Oral health is an essential part of an individual's overall well-being. However, this can be overlooked when tending to other, more serious health issues. For example, in the community nursing setting, large leg wounds are tended to, unstable blood sugars are the priority, or a patient may have multiple disabilities and a complex array of health needs. Oral health is important; yet, with the staffing difficulties we see in the NHS and social care systems, it is hard to ensure the amount of care given to the patient involves everything, including oral hygiene tasks. This is why it is essential to bring to the attention of the carers and the wider team of community nurses that this health aspect might be overlooked, and careful consideration should be made, as the patient can be at risk if this part of their care is not fulfilled. Often, a patient is able to do much of the tasks themselves and may require prompting or even training in appropriate oral hygiene, but some rely heavily on others to do this task for them.
The Lancet Commission on Oral Health (The Lancet, 2019) stated that despite oral diseases being easily preventable, tooth decay, periodontal (gum) disease and oral cancers are among the most prevalent diseases worldwide, affecting over 3.5 billion people globally. These conditions carry significant health, psychosocial and economic burdens and, thus, reduce the quality of life of the person. Taking into account with the other conditions that the patient may have on the community nursing caseload, these burdens are drastically increased. Also of concern, is that these oral health problems mostly affect poorer, marginalised and vulnerable groups in society, and are associated with the much broader social determinants of health (The Lancet, 2019). Therefore, much of the caseload may fall into this category, depending on the location covered by the nursing team. The types of problems facing those in poorer socioeconomic groups include having a higher sugar consumption, higher use of tobacco and harmful alcohol consumption, which elevates risk of oral conditions. However, in the community nursing caseload, this, coupled with conditions that prevent the patient from carrying out good quality oral healthcare, increases that risk further.
The National Institute for Health and Care Excellence (NICE) (2023) notes that patients who live in care homes, and who may make up some of the community nursing caseload, are at a greater risk for oral health problems, due to long-term conditions such as arthritis, Parkinson's disease and dementia. Such conditions can compromise dexterity and can make holding a toothbrush and thus, mouth care, more difficult to be carried out. Movement disorders of this kind also affect mobility, meaning it is harder for these patients to get to appointments or to even use the phone to arrange an appointment, in order to receive appropriate dental care and treatment.
Another risk factor is medication. NICE (2023) notes that many medications that are taken by patients (who often have long lists of medications for multiple conditions), can reduce the amount of saliva the mouth can produce, which leads to dry mouth. Dry mouth, in turn, can lead to poor oral hygiene and infection, among other conditions, including gum disease over the longer term.
The ageing population means that people living into their older age, despite their longevity, also face greater oral health risks. Older adults tend to keep their natural teeth into their later years, compared to some decades ago when many people had dentures fitted. By keeping ageing teeth for longer, complex dental needs may arise over time and therefore, age is a risk factor for more complex oral health concerns.
Assessment
NICE (2023) discusses the importance of mouth care plans for patients, appropriate training for staff in meeting oral health requirements, and thorough assessments for all patients in order to reduce pain, disturbed sleep and health problems that poor oral health can lead to.
The assessment can be directed to carers to carry out, but overseen by the named nurse for the patient and wider team as part of a more comprehensive care plan for all health needs. The person assessing the patient's oral health should be asking how the patient usually manages their daily mouth care and what help they would like; what dental aids the patient uses (i.e. manual or electric toothbrush, mouthwash, floss); whether the patients has dentures and would they like these to be marked with their name; when the patient last saw their dentist; who did they see; and if they do not have a dentist, then would they like help in finding one? (NICE, 2023).
Vulnerable adults who are especially lacking in manual dexterity and mental capacity are most at risk and require assistance and support with toothbrushing, as part of daily self-care (NICE, 2016). Those with learning disabilities require professional expertise that considers their needs and preferences, as well as those of the carer for the patient. For dexterity or learning disability/capacity considerations, a grip handle may help assist with toothbrushing. NICE (2016) notes there are community dental teams who can help train the patient and/or carers with essential oral care, while supporting the delivery of this through the nursing team. They may also see the patient regularly enough to routinely check the health of the patient's mouth/gums in a generalised brief assessment, while also ensuring they oversee that good oral care is conducted regularly by their team or the carers who visit/live there with the patient.
The main aspects of daily dental care in a patient who requires nursing home care or, for example, is living in the community under nursing care or is hospitalised, would involve daily provision of oral care for full or partial dentures. This would involve brushing, removing food debris and removing dentures overnight. Care would also include using the patient's choice of cleaning products for the dentures, using the patient's choice of toothbrush, and using the daily prescribed mouth care products as prescribed by dental clinicians, such as a high fluoride toothpaste or a prescribed mouthwash or rinse (NICE, 2016).
Oral health in the community setting
Stark et al (2022) examined the interventions that support community nurses in meeting oral care requirements for patients who live at home. They noted that oral health is a critical issue for public health and that a low-quality of life and chronic health conditions all link back to poor oral health. The authors noted that there has not been a significant focus on the provision of oral healthcare to those who live at home, with the focus being mostly on people who are hospitalised or living in a care home. It can be more of a challenge to meet the needs of a patient living at home, who may have a vast array of health conditions that compromise their ability to perform good oral hygiene, but do not meet the criteria for daily nursing care or a larger social care package. Therefore, some at-risk patients may be without care from anyone on some days, and may live alone, as many elderly people do, leading to significant gaps in the patient having their oral health needs met. This, therefore, is something that requires a new focus, given the public health concern of what compromised and poor oral health can cause. Stark et al (2022) noted that little is known as to what interventions are effective for community nurses delivering education or training that can help meet the oral care needs of this cohort of patients, due to a lack of research in this area.
Therefore, the authors carried out a scoping review, to analyse studies of oral health interventions that involved patients who receive community care from nurses, or nurses who deliver this type of care. The team extracted data for four main domains which included the setting and type of intervention (patient outcomes, changes to nursing practice and implementations and process evaluations of interventions). The team found 2080 papers through their initial search, but only found nine of these were eligible to be included in the study. A total of three studies covered community nursing for older people, and six studies involved health visiting or community nursing for children and infants. Stark et al (2022) found that there is a significant gap in the research surrounding interventions for community nurses to improve oral health, and that future interventions must be co-produced. One must consider the complexity of the nursing practice setting in the community, and the barriers in delivering care such as time pressure or lack of previous experience in the healthcare professionals involved in the patient's care.
Stark et al (2022) also found from the nine reviewed studies that changes to community nursing practice are possible, where education interventions are given to staff, and result in increased capability to make dental referrals from the community nursing team. The training was also seen to increase the ability in making a comprehensive oral health assessment and was also shown to increase the quality of patient education on the topic of oral healthcare. These are possible where there is professional support, to oversee staff training and ongoing learning. There would need to be support to help someone and a team change their practice, at a managerial level. Mentoring and procedural change are also important factors in the delivery of this change to incorporate better oral healthcare among the patient caseload. However, the team noted the difficulty in deciding from some of the studies reviewed, if oral health outcomes were improved despite a significant increase in the use of oral hygiene products, for example. Some interventions such as the latter may then be difficult to validate from the review conducted as to whether they are clinically significant in improving outcomes. A barrier to change identified by Stark et al (2022) was that high rates of staff turnover in home care nursing make it very difficult to ensure everyone is trained in maintaining a high level of implementation of oral hygiene support to patients. The team suggested this barrier may be met successfully with the implementation of digital learning, ensuring education can be delivered online, reducing staff time demand, and introducing the training promptly to all new staff.
The review by Stark et al (2022) found that there was a significant lack of prior training in oral care among staff, which indicates that institutional support would be required in order to maximise effectiveness of ensuring change. The authors also mention the NICE (2016) guideline, which fails to represent the patients who live at home alone and are lacking the more intensive support on hand in care homes and hospitals. However, the more recent NICE (2023) advice covers general advice for oral hygiene care that may be utilised in any care environment. Stark et al (2022) also stated that by increasing the oral health care skills and knowledge of registered nurses, further dissemination within the community can occur. This can then achieve better oral health outcomes among patients in the community, as nurses are often the ‘gatekeepers’ for many other services.
Nutrition is a key factor in maintaining overall health; high sugar consumption, while causing diabetes, obesity and other conditions, can also cause tooth decay and gum disease, among other oral conditions. The Office for Health Improvement and Disparities (OHID) (2022) stated that patients should be supported to cut down on sugar through advice and education, motivational interviewing interventions while delivering the advice, and appropriate referral to dietitian services, as required to support these needs.
OHID (2022) also states when to help refer a patient urgently to the dentist. Urgent referral is required where a patient has an unexplained ulceration in the mouth lasting for longer than 3 weeks, a persistent and unexplained lump in their neck, a lump on the inner or outer lip or in the mouth consistent with oral cancer, a red patch in the mouth consistent with erythroplakia, persistent unexplained hoarseness, or persistent pain in the throat or pain when swallowing, which lasts for more than 3 weeks.
Conclusion
Overall, it is clear that a myriad of complex issues are present among the community nursing caseload that indicate risk for poor oral health, and point to support that can be delivered in improving oral health outcomes through the nursing and carer teams and wider community services. It is key to carry out thorough oral health assessments and support as necessary with daily oral healthcare, whether it is through education and training or the delivery of physical support in a social care package or through the patient's informal carer. The nurses can also oversee the delivery of high quality oral healthcare and can oversee the need for dentist referrals in the community patient. It is important also to be aware of social determinants and economic disparities that place patients at higher risk, and to understand that among these groups usually the tobacco, alcohol and sugar consumption is higher, which may require external services to link up with the patient. A thorough oral health assessment can determine a range of care needs and wider team training and education is also essential in delivering this, alongside the range of daily care interventions required, as determined by the assessment. Oral health is a significant part of public health and we can all play our part in reaching better oral health outcomes with our patients.