1. Oral health: Important or not?
Julie Baker
Jen Beeston
Speech and Language Therapists

2. Definition
Oral health was defined by the Department of Health in 1994 as the ‘standard of health of the oral and related tissues which enables an individual to eat, speak and socialise without active disease, discomfort or embarrassment and which contributes to general well-being'
‘Oral health and quality oral health care contribute to holistic health. It should be a right not a privilege’
(Clark and Vanek, 1984)

3. Oral Hygiene: Why is it important?
Often seen as low priority but oral care is essential to holistic person centred care and quality of life
Link between ineffective oral care & aspiration pneumonia
Oral supplements have a high sugar content
Swallowing difficulties result in poor oral clearance of residue
The most dependent people have the poorest oral health.
People with eating & swallowing problems often become hypersensitive to touch and develop a bite reflex and withdrawal which makes oral care increasingly difficult.
Poor oral hygiene can result in pain and discomfort which
may also affect mood and behaviour
Can affect eating and drinking

4. Factors affecting oral health
Type, severity and stage of illness
Client’s mood, motivation, self esteem
Lack of perception of oral health problems
Habits, lifestyles and ability to self care
Socio-economic factors
Oral side effects of medication
Attitudes and knowledge of supporting staff
Local dental service unable to provide adequate care
A wide range of both acute and chronic medical and mental health conditions can adversely affect oral
health.

5. Dental disease
Two main dental diseases:
Tooth decay
Gum Disease

6. Gum disease

7. Who is at risk of gum disease?
Individuals with certain conditions
Medications
Hypersensivity, clamping or tongue thrusts
Limited dexterity
Reliance on others
Risk of aspiration
Non-oral feeders
Dysphagia, ALD, Diabetes

8. Not everyone who aspirates develops pneumonia...why?
Aspiration
Not everyone who aspirates develops pneumonia...why?
How fit and healthy the person is
How self caring they are
How clean their mouth is

9. Aspiration pneumonia: risk factors
Dependence for feeding
Dependence for oral care
Poor oral hygiene/decayed teeth
Poor functional status
Immobility/poor mobility
Multiple medications
Advanced age
Poor mental status
Previous history of pneumonia
More than one medical condition
Malnutrition
Dry mouth
Tube feeding

10. Aspiration pneumonia: risk factors
Presence of aspiration during swallow is bad enough but is further worsened by what is aspirated.
Poor oral care=higher amounts of bacteria in mouth
Food/liquid/saliva will pick up the bacteria and transport it to lungs if aspirated increasing risk of pneumonia

11. Acute infection

12. Oral Thrush

13. Importance of oral hygiene
One of the simplest ways to reduce pneumonia arising from aspiration is to improve oral hygiene
Proper oral care is essential to reduce the level of bacteria in the mouth and hence the risk of infection
Bacteria in saliva may be aspirated into the lungs causing infection
Explains why even tube fed patients are at risk of aspiration pneumonia

14. Nil by Mouth
Tube feeding is an established treatment regime for patients in whom aspiration of food and drink has been identified
Still remain at significant risk of aspiration pneumonia from secretions if oral hygiene is neglected
The problem is rigorous oral care may not be perceived as needed
Consequently bacteria grow rapidly and any aspiration of contaminated oral flora will cause pneumonia

15. This will minimise the risk of gum disease
So why should we brush?
To remove the sticky film of plaque bacteria which forms on everybody's teeth and gums
To minimise the risk of chest infections if an individual is tube fed or has a swallowing problem
This will minimise the risk of gum disease
To add fluoride to the teeth to help
control tooth decay

16. Oral Care: best practice
Use a small headed soft toothbrush and fluoride toothpaste
Gently brush teeth, tongue and soft tissues
If possible seated upright with their feet firmly on the ground
If bedridden, head titled forward and if reclining, head tilted to one side to assist drainage; tilt head away from weaker side
Stand to the side and support their jaw with free hand
Work in a methodical manner making sure all surfaces are cleaned
If unable to spit out excess toothpaste use a towel or sodium lauryl sulphate free
Brush twice daily especially last thing at night
If brushing is not possible use a gloved finger wrapped in gauze with gel
Remove & clean dentures after every meal if possible
Do in quiet, calm manner and persevere, it does get easier!

17. Difficulty swallowing
Those who have difficulty swallowing do require more care and attention when carrying out, supporting or providing routine oral care.
There is an increased risk of developing aspiration pneumonia therefore additional support and modifications are required during oral care routines
Good oral hygiene is essential for individuals who have difficulty swallowing
Assessment is vital

18. Toothbrushing when swallowing is difficult
To prevent aspiration, tilt the head forward
Use a non foaming toothpaste (without sodium lauryl sulphate)
Pink foam sticks and lemon & glycerine swabs should be avoided as they are a risk if a person is on thickened liquids
In non-oral feeders toothpaste is not needed
Chlorhexidine gel does not foam and provides chemical plaque control
Use an aspirating toothbrush (Plak Vak) which can be attached to a suction machine -

19. Equipment

20. Equipment

21. Twizzle Stick

22. Dentures
Everyone including those with full dentures should have regular examinations.
Dentures should be removed and cleaned every night and should be replaced when damaged or ill fitting.
Fungal infections can occur if dentures are ill fitting or not cleaned thoroughly.

23. Cleaning dentures
Dentures should be removed for cleaning at night
The inside of the mouth and tongue should be cleaned by gentle brushing, towelling or swabbing.
The dentures can be brushed with unperfumed soap
Rinse well with cold water
Placed back in the mouth or stored under cold water

24. Healthy tongue

25. Unhealthy tongue

26. Side-effect of many drugs. Linked to certain conditions.
Dry Mouth
Common condition that increases the risk of dental caries and periodontal disease.
Side-effect of many drugs.
Linked to certain conditions.
General prevention advice is needed.
Artificial saliva gel or spray* (sprayed into cheeks and under tongue), or frequent sips of iced water can provide relief (SBOHED)
*BioXtra, Biotene Oral Balance and Saliva Orthana

27. 4 stages of oral status Healthy Early warning Problem Serious Saliva
Adequate
Decreased
Too little
Taste alteration
Thick or absent
Mucosa
Pink & moist
Intact & comfortable
Pale & dry
Uncomfortable red areas
Dry & inflamed
Blistered & sore
Red & shiny
Blisters & ulcers
Painful
Tongue
Comfortable
Dry
Prominent papillae
Dry & swollen
White coating at base
Sore & lines of inflammation
Dry & thick
Coated & blistered
Red & ridged
Lips
Smooth & pink
Moist & comfortable
Wrinkled
Dry & cracked
Uncomfortable
Ulcerated areas & bleeding. Painful
Teeth
Clean & no food debris
Able to wear dentures
Dull
Localised areas of food debris
Food debris on half of the teeth
Areas of irritation.
Some pain
Lots of food debris along gum line or denture area.
Unable to wear dentures
Frequent dental pain

28. NHS Choices 0845 4647 www.nhs.uk/servicedirectories
Or you can refer to your local community dental service
Dental advice line:

29. Acknowledgements Thanks to: Vicky Brand
Oral Health Improvement Team Lead
Manchester Mental Health and Social Care Trust