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Oral health for adults in care homes

About

What is covered

This interactive flowchart covers oral health, including dental health and daily mouth care, for adults in care homes. The aim is to maintain and improve their oral health and ensure timely access to dental treatment. It includes recommendations on:
  • availability of local oral health services
  • oral health promotion services
  • general dental practices and community dental services
  • care home policies on oral health and providing residents with support to access dental services
  • oral health assessment and mouth care plans
  • daily mouth care
  • care staff knowledge and skills.
The recommendations should be considered alongside the advice in Public Health England's Delivering better oral health toolkit.
NICE and The Social Care Institute for Excellence have co-produced Improving oral health for adults in care homes: A quick guide for care home managers.

Updates

Updates to this interactive flowchart

6 June 2017 Oral health for adults in care homes (NICE quality standard 151) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on maintaining and improving the oral health of adults in care homes in an interactive flowchart

What is covered

This interactive flowchart covers oral health, including dental health and daily mouth care, for adults in care homes. The aim is to maintain and improve their oral health and ensure timely access to dental treatment. It includes recommendations on:
  • availability of local oral health services
  • oral health promotion services
  • general dental practices and community dental services
  • care home policies on oral health and providing residents with support to access dental services
  • oral health assessment and mouth care plans
  • daily mouth care
  • care staff knowledge and skills.
The recommendations should be considered alongside the advice in Public Health England's Delivering better oral health toolkit.
NICE and The Social Care Institute for Excellence have co-produced Improving oral health for adults in care homes: A quick guide for care home managers.

Updates

Updates to this interactive flowchart

6 June 2017 Oral health for adults in care homes (NICE quality standard 151) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Oral health for adults in care homes (2016) NICE guideline NG48
Oral health for adults in care homes quality standard (2017) NICE quality standard 151

Quality standards

Oral health for adults in care homes

These quality statements are taken from the oral health for adults in care homes quality standard. The quality standard defines clinical best practice for oral health for adults in care homes and should be read in full.
1Oral health assessment in care homes
2Recording mouth care needs in care plans
3Supporting daily mouth care in care homes

Quality statements

Oral health assessment in care homes

This quality statement is taken from the oral health for adults in care homes quality standard. The quality standard defines clinical best practice for oral health for adults in care homes and should be read in full.

Quality statement

Adults who move into a care home have their mouth care needs assessed on admission.

Rationale

Self-care can deteriorate before a person moves into a care home, so they may be admitted with poor oral health. Mouth care needs may not be visible and can be missed if they are not specifically assessed. It is important that mouth care needs are assessed as soon as possible when someone moves into a care home, so that tailored care can start straight away.

Quality measures

Structure
Evidence of local arrangements to ensure that adults have their mouth care needs assessed on admission.
Data source: Local data collection, for example, mouth care policies.
Process
Proportion of adults living in a care home who had their mouth care needs assessed on admission.
Numerator – the number in the denominator who had their mouth care needs assessed on admission.
Denominator – the number of adults living in a care home.
Data source: Local data collection, for example, audits of personal care plans.
Outcome
a) Satisfaction of resident or carer with the care home admission process.
Data source: Local data collection, for example, comments, feedback or surveys from residents and carers.
b) Satisfaction of resident or carer with the mouth care they receive.
Data source: Local data collection, for example, comments, feedback or surveys from residents and carers.

What the quality statement means for different audiences

Service providers (care homes) ensure that the mouth care needs of adults are assessed on admission to a care home. They ensure that care staff are trained to understand mouth care needs and carry out the assessment, and that they are aware of signs of dental ill health, for example tooth decay, abscesses, dry mouth and gum disease.
Health and social care practitioners (care staff in care homes) assess the mouth care needs of adults on admission to a care home and are aware of signs of dental ill health, for example tooth decay, abscesses, dry mouth and gum disease.
Commissioners (commissioners of care home services) ensure that care homes assess the mouth care needs of adults on admission. They should also ensure that care home services train care staff to understand mouth care needs and carry out the assessment, and that they are aware of signs of dental ill health, for example tooth decay, abscesses, dry mouth and gum disease.
Adults moving into care homes have a check to find out if they need help with their daily dental and mouth care when they move in. They (or their family members or carers if appropriate) are asked if they need help with brushing their teeth and looking after their dentures. Care staff also record details of the person’s dentist and their last appointment, or help them to find a dentist if they don’t have one. They also check if the person wants their dentures marked with their name.

Source guidance

Oral health for adults in care homes (2016) NICE guideline NG48, recommendation 1.2.1

Definitions of terms used in this quality statement

Assessment of mouth care needs
This should include establishing:
  • How the resident usually manages their daily mouth care (for example, toothbrushing and type of toothbrush, removing and caring for dentures including partial dentures). Check whether they need support.
  • If they have dentures, including partial dentures, whether they are marked or unmarked. If unmarked, ask whether they would like to arrange for marking and offer to help.
  • If the resident is experiencing any dental pain.
  • The name and address of their dentist or any dental service they have had contact with, and where and how long ago they saw a dentist or received dental treatment. Record if there has been no contact or they do not have a dentist, and help them find one.
Care homes can consider using an assessment tool, for example the Australian Institute of Health and Welfare’s Oral health assessment tool, to help with carrying out mouth care needs assessments.
The timing of regular follow-up mouth care assessments can be agreed with the resident during the initial assessment because this will vary depending on need. Some people may not need support on admission. This should be monitored so that support can be offered if their requirements change.
Staff in care homes can carry out mouth care needs assessments, however full oral health care assessments should be carried out by dental professionals.
[NICE’s guideline on oral health for adults in care homes, recommendation 1.2.1 and expert opinion]
On admission
The mouth care needs assessment should be completed as part of the admission process, or at least within a week of the person being admitted (sooner for people admitted for a short stay).
[NICE’s guideline on oral health for adults in care homes, the committee’s discussion]

Equality and diversity considerations

Adults with dementia and other cognitive difficulties may not be able to communicate their mouth care needs. When family and friends are involved in ongoing care, care staff should consider involving them in the assessment, with the resident’s permission, if it will help staff understand the resident’s usual mouth care routine. Some adults may have lost contact with family or friends, and care staff should make sure they establish the mouth care needs of these adults by carrying out the assessment.

Recording mouth care needs in care plans

This quality statement is taken from the oral health for adults in care homes quality standard. The quality standard defines clinical best practice for oral health for adults in care homes and should be read in full.

Quality statement

Adults living in care homes have their mouth care needs recorded in their personal care plan.

Rationale

Mouth care needs and the plan of support to address these needs should be recorded in the personal care plan for adults living in care homes. This will help to make sure that action is taken to meet the person’s needs, and that their needs are regularly reviewed and updated.

Quality measures

Structure
Evidence of local arrangements for adults living in care homes to have their mouth care needs recorded in their personal care plan.
Data source: Local data collection, for example, mouth care policies.
Process
Proportion of adults living in a care home who have their mouth care needs recorded in their personal care plan.
Numerator – the number in the denominator who have their mouth care needs recorded in their personal care plan.
Denominator – the number of adults living in a care home.
Data source: Local data collection, including audits of personal care plans.
Outcome
Care staff awareness of individual residents’ mouth care needs.
Data source: Local data collection, for example, staff interviews and surveys.

What the quality statement means for different audiences

Service providers (care homes) ensure that adults living in care homes have their mouth care needs recorded in their personal care plan, which is regularly reviewed and updated.
Health and social care practitioners (care staff in care homes) record the mouth care needs of adults living in care homes in their personal care plans. Practitioners regularly review the personal care plan and update it when mouth care needs change.
Commissioners (commissioners of care home services) ensure that care homes record adults’ mouth care needs in their personal care plan, which is regularly reviewed and updated.
Adults living in care homes have a record of any help and support they need with their mouth care included in their written care plan. The care plan will be reviewed and updated if the support they need changes.

Source guidance

Oral health for adults in care homes (2016) NICE guideline NG48, recommendation 1.2.4

Supporting daily mouth care in care homes

This quality statement is taken from the oral health for adults in care homes quality standard. The quality standard defines clinical best practice for oral health for adults in care homes and should be read in full.

Quality statement

Adults living in care homes are supported to clean their teeth twice a day and to carry out daily care for their dentures.

Rationale

For good oral health, adults with natural teeth should brush them with fluoride toothpaste twice a day and adults with full dentures should carry out daily care, such as brushing, removing food debris and removing dentures overnight. Adults with both natural teeth and partial dentures should do both. Good oral health is important to maintain self-esteem, dignity and quality of life. Adults with poor oral health often have problems with eating, speaking and socialising.

Quality measures

Structure
Evidence of local arrangements for adults living in care homes to be supported to clean their teeth twice a day and carry out daily care for dentures.
Data source: Local data collection, for example, mouth care policies.
Process
Proportion of adults in a care home who are supported with daily mouth care.
Numerator – the number in the denominator who are supported with daily mouth care.
Denominator – the number of adults living in a care home.
Data source: Local data collection, for example, audits of personal care plans.
Outcome
Oral health-related quality of life for adults living in care homes.
Data source: Local data collection. Oral health-related quality of life can be established for some groups of residents using an Oral Health Impact Profile.

What the quality statement means for different audiences

Service providers (care homes) ensure that adults living in care homes are supported with daily mouth care, including cleaning their teeth twice a day and undertaking daily care for dentures, if support is needed. They ensure that care staff are trained to offer this support.
Health and social care practitioners (care staff in care homes) support adults living in care homes with daily mouth care, including cleaning their teeth twice a day and undertaking daily care for dentures, if support is needed. This may involve carrying out daily mouth care for residents who are unable to do this for themselves.
Commissioners (commissioners of care home services) ensure that care homes provide support with daily mouth care, if needed. They should also ensure that care staff are trained to offer this support.
Adults living in care homes who need help with mouth care are supported to brush their teeth twice a day, if they have their own teeth, and to care for their dentures every day, including cleaning and removing them overnight.

Source guidance

Oral health for adults in care homes (2016) NICE guideline NG48, recommendation 1.3.1

Definitions of terms used in this quality statement

Support to clean teeth and carry out denture care
This is the help that some people may need to carry out these tasks. This could include, but is not limited to:
  • brushing natural teeth at least twice a day with fluoride toothpaste
  • providing daily oral care for full or partial dentures (such as brushing, removing food debris and removing dentures overnight)
  • using their choice of appropriate cleaning products for dentures if possible
  • using their choice of toothbrush, either manual or electric/battery powered
  • daily use of mouth care products prescribed by dental clinicians (for example, this may include a high fluoride toothpaste or a prescribed mouth rinse)
  • daily use of any over-the-counter products preferred by residents if possible, such as particular mouth rinses or toothpastes; if the resident uses sugar-free gum, consider gum containing xylitol.
Some people may not need support to clean their teeth or dentures. This should be monitored so that support can be offered if their requirements change.
[NICE’s guideline on oral health for adults in care homes, recommendation 1.3.1 and expert opinion]

Equality and diversity considerations

Care home managers should make sure care staff know what to do if a resident declines support with mouth care, in line with the Mental Capacity Act and local policies about refusal of care (see also NICE’s information on your care). People should not be forced to receive mouth care against their wishes. However, repeated refusal should not be ignored and some people may need additional support to feel comfortable receiving mouth care.
Reasonable adjustments should be made, in line with the Equality Act, to ensure that people with disabilities can receive the mouth care which is most suitable for them.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:
Oral health for adults in care homes
Oral health for adults in care homes quality standard

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Glossary

24-hour accommodation with either non-nursing care (for example, a residential home) or nursing care
24-hour accommodation with either non-nursing care (for example, a residential home) or nursing care
activities such as removing and cleaning dentures, toothbrushing and use of fluoride toothpaste
all adults aged 18 years upwards who live in care homes
all adults aged 18 years upwards who live in care homes

Paths in this pathway

Pathway created: July 2016 Last updated: September 2018

© NICE 2018. All rights reserved. Subject to Notice of rights.

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