hadno teeth in their mouths and this dropped to only 6% inImage shows implants to retain a denture - this will needmeticulous cleaning to keep healthy2009 (ADHS, 2009). Older people are more likely to havelarge fillings, crowns, bridges and dental implants, all ofwhich need additional care to maintain and keep healthy.Unfortunately as the population gets older, many peoplewill develop medical, cognitive or physical disabilities thatmean they are less able to care for their mouth.2.4We are taking more medicationPatients who are hospitalised are generally more likelyto be taking more medication. Dry mouth or xerostomiais a common side effect of over 400 medications (seeSection 24 for list of drugs). Having a dry mouth can havea significant negative effect on oral health, causing pain,difficulty in eating, speaking and an increase in dentaldisease such as dental decay, gum disease and thrush.Steroids and antibiotics can also lead to changes in ourimmune system and make patients more susceptible tofungal infections(oral thrush).2.5What are the barriers to providing goodmouth care in hospitals?There is a wealth of evidence that shows that mouth careis frequently neglected or not a priority for hospitalisedpatients. A study of hospitalised patients by Sousa et al.,(2014) found that patients’ oral health was not beingassessed and that hospitals had no policies in place forroutine oral health practices. It has also been shown thatthere is no standardisation in the delivery of oral care11
A guide for health care professionalsand that a lack of equipment, such as toothbrushes andtoothpaste, means that nurses are sometimes improvisingwith forceps and gauze (Stout, Goulding and Powell, 2009).Common nursing barriers to providing or assisting patientswith mouth care in hospital have been researched (Adams,1996; Preston et al., 2006). These include: Lack of knowledge Lack of training Lack of time Lack of equipment Lack of oral assessment tools A disagreeable attitude towards mouth care Attitude towards own dental health2.6ReferencesAdult Dental Health Survey (ADHS), 2009 – The NHSinformation Centre, March 2011.Adams, R. (199
A guide for health care professionals 1 Introduction6 1.1 What is Mouth Care Matters in hospitals? 7 1.2he Mouth Care Matters training programme T 8 1.3 Who is Mouth Care Matters training for? 8 1.4 Mouth Care Matters team 8 2 Why do we need Mouth Care Matters training? 10 2.1 What is the impact of hospitalisation on oral health? 11 2.2 We are a changing population 11 2.3 Our mouths are .
Mouth Care for Adult Patients in Hospital / Vers 5 (07/13) gum disease are almost entirely preventable and providing effective daily mouth care can help. Part two will focus on mouth care for more complex patients. Improving the oral health of adults in hospital is a key priority of Fundamentals of Care (WG 2003, standard 10).
Some fish have a mouth that is sword-shaped. The top jaw of the mouth has evolved into the shape of a long sword that protrudes from the front of the fish. Other fish have beak-shaped mouths. The triggerfish has a beak-like mouth. Having a mouth this shape makes it easy for the fish to break off small pieces of coral. The size of the mouth is .
starts once food enters the mouth The mouth receives food, tastes it and prepares it for The oesophagus ensures the smooth transit of a food bolus from the mouth to the . Sugar-free chewing gum can protect the teeth as it encourages saliva produc-tion, which reduces acidity in the mouth.
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