Oral health is an indicator of overall health, wellbeing and quality of life (World Health Organization, 2022). Good oral health allows people to eat, verbally communicate and socialise without discomfort or embarrassment. Oral health care forms an integral part of general health care, is often overlooked and is frequently identified as needing improvement (Terezakis et al, 2011).
Dental diseases are prevalent among both adults and children in the UK, with most people at risk of developing dental disease at some point during their lifetime (Office for Health Improvement and Disparities (OHID), 2019). Tooth decay, gum disease and dental erosion are the most common conditions, with the rarer but most serious disease being mouth cancer. Dental disease negatively affects quality of life with the main impact being pain, low self-esteem and absences from work and school (OHID, 2022).
In relation to hospital admissions, poor oral health has been linked with increases in hospital-acquired infections (such as pneumonia), poor nutritional uptake, longer hospital stays and increased care costs (Health Education England (HEE), 2017).
OHID et al (2021) have advised that regular, effective mouth care provision in hospital is essential to prevent a deterioration in oral health and to maintain a healthy, functioning and comfortable mouth. Therefore, evidence-based oral health care is an essential part of inpatient care, especially for those spending long periods of time hospitalised. Bonetti et al (2015) defined patients' oral hygiene as keeping the oral cavity healthy through cleaning of gums, teeth, tongue, lips and dentures. When hospitalised, and if patients are unable to undertake mouth care for themselves, it is the role of those who care for them to assist with this activity. There is recognition that assistance and encouragement with effective and daily mouth care can prevent deterioration in a patient's oral health (HEE, 2017).
Nurses provide or supervise the personal care of patients in hospital (Dolce, 2014). Oral health care is a vital part of this care provision and therefore it is essential that this is highlighted as an important part of nurse education. All nursing staff who provide personal care need a firm foundation in oral care and must be aware of the necessity of looking after people's oral health (Dolce et al, 2012; Grønkjær et al, 2017). However, from a global perspective, allied to a shortfall in health professionals, the Fédération Dentaire Internationale (FDI) (World Dental Federation) (2015) suggested that interprofessional education around oral health care is valuable. Interprofessional education enables students to learn with and from other professionals, which will have an impact on collaborative practice in the workplace. Binks et al (2017) noted that healthcare assistants, who often provide the majority of the mouth care to hospital inpatients in England, often receive no training in oral care. The Care Quality Commission (2019) advised that the curriculum for the Care Certificate released in 2014 by HEE, Skills for Care and Skills for Health (HEE et al, 2014), setting out standards for healthcare assistants, regardless of setting, did not directly include mouth care. This oversight suggests that oral health is not being fully considered as an essential part of patient care.
Improving oral health
OHID et al (2021) have created an evidence-based toolkit entitled Delivering Better Oral Health aimed at preventing oral disease and improving oral health. Since its first edition in 2007, this guidance has been used and referenced by dental and other health professionals across the fields of health and social care, both within the UK and beyond (OHID et al, 2021). The toolkit underpins the important role of health professionals as champions in promoting oral health and preventing oral disease as a fundamental pillar of contemporary healthcare. Although this is the only best practice guidance and toolkit endorsed by the OHID and is accessible to all health and care professionals, there is no evidence to demonstrate if this guidance is being used by professionals responsible for inpatient care or if this is having any impact on oral health care for patients while in hospital.
HEE (2017) saw the need to standardise the delivery of oral health care practices in hospitals in recognition of a need to improve oral health care while acknowledging the wider benefits to general health and wellbeing. Allied to the call for education of the healthcare workforce, ‘Mouth Care Matters’, an HEE-funded pilot project, aimed to improve the oral health of hospitalised adults (HEE, 2017) by creating a more responsive healthcare team. The project aimed to promote personalised care for patients, and bring an increased awareness of the importance of good mouth care. The Mouth Care Matters programme was launched as a pilot and had relevance for all staff providing personal care in acute, community or care home settings and included a range of resources, training and a toolkit. The toolkit was not only intended for nursing staff in hospitals, but also for other health professionals, including doctors, speech and language therapists, dietitians, occupational therapists and pharmacists. The initiative aimed to improve skills and empower nurses and allied health professionals to support vulnerable patients with mouth care through the provision of education and training and signposting to other services, and to ensure mouth care is delivered in a safe and compassionate way (HEE, 2017).
HEE noted that the project saw an improvement in the standards of mouth care but that there was more to do. The pilot closed in February 2020 (HEE, 2020) but a range of resources remain available on the Mouth Care Matters website (https://mouthcarematters.hee.nhs.uk) and the e-learning forms part of the HEE and e-Learning for Health platform (HEE, 2022a). There is evidence to suggest that a level of engagement has continued since the closure of the programme through access to the Mouth Care Matters e-learning (HEE, 2022b). Engagement levels vary between regions and within disciplines. Although the programme demonstrated some success, there is limited evidence to suggest whether the training is having an ongoing impact on the care received by inpatient service users.
Clinton et al (2023) recently evaluated current practice among Sussex Community NHS Foundation Trust staff involved with inpatient care in the Trust's bedded units, and their use and understanding of the Mouth Care Matters guidance. The evaluation found that both the oral health care given to patients and record keeping would benefit from improvements, further supporting the need for ongoing engagement with education. This research found that there is a need for engagement with organised education and it is vital that the momentum to drive improvement in oral health care is continued.
Providing good mouth care
Health and care staff with caring responsibilities in hospital or social care require knowledge of the links between oral health and general health and wellbeing, and to know how to carry out oral health risk assessments and implement good practice as part of a wider care plan. It is essential that health staff embrace the principles of good oral care and that they can access the tools needed to provide effective mouth care such as toothbrushes, toothpaste and denture pots, and have easy access to dry mouth products. They also need to know how to refer patients for support when necessary from doctors, dentists, dental care professionals and others such as hospital mouth care leads (Doshi, 2019).
Good mouth care support when people are in hospital can reduce the risk of infection and improve the experience for inpatients. Self-care is promoted as the first course of action where possible and appropriate. This may involve nursing staff asking the patient if they require any support with their daily mouth care routine or providing dental health resources to enable them to look after their own teeth or care for prosthetics such as dentures. It is good practice to distinguish between independent and dependent patients and undertake an oral health risk assessment and record this as part of a care plan (Doshi and Tomlinson, 2019). This will help to identify specific oral health needs and manage any potential risks relating to oral health. Daily mouth care is particularly important for people who are in hospital for long periods, to prevent deterioration in their oral health (HEE, 2017).
The first step in good practice interventions would be to check if patients have mouth-care products with them (toothbrush, toothpaste and denture products if necessary), to ask if people have any oral problems and to look out for signs of oral problems such as a patient not eating, rubbing or tugging at their face or having a swollen face. After asking for the patient's consent, the next step would be to look into the patient's mouth using a light source to check for any obvious signs of disease or discomfort, to record the findings and, finally, to assess the level of support the patient will need with their daily mouth care. It is good practice to provide assistance with toothbrushing and associated mouth care, particularly for dependent patients; however, it is important that only appropriately trained staff undertake this. If there are serious concerns about mouth care or oral problems, speaking to senior nurses or the medical team would be necessary, alongside signposting or referring to dental services.
There is a current focus on promoting health and preventing ill health through evidence-based advice and supporting behaviour change across the life course with the implementation of the All Our Health framework. This includes oral health and is aligned to the Mouth Care Matters programme (OHID, 2019). Promotion of self-care is always at the forefront; however, it is essential that health and care professionals provide direct support when appropriate while promoting consistent evidence-based oral health messages.
All health and social care professionals have a responsibility to support patients with their oral health care needs while in their care and this must be part of the wider care plan. It is recognised that hospitalisation is associated with a deterioration of dental health in patients and may be due to a decline in the quality of self-care prior to being admitted to hospital or due to lack of oral hygiene provision while there. Evidence-based best practice guidance for mouth care is available and over 100 provider trusts in the UK have been engaged in the Mouth Care Matters programme (Doshi, 2019).
Conclusion
Although best practice guidance including Delivering Better Oral Health exists (OHID et al, 2021), there is currently limited evidence on whether this is being used by health professionals and implemented consistently across inpatient care. This indicates that further research in this area would be beneficial in order to establish a greater understanding of the level of oral health care provided for inpatients and the impact that this guidance is having on the wider health and care workforce. It is clear that a level of engagement in the Mouth Care Matters training continues through the e-learning platform; however, exact numbers are unavailable. The impact this is having on day-to-day care for patients in hospital and other health and care sectors remains unclear.
Health and social care professionals generally recognise the importance of good oral health; however, good practice should be embedded in education and be given a strong focus through hospital and care home leadership to ensure effective oral care practices are implemented consistently across all healthcare settings. Further research and investigation into the important but neglected area of mouth care for those requiring inpatient care is required in addition to making it an important aspect of all health and care encounters.
KEY POINTS
- Adults and children in the UK are at risk of developing dental disease
- Oral hygiene and mouth care is an essential but neglected part of patient care in some areas
- Education and training around the importance of mouth care is inconsistent across the health and social care sector
- High-quality mouth care, provided by health and social care staff if necessary, is essential for patients' health and sense of wellbeing
CPD reflective questions
- Consider the impact poor oral health can have on a person's general health and reflect on whether mouth care is a standard part of care for all patients in your clinical area
- Reflect upon a patient you have cared for and assess if their mouth care needs were met
- Were you and other staff in your clinical area trained in how to offer mouth care to the patients you care for? Investigate what training in oral care is available for staff
- Are staff in your clinical area aware of who to refer to if a patient has a particular problem with their oral health?
- Reflect on how you might offer mouth care to the next patient you encounter