Dental care for older people, particularly if in residential or nursing home care has special needs.

This page is written in response to a couple who have an elderly relative in residential care. From their perspective the day to day oral care she receives is very poor. This page is written as an attempt to create a resource that will be able to be downloaded, so as it evolves, there will be points on the page where PDFs can be downloaded and printed as a teaching aid.

Our Practice has always provided care for those less fortunate than ourselves and domiciliary and special needs dentistry have been taken in our stride.

We believe we can spot a good residential home from a poor one the moment we walk in the door, but dental care in even the best is often lacking.

As we get older and start to decline, the conditions we suffer with change. As time takes its toll we suffer in both our general health and our dental health. The two inter-relate, so that a decline in our general health can affect our dental heath needs and a change in our oral health can seriously affect our general health.

The importance of any particular tooth is inversely proportional to the number of teeth in the mouth. If you've got 32 and you lose one, it doesn't really matter. Imagine you've got just three teeth left and they're holding your denture in. If you lose one it can be a total catastrophe. More and more people are surviving to old age with their teeth. It's actually a problem because dementia can take a terrible toll on the dentition. particularly if it's been heavily restored.

From a Care Quality Commission perspective, if you can't wear your dentures you lose your dignity and nutrition becomes a major problem. From a personal perspective, there comes a tipping point where if you have your own teeth, you've got to try and keep them forever. Starting to wear a denture when you're old is difficult - remember the old adage - "you can't teach an old dog new tricks".

TOOLKIT

Gloves - a message to managers of residential and nursing homes - don't expect anyone to look after someone's mouth or dentures without gloves. Mouths are horrible places. Saliva is horrible. And it's potentially full of infection. So, buy your staff gloves and expect them to wear them. we wouldn't put our hands in anyone's mouth without gloves, so why should anyone else?

Mouthcare recording sheet - someone needs to take ownership of mouth care if a patient (client, end user, human being) isn't capable of their own dental care. But how do we know if the client's mouth and/or dentures has been cleaned or not? The sensible thing to do is document it. Here's a downloadable sheet for recording.

Types of toothbrush to use - one of the major things to decline in all of us is dexterity. Indeed, some of us weren't very dextrous to start with! Trying to wield a toothbrush around your own mouth accurately is difficult for many, but add into the mix arthritis or a stroke and it can be all but impossible. I'll admit to being a dinosaur when it comes to toothbrushes. I used a manual brush - a Sensodyne Search 3.5 until recently and have had to move over to an electric brush due to loss of my own dexterity (don't worry, I only administrate these days!) If there ever was a case for an electric toothbrush, it's for people who lose their dexterity. Brushing for two or three minutes when your hands are painful or weak isn't a recipe for success. There comes a point when brushing your own teeth is all but impossible and someone else needs to lend a hand. Trying to brush someone else's teeth with a manual brush is very difficult - so again an electric brush is appropriate.

But which one? 

There are two basic brands we'd choose from and eliminate the rest  - Oral B Braun and Philips Sonicare. The Braun Oral B range are the ones with the round head that turns through a quarter turn back and forth. The Sonicare is a sonic design, where most of the work is done with high frequency sound and the brush just glides gently across the tooth surface. Whichever you may choose, you need to be trained how to use it by a dental hygienist or dentist.

OK, so which one should I use?

Firstly, it must be a rechargeable, not battery driven. Ordinary, disposable batteries fail slowly and don't get replaced on time. Secondly, the type of brush needs to be selected in conjunction with a dentist or hygirnist. Everyone's needs are different. Now, I have to admit I get cheesed off with Oral B Braun's marketing strategy. They're forever changing their range and "slashing prices" like a sofa store. Their range at present goes from dirt cheap to silly money like the Sonicares. Realistically, everyone should have their own unit, not sharing one with different heads. We'd individually name the units so that they're uniquely identifiable - there WILL be transmission of infection via the handle if it's shared. So this influences choice of unit, to be able to afford each person with teeth their own unit. you may choose a mid range brush with a timer on it. It's important to be able to time the brushing as we all brush for too little time unless timed. Once we get beyond buying the brush, it's mostly about technique.

Where do I buy my brush?

Try Argos, Amazon, Sainsburys, eBay and so on. The sheer bulk that these companies can buy in gives them better deals than we can ever match. (I just checked eBay and they had the better Braun Oral Bs for £50 - If you pay much more than this, you've been robbed!)

Types of toothpaste to use  - bear in mind that big brands may vary in their theoretical quality, but in practice they're much of a muchness. Pick a brand where the flavour is preferred. Not too strong in flavour because it makes the teeth feel temporarily clean even if they're not. Strong flavours can be unpleasant if you've got thin, tender skin in your mouth - and old people often do.

Standard toothpaste - there were 20 types of Colgate toothpaste in Sainsburys when last checked. There can't possibly be the need for twenty types of one brand of toothpaste. So I asked on the Colgate stand at a trade show which Colgate our patients should use - Total was the answer. I suppose that means the other 19 types are marketing hype. We all have to make a living! Buy a big brand, any big brand but make sure the flavour isn't too strong. 

More dentists use Colgate than any other brand for a reason - they give us more samples than anyone else and we like the mild flavour.

Dry mouth toothpaste - if you have a dry mouth there's only one sensible answer - Biotene. The Biotene system leaves a pleasantly wet surface on the skin of the mouth. There are no cultural or religious issues with it, unlike some artificial salivas and best of all it isn't horrible like some remedies. Beware of the old trick of adding lemon to water to try to stimulate saliva flow. The acidity dissolves the teeth and there's no saliva to repair them - so it's a quick route to destroying the dentition. Biotene can be bought over the counter from good pharmacists and it's also available on prescription from doctors, so it can be provided free! We have a page about dry mouth and the causes - follow this link to the page

Sensitive toothpaste - several different brands, but sensitive teeth are less common in this stage of life. The pulp (nerve) in teeth gets smaller with age. As the pulp retreats into the teeth, straighforward sensitivity gets rarer with age. If sensitivity becomes a problem, then the first port of call is the dentist. Get the teeth checked - there may well be a cavity lurking.

High Fluoride toothpaste - really handy in cases of high decay rate. Available on prescription from your dentist (or feasibly your GP). We can prescribe at two strengths - 5000ppm and 2800ppm.  I can't mention the brand here because of restrictions on advertising of Prescription only Medicines.
Using a high fluoride paste has to be done with guidance from a dentist. The aim is to repair the tooth surface faster than it can be destroyed and create what is in effect a tough eggshell on the tooth.

Dry mouth - so much medication causes a dry mouth - and so much of it is prescribed to older people. Follow this link to our information about dry mouth.

Sponge swabs - on rare occasions the appropriate way to moisten a patient's mouth is using a sponge on a stick. However, they do have problems. The Medicines and Healthcare Regularity Authority (MHRA) issued a warning in April 2012 to beware that the sponge can separate when in the patient's mouth - sadly a patient had died from choking. The MHRA warning notice can be downloaded here

Marking of dentures - We've all heard the anecdotes about the carer/nurse who scoops up a load of dentures and throws them in a bowl to clean. Undoubtedly most of it is urban legend but we've seen dentures get mixed up. We've also seen dentures mislaid, either around the home or into the laundry. So being able to trace the denture if it goes walkabout is a very sensible idea. Denture marking kits are available which consist of a marker pen and a varnish to cover it. The problem is the varnish and the marker pen wear off. The method we prefer is to use a soft metal strip marked with the wearer's name. The strip is written on with a ballpoint pen, which imprints into the metal. This is inlaid into the denture under clear acrylic. It's fitted on the shiny side of the denture (the bit that faces away from the skin) and towards the rear of the denture. It can be inlaid when the denture is made, but can also be added as a later addition - this involves sending the denture to a denture laboratory. The method in placing the metal marking strip at the back of the denture is partly to hide it, but mainly in case of fire.

The victims of the Flixborough disaster were identified in Sheffield where Mike trained back in the dark ages. Two of the victims wore full dentures (this is pre DNA identification) and couldn't be identified by normal dental records. Fortunately, and despite the intensity of the fire the rear half of their dentures had survived and because their identities were known, their dentists could be traced. As a profession, we can spot our own work by subtleties in style, so identification was possible with the portion of denture saved. Imagine how much easier it would have been if the dentures had metal marking strips towards the rear. Also imagine the nightmare of a residential home burning down and lots of denture wearers having to be told apart. Better safe than sorry.

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© Hesslewood Lodge Dental Practice, 16/11/2015