Some patients admitted to hospital have pre-existing tooth decay or gum disease; others have healthy mouths on admission but will develop problems related to poor mouth care during their stay.
My son Nick had poorly controlled epilepsy, autism and learning difficulties, which made me very aware of the problems that could be a barrier to achieving good oral care. Some days brushing his teeth could be a real challenge.
I worked as a dental therapist/senior oral health promoter for 42 years, working in partnership with diverse target groups from parents and carers to health professionals, schoolchildren, people with learning disabilities and prisoners. Raising awareness of the importance of oral care was a key factor in motivating nurses, parents and carers to persevere, despite the problems they might face. (Numerous studies have shown that poor oral hygiene not only causes tooth decay and gum disease, but is also associated with hospital-acquired aspirational pneumonia, and is linked to cardiovascular disease, diabetes, infective endocarditis and stroke.)
Nick was in hospital several times in his life, spending weeks as an inpatient. Despite leaving his electric toothbrush, toothpaste and mouthwash by his bed and asking ward staff to clean his teeth (he lacked the skills and manual dexterity to do this himself), I was disappointed to find this did not happen. “Mouth care given” had been documented in his notes – but his teeth had not been cleaned. A pink sponge-tipped stick dipped in water was being used to swab around his mouth. This was not effective at removing plaque or oral secretions. I checked Nick’s mouth daily and was horrified one day to discover he had oral thrush. It had not been noticed by ward staff.
I asked the staff what happens to vulnerable patients lacking the skills to clean their own teeth or dentures and was shocked to learn that many hospitals do not provide training in oral health care. This has a huge impact on staff’s ability to provide effective oral care. Some hospital wards also do not have the essential resources/products available to provide good oral hygiene for vulnerable patients.
Most ward staff had never completed a mouth care assessment and did not know how to do so and no oral health assessment charts were used on the wards. As a result, staff were not aware if a patient had partial dentures, full dentures, broken teeth, mouth ulcers, gum disease or tooth decay. They were not trained to recognise signs of oral thrush or the early signs of oral cancer.
No toothbrushes or toothpaste were available for patients who hadn’t brought their own into hospital. Denture cleaner or denture pots were not available. Staff were unaware of saliva-substitute gels or sprays to relieve a dry mouth and of non-foaming toothpastes or suction toothbrushes, which could be used for patients with a nasogastric tube in situ or on ventilation.
It is unrealistic to expect staff to diagnose dental problems or oral cancer but they should be aware of abnormal signs in patients’ mouths and know how to escalate their concerns. Hospitals should have a pathway for urgent dental care.
Excellent e-learning programmes and resources are available to train all health professionals in this fundamental area of care. As an example, Health Education England’s Mouth Care Matters is an initiative to improve the oral health of patients in hospital. It comes in different formats and includes an e-learning package (Bit.ly/MouthCareMattersElearning) to support the training of all health professionals involved in mouth care.
Sue Jones is retired dental therapist
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