Due to oral health care currently being so prominent in the younger generations it is likely that more and more adults will retain some of their teeth until the end of their life. This means that whilst currently, many elderly individuals have full dentures in place, it may not be like this in the future. All care staff need to support all service users with their oral health maintenance, and it is therefore essential for all health workers to be able to under-stand and identify potential oral health diseases – most of which can be prevented!
You can download our oral care factsheet here
Oral health care is vital in supporting service users/clients general health and wellbeing and must be seen as a necessary daily activity to support the mental and physical requirements of an individual.
Teeth are required to help with:
• Mastication (chewing)
• To support a healthy and varied diet
• To aid digestion
• Speech and aid speech development
• Confidence- there is nothing better than smiling!
Practicing good oral health care is essential in supporting the human requirements of eating and digesting and promotes confidence in all of us.
What is good oral health?
Practicing good oral health is essential insupporting the human requirements(eating and digesting) and promotes confidence in all of us.
Signs of good oral health are:
- No bleeding on brushing
- No halitosis (bad breath)
- Gums (gingivae) are firm and stippled
- Gums are not red, swollen or rounded
- No pain or swelling
- No visible growths in the oral cavity
- Healthy coloured tongue and tissues
- No visible decay (caries) on teeth
What is poor oral health?
- If the gum appears to be swollen and overhang
- Bleeding when brushing
- Teeth are visibly discoloured or have white or dark spots
- If roots of the teeth can be seen
- Evidence of halitosis
- If the tongue looks dry or swollen
- If there are visible deposits of plaque or tartar can be seen
- If any changes to colour, texture or viscosity (dry mouth) can be seen
If any of the above points are detected, the individual will need to be seen by a dental professional for assess-ment. Some medical conditions and medications can cause contraindi-cations (side effects) in the mouth so they always need to be checked by a dental professional (and GP where required). For some medical conditions, the first signs and symptoms will be seen in the mouth (e.g. anaemia or HIV) so it always essential to check the mouths soft tissues (gums, cheeks, lips, tongue, tissues covering the mouth and throat) and hard tissues (teeth).
Please note: the above signs are not inclusive so any change in the tissues or structure, or any symptoms described by an individual, must always be assessed further.
There are many types of oral diseases that can occur, but the following are examples of the most common diseases that may be identified by staff for service users based in a care environment or are being supported in daily life and assisted activities.
Common Oral Diseases
Stomatitis is caused by poor fitting dentures, irritated soft tissues underneath a denture and fungal infections.
Following removal of the denture, there may be a red area underneath. There may also be red sore areas at the corner of
the lips. This is likely to cause soreness and will be uncomfortable for the wearer and likely lead to a change in diet/frequency of eating. Dental advice and consultation will be required as advice and treatment may include medication –most will include tablets or mouth lozenges. It is essential to not sleep in the denture to allow the soft tissues to heal during and individuals may be requested to remove dentures for as long as possible during the day too – this will depend on the individual’s choice which must be respected at all times.
Smoking encourages the growth of further yeast infections so this will also be explained to individuals.
Thrush is a fungal infection that can occur in the mouth and is quite commonly found in the elderly, the young, individuals with poor
oral health, and people who have underlying medical conditions. However, it can be seen in individuals who have hormonal related
changes e.g. teenagers and following a course of antibiotics. It is very common for denture wearers. A thick white film will cover
patches in the mouth and can include the lips and inside of cheeks, so care must be taken to carefully monitor any visible signs of this
in the oral cavity. GP advice will be required as anti-fungal medication will be required. During and after treatment, care must be taken to ensure that the mouth is kept clean and dentures are cleaned correctly and removed for sleeping.
This causes red patches in one or both of the corners of the mouth, which can become sore and lead to open blisters. Common in elderly
patients but can be found in all ages. It is caused by a fungal or bacterial infection and is not contagious to others but can spread to adjacent skin. There is some evidence that links the initial onset of angular cheilitis with nutritional deficiencies, or preexisting medical conditions
so GP advice is required.
Dry Mouth (Xerostomia)
This is due to the salivary glands not making sufficient saliva which causes the mouth to be dry. This must not be confused with the term ‘dehydration’ which tends to be temporary, with xerostomia, the mouth is constantly dry. This is usually caused by natural aging processes, side effects of medications, and during radiation therapy for treatments of cancer. Due to the lack of saliva, this can affect oral health by increasing risks of periodontal disease and caries (decay), affecting speech and digestion, bad breath and reoccurring infections such as oral thrush.
It can prove to be uncomfortable and problematic for individuals. GP advice must be sought to support the individual. Whilst identification of contributing factors and a treatment plan will be agreed, it may help individuals to suck on sugar free sweets or sugar free gum and/or ice cubes and avoid smoking and caffeine. Oral health care is exceptionally important as the mouth will be unable to fight disease as effectively as normal.
This is an inflammatory disorder which usually appears on the top and sides of the tongue. Despite its appearance, it is harmless. Some people may experience pain or discomfort especially after eating acidic or spicy foods. Patches on the surface of the tongue are missing papillae and appear as smooth islands on the tongue with raised borders. It can sometimes heal then migrate to other parts of the tongue. If lesions do not heal within 10 days, then GP/dental advice is required.
Hand, foot and mouth disease
This is caused by a virus. Commonly seen in children under 10 years of age but is infectious during incubation periods. A fever, sore throat and painful red blisters on tongue, gums and inside of cheeks may be present (also located on palms of hands and soles of feet). In some individuals it can be mild with only a few blisters present and flu like symptoms. Please seek GP advice in case of any pre-existing conditions. Additional fluids will help prevent dehydration.
Can be caused commonly by irritation and/or trauma. Reoccurring ulcers and ulcers that do not clear within 2 weeks must be investigated to rule out mouth cancer or other underlying medical conditions. Lozenges, mouth-wash and sprays may help during the period of healing
(though always seek professional GP or dental advice).
Caries is caused by plaque, frequent sugar consummation and ineffective toothbrushing. Damage to the outside of the tooth (enamel) will occur first before spreading to inside the tooth leading to pain, sensitivity, loss of function and effectively, loss of the tooth. Arrange an immediate professional consultation with a dentist at first signs of caries and improve diet/tooth brushing techniques.
Gum disease (Periodontal disease)
If plaque is not removed effectively from the mouth and around the gum area, it will accumulate and begin to irritate the gums. This can lead to halitosis, gums becoming swollen and red, bleeding on pressure or during toothbrushing. Microorganisms contained in plaque will flourish (multiply) and plaque will then harden if not removed (tartar) and will begin to travel downwards – effectively attacking the structure of the tooth (e.g. roots and alveolar bone—the structures which keep teeth in place), ultimately leading to pain, sensitivity and eventual loss of the tooth.
Simple tooth brushing techniques are required twice a day, and sugar intake advice to keep to specific times of the day, preferably at meal times. If able, interdental aids such as floss or interdental brushes should also be used, as they help remove the plaque build-up in between the gums and teeth (which a toothbrush is unable to reach). Regular attendance to see a dental professional will be required to maintain and advice on any individual support or treatment required. If mobility issues are likely to affect tooth brushing, then an electric toothbrush
would be advised.
Plaque is a natural substance which occurs in the mouth and consists of micro-organisms, food debris, salivary particles, dead cells and blood. Ten minutes after brushing, the first invisible layer of plaque occurs on the teeth and as the day progresses and more food and drink is consumed- the plaque multiplies and sticks to surfaces of the teeth especially the gum margins (the neck of the tooth) and in-between teeth. It feeds on carbs and sugars, producing acid as it metabolizes the sugars. Whilst the mouth has some self cleansing abilities (saliva naturally
neutralises acids) it must be manually removed through effective and regular toothbrushing (twice a day) and regular dental examinations are required to remove any build up. Plaque will become hard (tartar) after time due to natural reactions in the mouth caused by salivary salts. Once it becomes tartar only a dental professional can remove it.
Plaque build up has been linked to heart disease and other medical conditions therefore, it is imperative that plaque is removed effectively.
The build up of plaque can also then contribute to tooth decay due to the micro-organisms that then flourish as it contains specific bacteria that initiate tooth decay, and gum disease such as gingivitis and periodontal disease.
Cold sores are a common viral infection which commonly present on the lips, though inside the mouth and nose are also common sites. Vesicles can be seen (blisters) and the individual could show discomfort. They are infectious and can spread to other parts of the body so great care is needed to prevent this. They usually take 10 days to heal. Anti-fungal creams can be used to shorten the attack so always seek GP
and dental advice. If attacks prolong or become more frequent, then GP further investigations may be required.
Oral cavities need to be regularly checked for any changes of tissue colour, changes in the look of tissues covering the inside of the mouth (mucous membrane), any growths or abnormalities – all of which must be investigated by a dental professional. Even ulcers, warts, or white patches in the mouth, must always be checked. Unfortunately, oral cancer can be hard to detect and is often not identified until late stages which ultimately leads to a poor prognosis.
Please also check throat/tonsils areas for any changes in the tissues. Around 8,300 people in the UK are diagnosed each year and mouth cancer now accounts for just over 2% of all cancers (this is a rise of 68% over the last two decades).
Lifestyle and risk factors such as smoking and alcohol are the most likely causes, though other factors include diets low in fruit and vegetables and the Human Papilloma Virus (HPV).
During routine dental examinations, the dental professional will also check and examine the hard and soft tissues of the mouth and surrounding areas and will routinely check for any changes and abnormalities. Therefore, is it essential that regular dental examination occurs for all individuals. Survival rates for mouth cancer are dependent on what stage it is detected which again reinforces the importance of regular dental examinations and checks.
Abscesses can be caused by trauma, irritation and ongoing infection. This is likely due to caries, periodontal disease or death of the nerve and they tend to be present on the gums usually above or below a specific tooth, in the form of a large swelling with clear signs of inflammation. This will cause great pain and will need immediate dental consultation, as antibiotics or draining may be required. Following consultation, x-rays and investigations will occur to diagnose the initial problem whereby an individual treatment plan will be agreed.
HIV (Human Immunodeficiency Virus)
HIV can commonly be first identified in the mouth, following reoccurring mouth ulcers, cold sores, bleeding gums and inflammation of the tongue (glossitis). If an individual is diagnosed with HIV, then special care will be required to avoid the spread of infection as it can be spread via blood (open wounds or via sexual intercourse). More frequent dental examinations could be agreed and planned due to possible deterioration of the tissues.
This is a natural process of ageing, as due to the alveolar bone shrinking, the tissues also shrink back, which can expose the roots of teeth. It is exacerbated by toothbrushing technique and poor removal of plaque formation, so oral health maintenance is essential. Toothbrushing techniques are vital to prevent any further shrinkage as incorrect methods used can lead to the gums to shrink and expose even more of the roots. This will cause extreme sensitivity and mean that the patient may be prone to root caries. Professional dental help and treatment will be required as in some cases, fillings can restore the surface and prevent oral health from deteriorating. In severe cases, the tooth may need to be removed as over time it will become loose and be nonfunctional.
Although most people brush regularly, if the correct technique is not used then it will be ineffective in removing plaque. The correct technique is using small circular brushing with the brush pointed in a 45- degree angle, so it gently cleanses the gum margins. Gentle brushing only, as too much pressure and/or use of a scrubbing technique (such as a side-to-side action) can result in the gums shrinking, leading to exposure of the tooth root. This will cause extreme sensitivity and the exposed area will then be prone to decay.
The recommended brushing technique is:
Start with all the same surfaces first, for example start on the bottom left and clean all the outer surface nearest the inside of the cheeks all the way to the front of the mouth, then clean the inside surfaces, then move to the occlusal surfaces (biting surfaces). Then move to the bottom right area and repeat the process, until all the areas and surfaces of the mouth are clean.
There are different types of mouthwashes, so it does mostly depend on individual preferences, as long as they contain the recommended dosages of fluoride and contains no alcohol. Mouthwash should be used at a different time to toothbrushing – ideally at least 30 minutes after brushing but can be used at any time of the day. There are also anti-bacterial mouthwashes available which can be prescribed by a GP or a dental professional. These are usually for a short-term issue such as periodontal disease or a specific infection having been identified, follow instructions carefully, as some mouthwashes may cause staining.
Toothpaste is very much down to personal choice and price and using toothpaste that contains the required levels of fluoride is one of most effective ways to prevent decay. Toothpastes containing 1,350 to 1,500 ppm (parts per million) are the most effective.
Some individuals may prefer to use more natural versions of toothpaste, and professional dental advice is recommended to ensure that full understanding of the product is understood so an informed choice can be made.
Cleaning prostheses (dentures)
Dentures can be full or partial (a partial denture is where an individual has some natural teeth still in place, and needs a denture to only cover the spaces left by missing teeth)
To clean your dentures, the general rule is brush and soak every day. Brush your dentures first, to help remove any bits of food. Use a non-abrasive denture cleaner, not toothpaste. Be careful not to scrub too hard as this may cause grooves in the surface.
Make sure you brush all the surfaces of the dentures, including the surface that fits against your gums. This is especially important if you use any kind of denture fixative.
Soak your dentures every day in a denture-cleaning solution. This will help remove any plaque and stubborn stains that are left. It will also help to disinfect your dentures, leaving them feeling fresher. Always follow the manufacturer’s instructions. (Some individuals like to use a bleach-based substance – please advise service users that if soaked in bleach overnight, long term this will fade the colour of the dentures and can reduce their lifespan and make them brittle).
If your denture has metal parts, do not use anything that contains bleach, but use chlorhexidine instead. Do not use chlorhexidine every day as it will stain your denture. Use it once a week.
Dentures must be removed every night and NOT slept in. By sleeping in dentures, this can cause irritation and trauma to the
oral tissues, and also prevent bacteria to flourish – leading for example to thrush.
Over time, due to natural shrinkage of the gums and alveolar bone (jaw bone), dentures will become loose and ill-fitting.
Whereby a denture becomes loose and not fitting correctly, please make arrangements for the service user/client to be seen by a dental professional as treatment can consist of;
- Denture reline – where a special material can be placed in an existing denture to make it fit
more securely and be more comfortable
- New dentures can and will be made if necessary
If dentures are not fitted correctly, then the service user will be uncomfortable, distressed and possibly in pain, and can make them feel self-conscious. It will also impact heavily on ones’ diet and ability to masticate (chew). In addition to affecting the service user, it can greatly distress the family of service users.
Useful Contacts/ Websites
- General Dental Council – https://olr.gdc-uk.org/searchregister
- Oral Heath Foundation – https://www.dentalhealth.org/
- World Health Organisation – https://www.who.int/oral_health/strategies/hp/en/
- NICE Oral Health in care homes – https://pathways.nice.org.uk/pathways/oral-health-foradults-in-care-homes
- British Dental Association – https://bda.org/
- CQC – Smiling Matters—Oral health care in care homes report
- Colgate-How to brush teeth correctly- https://www.colgate.com/en-us/oral-health/basics/brushing-and-flossing/how-to-brush
- Oral B-How to brush teeth properly- https://www.oralb.co.uk/en-gb/oral-health/solutions/electric-toothbrushes/how-to-brush-teeth-properly
- Oral Health Foundation- Fluoride-https://www.dentalhealth.org/fluoride
- NHS-Fluoride –https://www.nhs.uk/conditions/Fluoride/
- NHS-How to keep teeth clean-https://www.nhs.uk/live-well/healthy-body/howto-keep-your-teeth-clean/