Oral health care domain - Care of older people toolkit

Please refer to the following resources for more information: 

This domain was developed by the South Australian Dental Service.

Five facts everyone should know about oral health

  1. The risk of poor oral health increases when older people become less able to self-manage due to issues of functional dependence, physical frailty, medical co-morbidity, poly-pharmacy and cognitive impairment.
  2. Increasing numbers of older people are retaining at least some of their natural teeth. As their ability to self-manage oral hygiene decreases, their risk of oral disease and infection increases.
  3. Oral disease impacts on other areas of health and quality of life.
  4. Oral Health Assessment of older people on admission is essential for identification of issues and implementation of management strategies.
  5. Simple oral health strategies involving a multi-disciplinary approach can assist with promoting and maintaining good oral health.

Why is oral health care important for older people in hospital?

As the ageing population is increasingly retaining their natural teeth, their need for optimal oral health care also increases.

Older peoples’ mouths are prone to oral disease and those with natural teeth are more likely to have advanced gum disease (gingivitis or periodontitis).  Oral health care for older people is often further complicated by a past dental history including crown and bridge work, partial dentures and implants.

Oral health is linked to general health, and oral conditions involving teeth, gums and dentures can significantly affect overall well-being and the ability to age positively.

For example:

  • Oral pain and difficulty with eating can affect nutritional intake and body weight and therefore skin integrity, strength and mobility, and continence.
  • Oral pain may also affect mood and behaviour, especially for people with dementia who find it difficult to self report their pain and discomfort.
  • Poor oral health is linked to increased risk of cardiovascular disease, stroke and aspiration pneumonia. Aspiration pneumonia is a major cause of morbidity and mortality for hospitalised and institutionalised frail older people.
  • Chronic oral infection can complicate the medical management of general illnesses such as diabetes, chronic heart failure and respiratory diseases.
  • Poor oral health results in bad breath and affects people’s ability to speak, socialise and feel happy with their appearance.
  • Medications taken by older people often cause dry mouth (xerostomia) which affects speaking, eating and also increases the levels of oral bacteria and infection.

Oral health care may be overlooked by community-living patients with decreasing levels of cognition, health and mobility.  Cost and transport is also a factor affecting older people and their decisions around accessing dental treatment services.

As people age they tend to interact with a range of health workers more frequently than they do a dentist. For older people admitted to acute hospitals, oral health assessment and oral health care should be considered as an integral component of patient-centred care and a valuable opportunity to address these health issues.

Older people may have a range of health problems or disabilities that impact on their ability to care for their own oral health and may need assistance during their hospital stay as well as follow up care on discharge. This may be related to issues associated with cognitive impairment or functional limitations such as hand and upper limb function due to poor dexterity, pain and strength. It may also involve functional problems with mouth and tongue movements and swallowing.

What is oral health care?

Oral health care involves a multi-disciplinary approach and includes simple strategies to assess oral health and provide oral health care of the following:

  1. lips
  2. tongue
  3. gums and tissues
  4. saliva
  5. natural teeth
  6. dentures
  7. oral cleanliness
  8. dental pain.

How can I help older people to maintain good oral health in hospital?

Oral diseases and conditions are progressive and cumulative. If untreated they become more complex over time.

The following is a standard protective oral hygiene regimen for older people based on 6 of the best ways to maintain a healthy mouth.

Additional oral care management may be identified and prescribed by the doctor or dentist. For example: antifungal, antibiotic and pain medication.

An Occupational Therapy assessment may be required to facilitate the older person’s independence with oral hygiene tasks. This assessment will provide recommendations regarding the amount of personal assistance required and may suggest aids or adaptions such as enlarged handles or one handed techniques.

Six of the best ways to maintain a healthy mouth for older people:

1. Brush morning and night

  • Poor oral hygiene allows the bacteria in dental plaque to produce acids and other substances which damage teeth, gums and surrounding bone.
  • Dental plaque forms continuously and begins as an invisible film that sticks to all surfaces of the teeth and or dentures, gums and tongue. When it is not removed it hardens into calculus (tartar).
  • Brushing is the most effective and economical method of physically removing dental plaque from gums, tongue, teeth and or dentures.
  • Note that while oral swabs may be useful for applying therapeutic products they do not effectively remove plaque and food debris.

Natural teeth

  • Place the toothbrush at a 45% angle to the gum line.
  • Gently brush front, back and chewing surfaces of the teeth and gums in a circular motion. Give particular attention to the gum line.
  • If some teeth are missing make sure all surfaces of single teeth are cleaned.

Dentures

  • Older people who wear dentures are at risk of developing fungal infections.
  • Fungal infections can be attributed to wearing dentures at night, poor cleanliness of dentures, denture plaque, permeability of acrylic denture resin, diet and pre-existing general health factors such as diabetes.
  • Clean dentures with a denture brush and mild soap to remove plaque from all surfaces, then rinse well under running water.
  • Hold dentures carefully while brushing and clean them in a bowl of water placed in a sink, to protect from breakage if dropped.
  • Do not use fluoride toothpaste as it is abrasive and can damage the denture surface.
  • A scratched denture can be a source of irritation and increase the risk of oral infections.
  • Remember gums and tongue should also be brushed using a soft toothbrush to remove plaque.
  • Gum tissue needs time to rest from denture wearing.
  • Encourage the older person to remove dentures overnight.
  • Store cleaned dentures in cold water overnight in a denture container labelled with the person’s name.

2. Use fluoride toothpaste on teeth

  • Fluoride protects natural teeth by remineralising and strengthening tooth enamel.
  • For frail and dependent older people, high fluoride (5000ppm) toothpaste is recommended to therapeutically protect against tooth decay.
  • Use a pea-size amount of toothpaste when brushing teeth.
  • Encourage the older person to spit but not to rinse the mouth after brushing to allow the fluoride to effectively soak into the teeth.

3. Use a soft tooth brush on gums, tongue and teeth

  • A soft tooth brush is gentle on oral tissue and gums.
  • Regardless of whether an older person has teeth or dentures/partial dentures or has no teeth and chooses not to wear dentures, it is important to brush gums and tongue.
  • Bacteria on the tongue is linked to bad breath as well as aspiration pneumonia. Ask the person to stick out their tongue and carefully brush the tongue carefully from back to front.
  • Brushing the tongue can also improve an older person’s taste and hence enjoyment of food.
  • Following brushing, thoroughly rinse the toothbrush under running water, tap to remove excess water then store in a dry place.
  • As an infection control measure a toothbrush should be replaced:
  • when the bristles become shaggy
  • every three months
  • following an acute infection such as thrush or common cold.

4. Use antibacterial product after lunch

  • The long term application of a chlorhexidine product which is low strength (0.12%), alcohol free and non-teeth staining is recommended for frail and dependent older people to reduce harmful bacteria in the dental plaque and help to treat gum disease.
  • Avoid using chlorhexidine and toothpaste (containing sodium lauryl sulphate) within 2 hours of each other, as the product effectiveness is reduced.
  • For this reason after lunch is a good time to apply a daily pea-size amount of chlorhexidine to gums.

5.  Keep the mouth moist

  • Saliva has antibacterial properties. When the quantity and quality of saliva is reduced, oral disease can develop very quickly.
  • Dry mouth is also linked with increased risk of aspiration pneumonia.
  • Dry mouth is uncomfortable, unpleasant and can impair taste, chewing, swallowing and speech.
  • Note that some oral care products exacerbate dry mouth and damage oral tissue. Unless otherwise directed do not use mouthwashes or swabs containing:
  • alcohol
  • hydrogen peroxide
  • sodium bicarbonate
  • lemon and glycerine.
  • Keep the mouth moist by frequently rinsing or sipping water.
  • Keep lips moist by frequently applying a water-based moisturiser.
  • Discourage sipping of fruit juices, cordial or sugary drinks.
  • Try to reduce intake of caffeine drinks.
  • Stimulate saliva production with ‘tooth friendly’ lollies as required.
  • Use dry mouth products (saliva substitutes) as directed.
  • Seek a medical review of medications.

6. Cut down on sugar

  • Tooth decay is directly related to the frequency of sugar intake rather than the total amount of sugar eaten.
  • Encourage a drink of water after meals, after sugary drinks or snacks and after taking medications especially if they have been crushed and mixed with a sweetener. This helps to reduce the acid that causes tooth decay.
  • Meals or snacks containing milk or cheese also help reduce acid that causes tooth decay.
  • Encourage a selection of ‘tooth friendly’ alternatives in food, drinks and medications such as xylitol products.

Strategies for managing oral health care and changed behaviour

Older people, especially those suffering dementia or delirium, can behave in ways that are resistive to oral health care.

  • Changed behaviour includes:
  • fear of being touched
  • not opening the mouth
  • not understanding or responding to directions
  • biting the toothbrush
  • grabbing or hitting out.
  • Establish effective verbal and non-verbal communication:
  • speak clearly
  • adopt a caring attitude
  • choose the right environment
  • use appropriate body language, such as approaching the person from the diagonal front and at eye level.
  • Improve access to mouth by:
  • Overcoming fear of being touched by taking the time to build up a trusting relationship and using a gentle and staged approach to oral care.
  • Bridging - engage the person’s sense of touch and sight by showing them the toothbrush as well as mimic what you are going to do.
  • Chaining – with the person holding the toothbrush gently bring it up to their mouth, coach them through what they need to do and encourage them to take over.
  • Hand over hand – if chaining does not work then place your hand over theirs and brush the person’s teeth with them.
  • Distraction – if the hand over hand method is not successful, place another toothbrush or a familiar item such as a towel, cushion or activity board in the person hands while you proceed with brushing their teeth.
  • Rescuing – if distraction does not work and your relationship is deteriorating tell the person that you will leave what you are doing for now. Ask for help and have someone else attempt the care later.
  • Modified oral hygiene methods:
  • wipe high fluoride toothpaste onto teeth
  • mouth props
  • modified toothbrush techniques
  • use of a spray bottle.

Poor oral health will impact on other domains of functioning

Continence - Poor oral health affects food selection in particular the ability to chew foods with high fibre content. This can affect continence management.

Delirium - Chronic infection from poor oral health can compromise the immune system and contribute to a systemic inflammatory response. This in conjunction with oral pain can exacerbate a change in behaviour especially for older people with dementia.

Dementia - Older people with dementia are particularly at risk of developing complex oral disease and conditions. Dementia compromises their ability to reliably report their experience of oral health problems and dental pain. In addition, older people with dementia can sometimes behave in ways that make it difficult to provide oral health care.

Depression - Poor oral health may cause pain and discomfort, bad breath, impact on people’s ability to speak, sleep well, socialise and feel happy with their appearance.

Medication - Polypharmacy can impact on oral health by causing dry mouth (xerostomia). Drug classes which especially contribute to dry mouth are those with anticholinergic effects such as ACE inhibitors and diuretics. For further information contact the Therapeutic Advice and Information Service.

Mobility - As a consequence of poor oral health, nutritional status may suffer and have an impact on maintaining weight, muscle mass and strength.

Nutrition - Tooth loss, poorly fitting dentures and oral infections affect appetite, food enjoyment and ability to chew which impacts on food intake and food selection.

Skin integrity - As a consequence of poor oral health, nutritional status may suffer and have an impact on skin integrity and wound healing.

How can I recognise problems with oral health?

When assisting with an older person’s oral hygiene check for and report/follow up on signs of the following oral health conditions:

  • soreness and cracks at corners of the mouth
  • sore, swollen or inflamed or coated areas on the tongue
  • red swollen mouth
  • bad breath
  • dry oral tissues
  • saliva which is thick, stringy or rope like
  • swollen red gums that bleed easily when brushed
  • loose or broken teeth or exposed tooth roots
  • oral pain or tooth sensitivity
  • difficulty eating and or speaking
  • changed behaviour and refusing to open mouth
  • poor oral cleanliness and food left in mouth
  • chipped or broken teeth on denture
  • chipped or broken acrylic areas on the denture
  • bent or broken mental wires or clips on partial denture
  • check for a name on the denture.

What can I do if I recognise an older person has problems with oral health?

It is recommended that an appropriate health professional such as registered nurse or doctor perform an oral health assessment using the Oral Health Assessment Tool (OHAT) on admission and repeat as required

A ‘healthy’ or ‘changes’ assessment can be managed using the Oral Health Care Planning Guidelines.

An ‘unhealthy’ assessment indicates a referral to a dental professional is recommended. As most referrals are likely to be of a non-urgent nature, this information should be included in discharge planning advice and correspondence.

What care or management principles should I follow if an older person has an oral health problem?

Management principals should be based on a Model of Oral Health Care which integrates 4 key oral health processes into general care:

  1. oral health assessment
  2. oral health care planning
  3. assistance with daily oral hygiene
  4. referral for dental treatment.

What should I consider when discharge planning to help an older person maintain good oral care?

Based on the findings of the Oral Health Assessment, discharge planning advice to the General Practitioner should acknowledge the patient’s need for dental examination.  Options for dental treatment include both private and public pathways.

Further discharge planning may require Occupational Therapist or Dietitian follow up.

What can patients, families or carers do to help an older person maintain good oral health in hospital and at home?

For healthy teeth and gums follow these simple steps:

  • use a soft toothbrush
  • clean your teeth or dentures twice a day
  • use a fluoride toothpaste
  • drink water when you are thirsty
  • sip water if your mouth is dry
  • eat a healthy diet
  • avoid sweets and sugary drinks between meals
  • visit your dentist for a regular check up.