Community nurses provide invaluable care to patients across the life course—from health visitors supporting new mothers and newborns, to frailty nurses supporting older adults living with frailty and complex needs (NHS England, 2023). Community nursing teams form part of the largest group of professionals in the healthcare workforce and serve patient groups that are at greater risk of oral disease. Furthermore, contact with a wide range of patients mean that community nursing teams are in a prime position to promote and reinforce positive health messages, particularly to vulnerable groups. This is in alignment with the principles of ‘Making every contact count’—an approach to behavioural change that utilises the multiple day-to-day interactions that organisations and teams have with patient groups to support them in making positive changes to their physical and mental health, and wellbeing (Public Health England and NHS England, 2016).
Oral health is indeed a key indicator of overall health, wellbeing and quality of life, and is defined by the World Health Organization (WHO, 2021) as:
‘… a state of being free from chronic mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum) disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual’s capacity in biting, chewing, smiling, speaking, and psychosocial well-being.’
As health professionals, community nurses have a duty to promote health and prevent disease, which includes oral health (Nursing and Midwifrey Council, 2018). If left untreated, oral conditions could impact quality of life and lead to pain, infection and difficulty eating (Petersen et al, 2005; Haag et al, 2017); oral conditions also disproportionately impact the disadvantaged (Sabbah et al, 2007; Public Health England, 2021a). Poor oral health and untreated oral diseases are associated with multiple health conditions and may share common risk factors with other chronic diseases (Sheiham and Watt, 2000). For example, systemic conditions such as cardiovascular diseases and the increased risk of stroke are associated with gum disease, and diabetes shares a bi-directional relationship with gum diseases (Casanova et al, 2014; Genco and Sanz, 2020). Increased sugar consumption is associated with an increased risk of tooth decay, increased weight, type 2 diabetes and coronary heart disease (Huang et al., 2023). Furthermore, dental neglect in children may be an indicator of a wider safeguarding issue (Greene et al, 1994). Despite most oral conditions being largely preventable, oral diseases are among the most prevalent chronic diseases, affecting 3.5 billion people globally, of which 2.3 billion cases are untreated tooth decay in permanent teeth (GBD 2017; Oral Disorders Collaborators et al, 2020). Further details of the epidemiology of common oral diseases in the UK can be found in Table 1. Moreover, many of the patient groups that community nurses support are at greater risk of oral disease due to the risk factors outlined in Table 2. Gallagher (1998) outlined the aetiology for common oral health conditions and this paper updates the evidence.
Table 1. Common oral conditions and their prevalence in the UK for adults
| Main oral health conditions‡ and their prevalence in the UK |
|---|
Tooth decay
|
The prevalence for the three main oral conditions is given for all adults; however, it is important to note that mucosal lesions and tooth wear are also important oral conditions to be aware of and preventative advice for some of these conditions is given in Table 3.
Sources:
1.Office for National Statistics (2011)
2. 3. 4. 5. 6.Table 2. Some of the areas supported by community nurses (NHS England, 2023)
| Area supported by community nurses (NHS England, 2023) | Common oral conditions | Additional risk factors for oral conditions |
|---|---|---|
| Mental health |
|
|
| Immunocompromised children and adults | Oral thrush (candidosis) |
|
| Sexual health | Oral manifestations of HIV | HIV |
| Inclusion health* |
|
|
| Vulnerable older adults |
|
|
Sources: Kisely et al (2015); Archer et al (2020); Martin et al (2020); Office for Health Improvement and Disparities et al (2021)
Note: Inclusion health refers to patients that are socially excluded. This includes community nurses that help to support patients who experience homelessness, drug and alcohol dependence, vulnerable migrants, sex workers, people in contact with the justice system and victims of modern slavery, but can also include other socially excluded groups (but this list is not exhaustive) (Public Health England, 2021d).
Oral health in the community
Oral diseases affect patients across the life course, with tooth decay listed as the number one reason for hospital admissions in children aged 6 to 10 years old (Office for Health Improvement and Disparities, 2023). Hence, the management of oral diseases impacts services across the healthcare system, and as the population continues to age, this will become increasingly important. Adults are maintaining their teeth for longer (including teeth with restorations and dental implants), which require maintenance. The most recent Adult Dental Health Survey in 2009, of adults in Wales, England and Northern Ireland showed that 94% of the population had at least one tooth, and the majority (60%) of adults among this group have almost all (27–32) their teeth (NHS Digital, 2011).
As the volume of our elderly population increases and forms a higher proportion of society (Office for National Statistics, 2023), so will the likelihood of experiencing multiple chronic and complex health conditions, leading to increased demand on healthcare services. Moreover, community nurses are also in a unique position to provide, as well as reinforce, preventative messages given by members of the dental team.
Although, the oral health of the population seems to be improving (NHS Digital, 2011; Pitts et al, 2017), inequalities still exist across all stages of the lifespan of patients and with different clinical indicators such as tooth decay and related quality of life measures (Public Health England, 2021b). Inequalities span across healthcare and are not new (Gray, 1982), but the COVID-19 pandemic is widely recognised as having exacerbated existing inequalities. This is due to both the direct and indirect impact of the pandemic disproportionately affecting many already disadvantaged populations, including their dental access (Public Health England, 2020; Stennett and Tsakos, 2022). Community nurses work alongside multidisciplinary teams with patients, families and carers across all spheres of society and have increased possibility to come into contact with those that need the most help and support (NHS England, 2023).
Gallagher and Rowe (2001), provided a comprehensive overview of the assessment, symptoms, advice and treatment required for common oral conditions, including medication that community nurses are able to prescribe. Although research regarding interventions used by community nurses to improve oral health care for people receiving care in their own homes is limited (Stark et al, 2022), there is existing evidence to suggest that nursing teams in the community have the potential to play a critical role in oral health promotion and improve oral health outcomes for patients (Abou El Fadl et al, 2016; Poudel et al, 2017). The commitment of community nurses to oral health improvement and desire for additional educational support is present (Garry and Boran, 2017). The aim of this article is to support community nurses with a practical resource for key evidence-based oral health preventative advice, and provide guidance on how their patients can access dental care.
Oral health promotion for community nursing teams
Community nurses are often the first point of contact and frequently see patients, together with the provision of care in, or close to, peoples’ homes. This provides an invaluable opportunity to provide context-specific advice and to also reinforce positive behavioural patterns. As mentioned earlier, the majority of oral conditions are preventable and the ‘Delivering Better Oral Health’ (DBOH) toolkit for the prevention of oral disease was first published in 2007, with the most recent edition (version 4) being published in 2021 (UK Government, 2021). The toolkit serves as an invaluable online evidence-based resource for all health and social care professionals to deliver patient-centred preventative advice for patients of all ages. The toolkit promotes oral and general health, and outlines additional support and advice that can be provided for patients who may be at greater risk of oral disease.Table 3 summarises some of the information in the DBOH toolkit, with additional useful for the patients that community nursing teams support (Faculty of Dental Surgery, 2012; UK Government, 2021; British Society of Paediatric Dentistry, 2023).
Table 3. Advice for adults and older adults on oral health from the Delivering Better Oral Health Toolkit V4
| Evidence-based advice for oral health for all patients | Additional oral health advice for patients at higher risk |
|---|---|
Toothbrushing and toothpaste
|
Caries prevention
|
Diet and medication
|
Other common oral conditions
|
| Visiting the dentist Risk-based recalls every 3–24 months |
Sources:
1.British Society of Paediatric Dentistry (2017)
2.National Rheumatoid Arthritis Society (2023)
3. 4.Raising awareness of local dental services
As community nurses play an active role in delivering and reinforcing oral health advice, they can further facilitate holistic joined up care, or patients that are dependent on multiple health services, especially for those who may be less likely to access dental services, through working alongside dental teams (Health Education England, 2019). This is promoted through the Health and Care Act 2022, and further contributes to collaborative practice, which is recognised by the WHO as a contributing factor to the delivery of the highest quality of care for patients (WHO, 2010). This promotes the achievement of local health goals and strengthens health systems and improves health outcomes (WHO, 2010). In addition to the prevention listed in Table 3, for many of the adults at higher risk of oral diseases, members of the dental team undertake a range of preventive procedures at appropriate points in the life course, including:
- Prescribe a higher fluoride toothpaste
- Prescribe fluoride mouth rinses
- Administer topical fluoride varnish
- Correct and modify areas on teeth or restorations to better facilitate oral hygiene (UK Government, 2021).
Community nurses may encounter patients with dental pain during their visits, and Gallagher and Rowe (2001), provided a useful summary regarding the assessment and treatment of common oral conditions for the team, including prescription where required. In addition to this, community nursing teams are able to signpost patients to dental services available to them (Gallagher, 1998). Most patients encountered in the community will be able to access regular care through high street dental services, which may be private or NHS dental care. However, where there are access requirements or specialist input is required, care can be accessed through the community dental services, secondary and tertiary specialist services and domiciliary services (Table 4). Furthermore, it is invaluable for community nursing teams to interact and familiarise themselves with the options available for their patients, namely the local community dental service options available to them. This includes their referral criteria, which is dependent on each community dental service. Where patients do not have a dentist, community nursing teams should be able to signpost patients to the NHS website to find a dentist (https://www.nhs.uk/service-search/find-a-dentist).
Table 4. Routes for entry into dental care in UK
| Regular care | Urgent dental care |
|---|---|
|
Note: *Accessed through referral
Conclusion
As part of holistic contemporary healthcare, community nurses have a crucial role to play in the delivery of oral health advice. It is important to acknowledge that patients from disadvantaged or socially excluded groups are at greater risk of disease and may be less likely to attend dentist due to various barriers, but may be willing to meet community nursing teams. Hence, it is important to recognise that existing health messages delivered by community nursing teams will support oral health. Therefore, oral health promotion and advice should not be considered as burdensome, and adding further tailored oral health messages will make a major contribution to the wellbeing of individuals (Gallagher and Rowe, 2001). This will involve providing timely advice, support, referral and, if appropriate, prescription for patients and appropriate liaison with other members of the primary care team (Gallagher and Rowe, 2001).
Key points
- Good oral health is a crucial part of good overall health
- Existing positive health advice and support delivered by community nurses contribute to the maintenance of good oral health
- Community nurses should be aware of how to signpost their patients to local dental services and make referrals where appropriate
- Adults should visit their dentist at least once every two years (but more often if higher risk)
CPD reflective questions
- What are the main risk factors for common oral conditions for your patients?
- What suggestions could be given to patients and families that struggle with toothbrushing due to sensory issues?
- Considering the impact optimal oral health has on the overall wellbeing of patients, what are the different types of dental services that your patients can access to receive regular and/or urgent dental care?
- Give some examples of resources for further learning about oral health