The third process in helping to improve an older person's oral health is putting the oral health care plan into action by supporting the delivery of daily oral care.

Nurses and care workers play a key role in encouraging older people to maintain good oral health. Effective daily oral care is one of the best ways of managing and/or preventing oral health problems.

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.

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 (7MB PDF) 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 (200KB PDF) 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 that 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 the 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, the 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 them 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.

• Therapeutic guidelines state dry storage for dentures is best practice overnight, 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 toothbrush on gums, tongue and teeth

• A soft toothbrush 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 the antibacterial products 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 an 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 or 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 (excessive intake of xylitol products can have a laxative effect).

Older people, especially those suffering from 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's 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.

• 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 diseases 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 oral health by causing dry mouth (xerostomia). Drug classes that 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 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.