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.

Dental periodontal procedures: a systematic review of contamination (splatter, droplets and aerosol) in relation to COVID-19.

INTRODUCTION: The emergence of the SARS-CoV-2 virus and subsequent COVID-19 pandemic has had a significant effect on the delivery of routine dentistry; and in particular, periodontal care across the world. This systematic review examines the literature relating to splatter, droplet settle and aerosol for periodontal procedures and forms part of a wider body of research to understand the risk of contamination in relation to periodontal care procedures relevant to COVID-19. METHODS: A search of the literature was carried out using key terms and MeSH words relating to the review questions. Sources included Medline (OVID), Embase (OVID), Cochrane Central Register of Controlled Trials, Scopus, Web of Science and LILACS, ClinicalTrials.Gov . Studies meeting inclusion criteria were screened in duplicate and data extraction was carried out using a template. All studies were assessed for methodological quality and sensitivity. Narrative synthesis was undertaken. RESULTS: Fifty studies were included in the review with procedures including ultrasonic scaling (n = 44), air polishing (n = 4), prophylaxis (n = 2) and hand scaling (n = 3). Outcomes included bacterial (colony-forming units e.g. on settle plates) or blood contamination (e.g. visible splatter) and non bacterial, non blood (e.g. chemiluminescence or coloured dyes) contamination. All studies found contamination at all sites although the contamination associated with hand scaling was very low. Contamination was identified in all of the studies even where suction was used at baseline. Higher power settings created greater contamination. Distribution of contamination varied in relation to operator position and was found on the operator, patient and assistant with higher levels around the head of the operator and the mouth and chest of the patient. Settle was identified 30 min after treatments had finished but returned to background levels when measured at or after an hour. The evidence was generally low to medium quality and likely to underestimate contamination. CONCLUSION: Ultrasonic scaling, air polishing and prophylaxis procedures produce contamination (splatter, droplets and aerosol) in the presence of suction, with a small amount of evidence showing droplets taking between 30 min and 1 h to settle. Consideration should be given to infection control, areas of cleaning particularly around the patient and appropriate personal protective equipment, with particular attention to respiratory, facial and body protection for these procedures. In addition, the use of lower power settings should be considered to reduce the amount and spread of contamination.

A systematic review of contamination (aerosol, splatter and droplet generation) associated with oral surgery and its relevance to COVID-19.

INTRODUCTION: The current COVID-19 pandemic caused by the SARS-CoV-2 virus has impacted the delivery of dental care globally and has led to re-evaluation of infection control standards. However, lack of clarity around what is known and unknown regarding droplet and aerosol generation in dentistry (including oral surgery and extractions), and their relative risk to patients and the dental team, necessitates a review of evidence relating to specific dental procedures. This review is part of a wider body of research exploring the evidence on bioaerosols in dentistry and involves detailed consideration of the risk of contamination in relation to oral surgery. METHODS: A comprehensive search of Medline (OVID), Embase (OVID), Cochrane Central Register of Controlled Trials, Scopus, Web of Science, LILACS and ClinicalTrials.Gov was conducted using key terms and MeSH (Medical Subject Headings) words relating to the review questions. Methodological quality including sensitivity was assessed using a schema developed to measure quality aspects of studies using a traffic light system to allow inter- and intra-study overview and comparison. A narrative synthesis was conducted for assessment of the included studies and for the synthesis of results. RESULTS: Eleven studies on oral surgery (including extractions) were included in the review. They explored microbiological (bacterial and fungal) and blood (visible and/or imperceptible) contamination at the person level (patients, operators and assistants) and/or at a wider environmental level, using settle plates, chemiluminescence reagents or air samplers; all within 1 m of the surgical site. Studies were of generally low to medium quality and highlighted an overall risk of contaminated aerosol, droplet and splatter generation during oral surgery procedures, most notably during removal of impacted teeth using rotatory handpieces. Risk of contamination and spread was increased by factors, including proximity to the operatory site, longer duration of treatment, higher procedural complexity, non-use of an extraoral evacuator and areas involving more frequent contact during treatment. CONCLUSION: A risk of contamination (microbiological, visible and imperceptible blood) to patients, dental team members and the clinical environment is present during oral surgery procedures, including routine extractions. However, the extent of contamination has not been explored fully in relation to time and distance. Variability across studies with regards to the analysis methods used and outcome measures makes it difficult to draw robust conclusions. Further studies with improved methodologies, including higher test sensitivity and consideration of viruses, are required to validate these findings.

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.