Worldwide, people are living longer and keeping their teeth for longer (Public Health England (PHE), 2016). At present, there are 11 million people in the UK over the age of 65 years, and this figure is set to increase to 14 million by 2032 (PHE, 2016).These older adults are part of the ‘heavy metal generation’, which includes those with high levels of past (and present) dental disease that was treated with fillings and other complicated dental procedures. The oral health of this current older generation and future ones needs to be safeguarded. Most oral health surveys in this generation of older adults tend to involve those in residential or care home settings, and their findings do not reflect the situation for people who may be living independently or being cared for at home (PHE, 2016).Thus, the available picture of the oral health of this generation may not be an accurate one. Many older adults will have complex care needs and may require support for daily tasks, such as mouth care and tooth brushing (Welsh Government, 2016). This article offers some evidence-based oral health advice to aid community nurses and other caregivers in supporting their patients. It also aims to raise awareness of the links between oral health and systemic health, the comorbidities associated with ageing and their effect on the mouth and the need for increased domiciliary care.
Oral health means far more than just good teeth. Good oral health is essential for healthy ageing and systemic health and wellbeing, and poor oral health is closely linked to economic deprivation, social exclusion and cultural differences (Peterson, 2003; World Health Organization (WHO), 2003; Mason, 2005; Watt, 2007). Periodontal disease (gum disease) is associated with systemic disease such as cardiovascular disease, stroke, respiratory infection, diabetes and nutritional problems (Davies and Finley, 2005; Meurman and Grönroos, 2010). In turn, systemic disease can have an effect on oral health, for example, xerostomia or dry mouth can be caused by over 500 medications for common systemic aliments (Sreebny and Schwartz, 1997; Porter et al, 2004; Gueiros et al, 2009). Dry mouth effects speech, nutrition and hydration and can make the wearing of dentures difficult, which can lead to malnutrition and weight loss. This may also explain why a lot of dentures get lost or are misplaced, as if they are ill-fitting, they are more likely to be removed, resulting in their loss.The consequences of this are further weight loss, embarrassment and loss of dignity. Having a dry mouth can also make the ingestion of medication difficult. Difficulty with swallowing and medication remaining in the mouth can lead to caries (tooth decay), and aspiration can also become an issue, with food and medication debris remaining in the mouth, leading to aspiration pneumonia or community-acquired pneumonia. This can result in lengthy and costly hospital stays, or even death. Other ageing-related comorbidities, such as arthritis, Parkinson's disease, cognitive impairment and dementia, can make oral hygiene difficult and can lead to resistive behaviour, because of which people avoid oral care and experience a further decline in their oral health (Sreebny and Schwartz, 1997; Xavier, 2000; Porter et al, 2004; Sweeney, 2005; Levine and Stillman-Lowe, 2009).
Nurses, carers, families and support staff who work in the community need to have some training or information regarding mouth care and the tools available to make mouth care more achievable and as effective as possible (see Box 1). This may lead not only to an improvement in oral health but in systemic health as well, thereby preventing hospital admission in the first place. Discussion with the older person (and their families) in the early stages of dementia or Alzheimer's disease regarding their wishes, concerns and fears regarding dentistry could be placed in their ‘hospital passport’ or their ‘this is me booklet’. These simple steps would aid future carers, medical and dental staff.The Alzheimer's Society have informative fact sheets about mouth care, with hints and tips on looking after someone else's mouth (http://tinyurl.com/y5tq5jja). Advice can also be gained from the individuals's own general dental practice or the community dentist who may visit.This advice should ideally be shared with all carers and family members who may help with care, and it should also be shared with the person themselves, as prevention is definitely better than cure.
The Strategy for Older People in Wales 2013–2023 (Welsh Government, 2013) aims to address barriers faced by older people in Wales and to ensure that wellbeing is within reach of them. It also aims to tackle social and environmental factors that influence the health of older adults and the wider determinants of health. This strategy addresses normative needs. For example, the residents of nursing and care homes have higher untreated caries rates than the general population, and care home managers have reported that they experienced much more difficulty in accessing dental care for their residents. This strategy addresses the needs of not only the residents of care homes but also those of the care home managers.
The implementation of the strategy eventually led to the development of a Welsh Health Circular (WHC/2015/001) entitled ‘Improving oral health for older people living in care homes in Wales’ (Welsh Government, 2016). This document intends to provide details of a policy and funding to deliver an effective mouth care programme to the older residents of care, nursing and residential homes in all health boards across Wales. It outlines a person-centred training programme for staff, introducing and highlighting good practices, including mouth care assessments. The training programme provides consistent care for residents and increases staff knowledge and skills. It also aids staff in detecting areas of concern or people who may require more care or urgent care, and aims to highlight the referral pathways for the community dental service. It uses national improvement methodologies, and is led by the care home staff and supported by community dental teams. The name of this programme is Gwên am Byth (Smile Forever). In 2017–18, there were 657 care homes across the 7 health boards in Wales, and 3211 residents had a mouth care plan being delivered to them (Welsh Government, 2018). Sixteen of the participating homes have had external reviews, which have highlighted good or excellent mouth care, and 210 can identify local dental services that their residents can access.There has been positive feedback from staff, care home managers, community dental officers and specialists in special care dentistry.
As with any healthcare intervention, the difficulty is in measuring outcomes, although the programme does align with all but one of the quality standards published by the National Institute for Health and Care Excellence (2017). Additionally, it also follows the Delivering Better Oral Health Toolkit (DHSC, 2014). Anecdotally, staff have reported fewer chest infections and oral thrush episodes among residents since implementation of the programme. It has enabled appropriate referrals to dental teams rather than to GPs. Staff have also reported more confidence in product choice for the residents (e.g. with regard to toothpastes and toothbrush size) and have said that they feel there is better teamwork and a more positive attitude towards mouth care and its importance, not only for the residents but also for themselves.
Gwên am Byth, Scotland's Caring for Smiles and Northern Ireland's guidelines (Department of Health, 2012) will aid in the improvement of oral healthcare among older adults, leading to improvements in overall health, reduction in hospital admissions and a reduction in the number of dental appointments that may be required. A recent review of the Australian Senior Smiles programme (Wallace et al, 2016) showed the cost benefits of having such an oral care programme within its care, nursing and residential homes.
Conclusion
In a recent Commons debate, the MP Andrew Selous raised the importance of mouth care, oral health and access to dental services and the impact of poor oral care on vulnerable older people. He also emphasised the need for increased domiciliary care in the wider community. In raising this subject in the Commons, mouth care and its importance has been highlighted, although it must be emphasised that it is not just about the mouth. It highlights the need for person-centred care and that the delivery of the care should depend on the individual's needs, which would in turn impact the commissioning and delivery of services. Policy makers need to be aware that not everyone can attend or be treated in a general dental practice (Burtner and Dicks, 1994; Formicola et al, 2004) and that domiciliary dental care should be considered for older adults living at home or in care homes.
Wales, Scotland and Northern Ireland's mouth care programmes go some way to meet the needs and demands of the service, but what of England's older generations?
Community nurses armed with some knowledge of oral health and evidence-based interventions can help their patients to maintain good oral health and avoid infection, pain and discomfort. Enhanced support for older community-dwelling adults, their families, carers and healthcare professionals can allow for the development and commissioning of effective, collaborative preventative programmes such as Gwên am Byth and allow them to continue to improve the quality of life, reduce the burden of dental disease and put the mouth back into the body.