Oral care, loss of personal identity and dignity in residential care homes.

OBJECTIVE: The UK National Institute of Clinical Excellence (NICE) guidelines recommend that care staff who provide daily personal care to residents: "Understand the importance of residents' oral health and the potential effect on their general health, well-being and dignity." The aim of this study was to explore residents' views and perspectives of dental care in care homes in order to understand how to deliver this care. METHOD: Care homes were identified using care home inspection reports for Wales, the UK. Care homes for older people with residents having mental capacity to consent were invited to participate. Data were collected using semi-structured one-to-one interviews with care home residents, care home managers and oral healthcare leads. Interviews were audio recorded, transcribed and analysed using a thematic approach to data. Analysis was assisted by NVivo 10 software. Data collection was completed when no new themes emerged. RESULTS: This analysis presents findings from 26 interviews with residents, across five care homes. Going into care was associated with a loss of identity. Having teeth and looking after teeth (natural teeth or dentures) was part of keeping that identity. All prioritised privacy, pride and independence above effective oral hygiene. Oral hygiene was viewed as a very private event. Carers adapted oral care, to balance time constraints, care, privacy and dignity. Teeth were a part of personal pride to the extent that two residents said they did not want to die without dentures in their mouths. CONCLUSION: Whilst oral care is important to residents, dignity and privacy are often more important; care routines and practices are adapted around this. Carers need to adopt an individualised, pragmatic and sensitive approach to oral care to account for personal dignity when looking after residents to be able to provide appropriate oral care in accordance with guidance. Members of the dental team need to support carers to provide effective oral care, which allows dignified and effective care.

Professional consensus on orthodontic risks: What orthodontists should tell their patients.

INTRODUCTION: Effective communication of risk is a requisite for valid consent, shared decision-making, and the provision of person-centered care. No agreed standard for the content of discussions with patients about the risks of orthodontic treatment exists. This study aimed to produce a professional consensus recommendation about the risks that should be discussed with patients as part of consent for orthodontic treatment. METHODS: A serial cross-sectional survey design using a modified electronic Delphi technique was used. Two survey rounds were conducted nationally in the United Kingdom using a custom-made online system. The risks used as the prespecified items scored in the Delphi exercise were identified through a structured literature review. Orthodontists scored treatment risks on a 1-9 scale (1 = not important, 9 = critical to discuss with patients). The consensus that a risk should be discussed as part of consent was predefined as ≥70% orthodontists scoring risk as 7-9 and <15% scoring 1-3. RESULTS: The electronic Delphi was completed by 237 orthodontists who reached a professional consensus that 10 risks should be discussed as part of consent for orthodontic treatment; demineralization, relapse, resorption, pain, gingivitis, ulceration, appliances breaking, failed tooth movements, treatment duration, and consequences of no treatment. CONCLUSIONS: A professional orthodontic consensus has been reached that 10 key risks should be discussed with patients as part of consent for orthodontic treatment. The information in this evidence base should be tailored to patients' individual needs and delivered as part of a continuing risk communication process.

Family and friends: Supporting oral care in care homes.

OBJECTIVE: To consider the role of family and friends in supporting oral care. BACKGROUND: People who live in care homes are susceptible to oral health problems, which can be detrimental to their health and personal and social well-being. External support from family members and friends has been indicated as being important for maintaining oral health for this vulnerable group of care home residents. MATERIALS AND METHODS: Qualitative one-to-one interviews were undertaken with care home residents, in Cardiff, UK. Further interviews were undertaken with care home personnel with responsibility for oral health care in order to contextualise residents' interview data. Interviews were audio recorded, transcribed and analysed using a thematic approach. RESULTS: A total of 26 interviews were conducted with care home residents and four interviews with care home personnel, across five care homes. Three main themes emanated from the data relating to co-supporting oral care: supplying oral care products; accessing dental care and enabling self-management of oral care problems. There were no spouse caregivers; family and friends acted as co-supporters of oral care providing a link to residents' pre-care home lives by informing the care home personnel of their relatives' normal routines. An overarching theme "balancing roles - maintaining the equilibrium" emerged from the data reflecting the roles that both care home personnel and family and friends had in balancing the needs, care and well-being of the resident. CONCLUSION: This study suggests that there are opportunities to improve oral health by providing support for family and friends of those people who are living in care, especially in relation to supplying oral care products, enabling self-management of oral care problems and accessing dental care.

Dentist skill and setting to address dental treatment needs of care home residents in Wales.

OBJECTIVE: To explore the relationship between treatment plans, complexity anticipated in delivering those plans, and the special care dental skills and settings identified as appropriate. BACKGROUND: In older adults, many factors may complicate dental treatment including health and disability problems. Assessment of dental treatment needs amongst care home residents provides information about clinical care required and clinical experience needed for this population. MATERIAL AND METHODS: Analysis of dental data collected in a 2010 Welsh survey. Data analysed included treatment plan information, complexity assessment and dental expertise and settings required to deliver the treatment plans. RESULTS: The majority of participating residents needed simple dentistry, that is examinations, oral hygiene instruction, scaling of teeth, fillings, new dentures and fluoride application. Additional time was the commonest complexity factor. A large proportion of participants required dental treatment within a domiciliary setting. A similar proportion required care within a primary care setting (typically with care from a general dental practitioner) or a special care clinic (typically with care from a dentist with special care experience). Treatment plans involving specialists were more likely to be associated with poor general health, higher levels of interventional treatment and greater complexity. CONCLUSION: Most treatment need in care homes is basic restorative, periodontal and preventive care. Half of this could be managed by general dentists, some on a domiciliary basis and the rest in primary care dental clinics. The commonest complexity was additional time. More complex treatments were associated with care in clinics, skills in special care dentistry and multidisciplinary care.

Children's understandings and motivations surrounding novelty sweets: a qualitative study.

BACKGROUND: Novelty sweets resemble or can be used as toys, are brightly coloured, with striking imagery, and sold at pocket money prices. They encourage regular consumption as packaging can be resealed, leading to prolonged exposure of these high-sugar and low pH products to the oral tissues, risk factors for dental caries and erosion, respectively. AIM: To determine how children conceptualise novelty sweets and their motivations for buying and consuming them. DESIGN: Focus groups conducted using a brief schedule of open-ended questions, supported by novelty sweets used as prompts in the latter stages. Participants were school children (aged 9-10) from purposively selected state primary schools in Cardiff, UK. RESULTS: Key findings related to the routine nature of sweet eating; familiarity with and availability of novelty sweets; parental awareness and control; lack of awareness of health consequences; and the overall appeal of novelty sweets. CONCLUSIONS: Parents reported vagueness regarding consumption habits and permissiveness about any limits they set may have diluted the concept of treats. Flexible permissiveness to sweet buying applied to sweets of all kinds. Parents' reported lack of familiarity with novelty sweets combined with their low cost, easy availability, high sugar content, and acidity give cause for concern.

Gluten-free foods: a 'health halo' too far for oral health?

Background Over the past decade, the rise of consumers following a gluten-free diet has increased greatly. The majority of people following a gluten-free diet have not been diagnosed with coeliac disease or gluten or wheat intolerance but believe it to be a health benefit.Aim To assess the differences between gluten-free and gluten-containing products with regards to the implications this might have on oral (and wider) health.Method In total, 50 purposively selected products (25 gluten-free and gluten-containing pairs) available to UK consumers, classified using the UK National Diet and Nutrition Survey food categories, were analysed using content analysis of food packaging. The European Union front-of-pack labelling system revealed the nutritional composition of each product, focusing on carbohydrates, sugars and energy. Cost and use of emotive language to market products was also assessed.Results A nutritional comparison of the 25 product pairings found that, on average, all gluten-free products contained more calories, total carbohydrates and total sugar. The majority of the gluten-free products were classified as 'confectionary' or 'baked goods,' emphasising that products primarily consisted of foods high in sugar. The average sugar per 100 g for each category of food ranged from 2.5-37.0 g/100 g (gluten-free) compared to 2.1-30 g/100 g (gluten-containing). All gluten-free products were considerably more expensive when compared with the conventional version; the average price difference ranged from £0.08 to £4.40.Conclusion This study emphasises the 'health halo' phenomena, where foods for special diets are regarded by consumers as healthy when in fact they are not. This results partly from the products being mainly high-sugar 'treats', which are not a core of the UK Eatwell Guide food-based dietary guidelines. As many people consuming gluten-free products in the UK do not need them from a medical perspective, this could have implications for oral and wider health. It is important that members of the dental team are aware of the possible implications of a gluten-free diet where it is not medically indicated, coupled with reliance on convenience foods.

Gwên am Byth: a programme introduced to improve the oral health of older people living in care homes in Wales - from anecdote, through policy into action.

Introduction and context This paper describes how research and evidence influenced Welsh Government policy to fund a programme (Gwên am Byth - A Lasting Smile) with the aim of improving the oral health of older people living in care homes. It describes how collaborative multi-agency working supported development and delivery of the programme. The context was policy in Wales. This included the Welsh Government response to the public inquiry into Mid Staffordshire NHS Foundation Trust, the report into care homes by the Older People's Commissioner for Wales, and the Welsh Government Health and Care Standards for Wales which include a standard relating to oral health. The aim was to introduce a programme, Gwên am Byth, to support 'oral hygiene and mouth care for older people living in care homes through the development of a consistent all-Wales approach'; this aligns with contemporaneous NICE guidelines.Materials and methods Recurrent Welsh Government funding was identified to support a community dental service (CDS) led programme (Gwên am Byth). A multi-professional team led the development and testing of materials and resources to support the programme, underpin training for care home staff, and allow them to assess and provide safe mouth care for residents. A Welsh Health Circular was published to ensure a consistent all-Wales approachResults New staff have been employed in all health boards, and an assessment tool has been developed and is in the final stages of validation. All Wales resources have been published for induction, training and education, and to support care home staff. Evidence-based care plans have been produced which link to individual residents' risks and needs. There is close working with other health and social care professionals. By March 2019, half of all care homes were participating in the programme to a greater or lesser extent. Over 5,000 health and care staff had been trained, and over 5,600 residents had been assessed and supported with delivery of an individual mouth care plan. There has been positive feedback from care home staff, residents, carers and CDS staff, although barriers to delivery remain.Discussion This paper describes programme delivery in the four years since Gwên am Byth began. The drivers for change are described and the need to influence Welsh Government policy decisions when funding was available. The authors discuss issues which can impact on the pace of change, and ways in which health and care staff can effectively work together to implement improvements.Conclusions Starting with a blank page, a national programme has been established with the aim of improving the oral health of older people living in care homes in Wales. The paper describes the lessons learnt in implementing the programme and notes that Welsh Government has recognised the value of Gwên am Byth by committing to double the recurrent programme funding.

The top five selling UK energy drinks: implications for dental and general health.

Aim Energy drinks are widely consumed worldwide and are recognised for their adverse health effects, usually due to their high caffeine content. However, little is known about their impact on oral and general health. The aim of this investigation was to review the most popular energy drinks sold in the UK, for their possible effect on oral health and contribution to obesity. Materials and methods Five drinks representing 75% of the UK energy drinks market were purposively selected (Lucozade, Red Bull, Monster, Rockstar and Relentless). pH and sugar content were measured and their ingredients reviewed in the context of oral and general health, focusing on dental caries and erosion and obesity. Results All five energy drinks investigated had pH values below the critical value (5.5) associated with dental erosion; the lowest pH was 2.72 (Lucozade) and the highest was 3.37 (Monster). The drinks also contained excessive amounts of free sugars, ranging from 25.5 g (Red Bull) to 69.2 g (Rockstar). Differences in sugar content were mainly explained by portion size. Other ingredients contained within the energy drinks, caffeine and various acids, are also linked to oral and general health. Conclusion Regular consumption of energy drinks could contribute to dental erosion and the development of obesity. Lucozade and Rockstar were found to potentially have the greatest impact on oral health and obesity. Achieving a healthy product by reformulation is highly unlikely due to the very high initial free sugar content. Thus, health professionals need to acknowledge the popularity of these products and help their clients to reduce their use. This is the first study which compares in detail the potential oral and general health consequences of overuse of a selection of energy drinks popular in the UK.

The effect of dilution on the in vitro erosive potential of a range of dilutable fruit drinks.

BACKGROUND: Only one previous study has investigated the effect which dilution has on the erosive potential of dilutable fruit drinks. Based solely on measurement of neutralizable acidity, the authors concluded that the erosive potential of diluting juices may be reduced substantially by the addition of water. This has not been verified in an in vitro enamel erosion model. OBJECTIVE: The aim of this study was to examine the effect of dilution on the erosive potential of five dilutable fruit drinks. METHODS: For each product, the erosive potential of three dilutions (1 : 3, 1 : 6 and 1 : 15) was assessed by measuring the initial pH and neutralizable acidity; in vitro enamel erosion was measured by profilometry following immersion for 1 h. RESULTS: For the majority of products, increasing dilution from 1 : 3 to 1 : 15 produced a statistically significant rise in initial pH, though they remained markedly acidic. Increasing the dilution factor consistently produced a statistically significant decrease in neutralizable acidity. Increasing the dilution factor from 1 : 3 to 1 : 15 produced a statistically significant reduction in in vitro enamel erosion in only three of the five products tested. CONCLUSIONS: Increasing the dilution factor of dilutable fruit drinks within a range likely to be acceptable to the consumer may not effectively reduce their erosive potential.

Adolescent perceptions of orthodontic treatment risks and risk information: A qualitative study.

INTRODUCTION: For effective risk communication, clinicians must understand patients' values and beliefs in relation to the risks of treatment. This qualitative study aimed to explore adolescent perceptions of orthodontic treatment risks and risk information. METHODS: Five focus groups were carried out with 32 school/college pupils aged 12-18 in Wales, UK. Participants were purposively selected and had all experienced orthodontic treatment. A thematic approach was used for analysis and data collection was completed at the point of data saturation. RESULTS: Four themes emerged from the data; (a) day-to-day risks of orthodontic treatment, (b) important orthodontic risk information, (c) engaging with orthodontic risk information and (d) managing the risks of orthodontic treatment. Day-to-day risks of orthodontic treatment that were affecting participants "here and now" were of most concern. Information about preventing the risks of treatment was deemed to be important. Participants did not actively seek risk information but engaged passively with information from convenient sources. Perceptions of risk susceptibility influenced participants' management of the risks of orthodontic treatment. CONCLUSIONS: This study demonstrates that adolescent patients can understand information about the nature and severity of orthodontic treatment risks. However, adolescent patients can have false perceptions if the risks are unfamiliar, perceived only to have a future impact or if seen as easy to control. Adolescent patients must be provided with timely and easily accessible risk information and with practical solutions to prevent the risks of treatment. CLINICAL SIGNIFICANCE: The views and experiences gathered in this study can assist clinicians to better understand their young patients' beliefs about treatment risks, facilitate effective risk communication and contribute to improved patient-centred care.

Summary measures of caries prevalence to describe high-risk communities.

STUDY OBJECTIVE: This investigation compared the Significant Caries Index (SiC) with alternative summary measures of caries prevalence, designed to highlight high-risk communities and examined the implications of their use in health policy and planning in Wales. DESIGN: Data from the 2001 BASCD survey of 7,412, 12-year-old Welsh children were used in this analysis. As an alternative to the 33% cut-off value utilised in the SiC, the mean DMFT of children with the 10, 20 and 25% highest caries scores were calculated for 22 local health board areas, as was the mean DMFT for the whole population, %DMFT >0, and the mean for those with DMFT >0, >1, >2, and >3. SETTING: Examinations for the childhood epidemiology programme took place in Welsh secondary schools. PARTICIPANTS: 12-year-old children examined in the 2000/01 survey. MAIN RESULTS: The mean DMFT for the whole population was 1.31, and the mean DMFT of those with caries was 2.56. The mean DMFT for SiC 33%, 25%, 20% and 10% was: 3.39, 3.85, 4.28, and 5.31 respectively. When local health board areas were ranked according to mean DMFT score at different percentage cut-off points, variation in rank order was observed, the greatest difference in rank order being 6. Furthermore, when compared with summaries based on DMFT scores traditionally used in Wales, even greater rank differences were noted (up to 14 places). CONCLUSIONS: Rank order of geographical area is influenced by the definition of the index chosen when describing high risk populations using a variety of caries indices. This has implications for health policy planning and resource allocation.

A comparison of a computer-based questionnaire and personal interviews in determining oral health-related behaviours.

BACKGROUND: A major challenge for survey-based research is to reduce bias. In an interview, subjects may claim more favourable behaviour to please the interviewer or comply with accepted norms. OBJECTIVES: This study aimed to: (i) determine if adolescents give different answers when using a self-completed computer-administered oral health questionnaire compared with a personal interview, (ii) ascertain if responses to a face-to-face interview are dependant on whether a dentist or nonclinical researcher administered the questionnaire and (iii) examine if responses were influenced by whether they undertook the computer questionnaire first or second. METHODS: A randomized crossover design was used to investigate the responses to 15 closed questions on oral health-related practices. These were administered to 453, 12-year olds attending school dental inspections in South Wales. RESULTS: A total of 449 valid pairings of computer/interview responses were available for analysis. Responses to the questionnaire variables demonstrated good to very good levels of agreement (kappa 0.68-0.90) when comparing the face-to-face and computer-administered questionnaire. With the exception of questions on dental attendance, responses were not influenced by whether the questions were posed by the research officer or the dentist. A minimal order effect could be detected when undertaking the computer-administered questionnaire first. CONCLUSIONS: Whilst a study such as this cannot determine the true validity of the responses achieved, it is concluded that a computer-administered questionnaire, comprising closed questions, can be utilized to determine oral health-related behaviours in oral health surveys.

Mapping caries prevalence and water distribution in Wales-- Iechyd Morgannwg Health Authority as a case study.

STUDY OBJECTIVE: To investigate the use of mapping in targeting water fluoridation to areas of high need in lechyd Morgannwg Health Authority, as defined by the upper quintile of the distribution of the percentage with dmft > 0 in dental planning areas. DESIGN: Data from the 1997/98 childhood dental epidemiological survey and the Welsh Water Company water supply zones (as at 1997) were plotted. Maps were generated to identify the relationship between water supply areas, water supply sources and areas of high caries prevalence. SETTING: Maps focussed upon one Welsh health authority, Iechyd Morgannwg Health Authority. Examinations for the childhood epidemiology programme took place in schools. PARTICIPANTS: 5-year-old children examined in the 1997/98 survey. MAIN RESULTS: Data presented by very different geographical boundaries were compared without having to carry out complex mathematical transformations. It was possible to quickly identify areas of Iechyd Morgannwg Health Authority with high levels of oral disease, the associated water supply zones and their water treatment centres with a view to possible future targeting of fluoridation. The maps identify the possibility of dilution, when a particular water supply zone was served by more than one treatment works. CONCLUSIONS: This technique enables disparate and complex data bases to be combined enabling visual analysis of the results. The maps facilitate decision making as to the most beneficial areas to fluoridate. The results will be of value in determining the feasibility and targeting of water fluoridation in Wales.