The document provides training slides for dental therapists and dental nurses participating in the SENIOR trial. The SENIOR trial aims to test a "skill-mix" model of oral healthcare using dental therapists and dental nurses instead of dentists to provide care to older adults in care homes. The training covers an overview of the trial, roles and responsibilities, principles of working with medicines and older patients, and accounting for COVID-19. Trainees will learn about applying good clinical practice, working within their scope of practice, and documenting any adverse events from providing care.

1. uSing rolE-substitutioN In care-homes to improve
oRal health (SENIOR)
Training slides for Dental Therapists and Dental
Nurses

2. Detail of what we plan to cover
1. Learning objectives and outcomes
2. SENIOR trial: overview of the study
3. Good Clinical Practice and GDPR
4. Working with medicines
5. Working to your level of competence and Direct Access
6. Working with older patients
7. Accounting for !COVID!

3. Learning objectives and outcomes
• We will:
– Provide an overview of the
trial
– Provide an overview of Good
Clinical Practice (GCP) & GDPR
– Detail the role of Dental
Therapists (DTs) and Dental
Nurses (DNs) in the trial
– Explain the principles of
working with medicines
– Explain the principles of Direct
Access (DA)
– Provide an overview of
working with older patients
• We will be able to:
– Understand the nature of the
trial
– Understand the importance
of GCP/GDPR and how it
relates to your role
– Understand the role of DTs
and DNs in the trial
– Apply the protocol for
working with medicines
– Understand the implications
of working under DA
– Appreciate how to work with
older patients

4. SENIOR: why are we doing the study?
• Dental caries and periodontal
disease are very common
problems for older adults residing
in care-homes
• Oral health is also strongly
connected to general health in
this age group
• Oral health has a major impact on
how residents eat, speak and
smile, their quality of life and
their dignity
• This issue is increasingly
becoming recognised as a
significant UK-wide problem

5. SENIOR: what are we proposing to do?
• Instead of using dentists to
provide dental care, other
members of the dental team
could offer an alternative to
improve the provision of care and
access to services
• Dental Therapists and Dental
Nurses have been used in a
number of research studies that
have shown their potential in
these settings
• 'Skill-mix' has been used for some
time in dentistry, but limited
research has been undertaken in
care-homes

6. SENIOR: what are we proposing to do?
• We plan to run a randomised
controlled trial over a twelve
month period comparing usual
care with a model based on 'skill-
mix'
• One group of care-homes will
receive dental care from DTs and
DNs ('skill-mix') for six-months,
whilst the other group of care-
homes will receive their usual
care

7. SENIOR: what are we proposing to do?
• The eligibility criteria for care-
homes (what they have to fulfill
to take part in the study) will be
that they should have at least ten
residents 65 years and over
• Care-homes won't be able to take
part if they:
1. Are currently participating
in an oral health
programme or a research
study for older people in
care homes
2. Specialise in end-of-life or
palliative care
• Residents in each care-home will
be chosen according to the
following:
1. 65 years and over
2. Have at least six natural
teeth
3. Full-time resident in care
facility
• Of the residents that fit these
criteria, a maximum of fifteen
residents will be chosen per care-
home (minimum of five) by the
study team

8. SENIOR: what are we proposing to do?
• Levels of dental plaque will be
measured before the study starts,
at six-months and then again at
twelve-months
• We will also be recording the
following clinical measures:
– Bleeding on probing1
– Pain1
– New coronal and root caries lesions1
– Quality of life1
– Episodes of unscheduled care2
1-Measured by dentists in your Community Dental Service on six index teeth per resident
2-Measured by the care-homes

9. SENIOR: role of the CDS is two-fold
1. Measurement of
clinical indices at base-
line, six and twelve
months in all
participating care-
homes
2. Delivery of the
intervention (DT and
DN care) in care-
homes that are in the
intervention group

10. SENIOR: what will DTs and DNs do?
• Care-homes that receives dental
care from DTs and DNs will have:
– Appropriate dental care1
– Prescription of high-fluoride
toothpaste1
– Application of high-fluoride varnish
every three-months2
– Oral hygiene advice2
– Information about healthy eating2
– Advice and guidance for care-home
staff2
• The other group of care-homes
will receive their usual dental
care
1 Provided by DTs
2 Provided by DNs
Dentists undertaking the baseline examination will provide the prescription for the fluoride

11. SENIOR: timeframe of the intervention
• Resident provides consent
(undertaken by study team
and care-home manager)
• Dental examination by the
CDS epidemiologist
• Month 1: DT visit
• Month 1: DN visit
• Month 2: DN visit
• Month 3: DN visit
• Month 6: DN visit
• Month 6: DT visit
• Month 6: Dental
examination by the CDS
epidemiologist
• Month 12: Dental
examination by the CDS
epidemiologist

12. SENIOR: timeframe of the intervention
• DTs will visit their care-
homes twice (M1 and M6
before the six-month
measurement):
– Appropriate dental care
– Oversee high-fluoride
toothpaste use
– Oral hygiene advice
– Information about healthy
eating
– Advice and guidance for care-
home staff
• DNs will visit their care-
homes after baseline:
– Advice and guidance for care-
home staff (after baseline)
• DNs will again visit in M1,
M2, M3 and M6:
– Application of high-fluoride
varnish every three-months
– Reinforce oral hygiene advice
– Reinforce information about
healthy eating

13. DNs as oral health champions
• The DNs should work with the care-home staff to improve the
oral health of the residents
• This will involve appointing a local champion (member of the
care-home staff) who will work with the DN
• The local champion will be responsible for coordinating the
delivery of good oral healthcare to individual residents:
– Establish oral health care plans for each resident, which should be
displayed in their rooms
– Ensure a daily oral care monitoring form is displayed and completed
on a daily basis
– Be aware of common oral health complaints and when to seek advice
– Understand the range of oral healthcare products and where to obtain
them

14. Intervention documents for DNs

15. Intervention documents for DNs

16. Intervention documents for DNs

17. Good Clinical Practice and GDPR

18. Good Clinical Practice
• Good Clinical Practice (GCP) is a term that describes how
research studies should be conducted
• It is similar in principle to the guidance that covers how you
provide clinical care
• It is important that you are aware of GCP, but most of what
follows has already been undertaken or is overseen by the
research team
• GCP is a set of internationally agreed ethical and scientific
quality standards that ensures the rights, safety, dignity and
well-being of study participants are protected
• GCP covers trial design, conduct, recording and reporting
(ensuring and protecting the credibility of the study)

19. Good Clinical Practice
• Your Local Study Team will be ensuring that GCP is maintained
• There are thirteen basic areas of GCP
1. Ethical conduct: trials should be conducted according to the ethical
principles originating from the Declaration of Helsinki
2. Risks & benefits: trials should only be conducted if the anticipated
benefits justify the risk
3. Participants (residents) safety: trials should ensure that participants
rights and safety prevail
4. Adequate background information: trials should only be conducted
when there is adequate justification
5. Protocol: all trials should have a clear and detailed protocol,
describing the rationale and process of the study (peer reviewed)

20. Good Clinical Practice
• Continued…:
6. Follow the protocol: those involved in trial delivery should ensure
they follow the protocol and a system to review the process and
monitor non-compliance needs to be in place
7. Responsibility for medical care: those responsible for medical care of
participants must be appropriately qualified and this should be
overseen by the Principal Investigator at each site
8. Training, education, experience: Everyone involved in a trial must be
suitably educated, trained and experienced to perform their
delegated task(s)
9. Informed consent: all participants must provide informed consent

21. Good Clinical Practice
• Continued…:
10. Trial documentation: all study records (called Case Report Forms)
need to be handled and stored in a manner that ensures accurate
reporting, interpretation and verification
11. Data protection/security: Personal Identifiable Data must be
collected, stored and handled in accordance with the 2018 Data
Protection Act (including GDPR)
12. Investigative Medicinal Products: not applicable to SENIOR
13. Quality Assurance: systems and procedures must be in place to
ensure the quality of trial conduct and delivery

22. Key roles and responsibilities
Sponsor
Bangor University
Chief Investigator (CI)
Paul Brocklehurst
Principal Investigator (PI)
London
George Tsakos
Local study team
Care homes
Local study team Local study team
Care homes Care homes
Principal Investigator (PI)
Wales
Paul Brocklehurst
Principal Investigator (PI)
Northern Ireland
Gerry McKenna
• All responsibilities and tasks are documented in a delegation log in the Abridged Trial
File held by CHM

23. Abridged Trial File
• The care-home manager will hold the Abridged Trial File
• This contains all the important study documents (see next slide)
• This will be kept in a safe and secure but easily accessible place
• Consent forms for the study will be kept in a separate locked
cabinet/drawer
• The local study team will help the care-home manager keep the Abridged
Trial File up-to date
• All the detail of the study can be found in the study protocol (in the
Abridged Trial File)
• A copy of the ethical and other approvals are also found in the file

24. Good Clinical Practice (trial records)
• You'll need to ensure that
you'll keep all your clinical
records as per normal
• You'll also complete a Case
Report Form which is to be
handed to the care-home
manager afterwards
• This anonymized form
details what has been
undertaken on each patient
• NO Personal IDENTIFIABLE
DATA ON THE CRF (ID only)

25. Good Clinical Practice (AEs/SAEs)
• In keeping with GCP, we
have to record anything
untoward that could have
been caused by the trial
• These are known as Adverse
Events (AEs) and Serious
Adverse Events (SAEs)
• AEs are any adverse
occurrences that happen to
the resident as part of the
study (even if it appears
unrelated e.g. a fall)
• SAEs are occurrences that
cause the death of the
resident, are life
threatening, lead to
significant disability or
incapacity or where the
resident requires
hospitalisation
• Your role here is not to
distinguish between these,
only to report anything
untoward to the care-home
manager

26. Good Clinical Practice (AEs/SAEs)
• The care-home manager
will be required to keep a
record of all AEs and SAEs
during the trial
• So, if you see anything
untoward, you just need to
report this to the care-
home manager and they
will complete the necessary
Case Report Form
• Any AEs and SAEs linked to
FV and HFTP s/be reported
• The lead researcher will
review these forms on a
regular basis and determine
whether the AEs/SAEs have
been caused by the trial
• These are also reported to
two independent panels
which provide over-sight on
the trial
• Pre-existing conditions do
not qualify as AEs unless
they worsen

27. Good Clinical Practice (summary)
GCP principle How this applies to your role
1-Ethical conduct: trials conducted according to the Declaration of Helsinki Ensure you follow this training
2-Risks & benefits: benefits outweigh the risk Not directly applicable to you
3-Participants' safety: participants rights and safety prevail Ensure residents' rights and safety
4-Adequate background information: trials should have adequate justification Not directly applicable to you
5-Protocol: all trials require a detailed protocol Not directly applicable to you
6-Follow the protocol: all involved should follow the protocol Ensure you follow this training
7-Responsibility for medical care: interventions should be undertaken by appropriately people Ensure you follow this training
8-Training, education, experience: everyone involved in a trial must be trained Ensure you follow this training
9-Informed consent: all participants must provide informed consent This is undertaken by the Local Study Team
10-Trial documentation: all study records need to be handled and stored appropriately Anonymised CRF given to the care-home manager
11-Data protection/security: Personal Identifiable Data must be managed appropriately Do not enter personal details on Case Report Form
12-Investigative Medicinal Products: not applicable to SENIOR Not applicable
13-Quality Assurance: systems/procedures needed to promote robust trial conduct and delivery Not directly applicable to you

28. Summary

29. What is GDPR?
• The General Data Protection
Regulation (GDPR) is a European
law that came into effect in May
2018
• Along with the Data Protection
Act (2018), it seeks to strengthen
personal data protection
• The Information Commissioner’s
Office (ICO) leads on GDPR in the
UK and penalises breaches
• New principles have been
introduced:
– New rights (e.g. ‘right to be
forgotten’)
– Emphasis on transparency and
record-keeping
– Mandated data breach reporting
– Larger fines

30. What is GDPR?
• We need to be open and explicit
about how Personal Identifiable
Data (PID) is used
• We shouldn't keep data longer
than necessary
• We need to ensure it is accurate
• We need to ensure it is safe
• We need to recognise and know
what to do in a breach
• The good news is that many of
these principles are also
enshrined in GCP and align to the
processes in this training
• What is personal data?
– Any information that can be used
to identify a living person
(directly and indirectly) e.g.
resident's name
– It could also include other
information that leads to an
individual being identified (which
could be: physical, genetic or
cultural)
– Care needs to be taken with
sensitive personal data e.g.
health data

31. What is GDPR?
• Under GDPR consent needs to
have the following elements:
– Must be informed
– Must be freely given
– Requires positive action i.e. opt-
in (failure to opt-out is not
consent)
– It must be granular: separate
consent should be given for
distinct activities
• The good news is that many of
these align to the processes in this
training
• What happens if there is a
complaint to the ICO?
• ICO take a risk based approach to
enforcement
• Minor complaints can trigger ICO
investigation into policies and
procedures
• Evidence will be sought that
everyone understands the rules
and how to achieve compliance

32. Working with medicines

33. Classification of medicines
General Sales List Medicine May be sold from a variety of retail outlets, including dental
practices, but pack sizes and tablet strengths are often less
than preparations available as pharmacy medicines
Pharmacy Medicines Only supplied from a pharmacy under the supervision of a
pharmacist
Can be prescribed by a doctor, dentist or recognised
supplementary / independent prescriber
Can be supplied under a Patient Group Direction (PGD) by
Dental Hygienists and Dental Therapists
Prescription Only Medicine Can only be supplied against a Patient Specific Direction
(PSD) also known as a 'prescription' from an appropriate
practitioner (doctor, dentist or recognised supplementary /
independent prescriber)
Can also be supplied under a Patient Group Direction by
dental hygienists and dental therapists
Controlled Drug All Controlled Drugs are Prescription Only Medicines,
regulations (The Misuse of Drugs Regulations 2001) place
additional restrictions in place

34. What is a PGD?
• 'A written instruction for the sale,
supply and / or administration of
named medicines in an identified
clinical situation. It applies to
groups of patients who may not
be individually identified before
presenting for treatment'
• For FV, these are locally
developed and issued by:
– Dentist
– Pharmacist
– Representative of an NHS Body
(Clinical Governance Lead)
– A representative of a registered
provider (CQC, HIW, SIW NIQA)

35. SENIOR: prescribing fluoride
• PGDs/PSDs would normally be
required for DTs/DNs to
prescribe/apply FV/HFTP
respectively
• To reduce the administrative
burden in the SENIOR trial, the
epidemiologist within each CDS
will issue a FV prescription that
provides the legal cover for its
use by DTs and DNs:
– "less than 0.75mls of 2.26%
sodium fluoride varnish applied
to all teeth repeated at 1/2/3/6
months"
• They will also provide a PSD
('prescription') for 5,000ppm
HFTP for the DNs:
– "three tubes of Duraphat
5000pm fluoride toothpaste"
(dispensed by local pharmacist)

36. SENIOR: prescribing fluoride AEs/SAEs
• Adverse reactions to Duraphat
are rare but include mucositis
and/or an allergic response
• Prevention is better than cure, so
screening questions are key
• Remove product TB and rinsing
• Record in the clinical notes
• If an adverse reaction occurs,
inform the care-home manager to
complete the AE/SAE form
• Complete a BNF yellow card
• Inform the clinician who
prescribed the varnish
Duraphat is contraindicated in patients
with ulcerative gingivitis and stomatitis
There is a very small risk of allergy to
colophony in Duraphat: application
should be avoided
where there is a history of
allergic episodes requiring hospital
admission, including asthma

37. Working to your level of competence and
Direct Access

38. Working to your competence
• Epidemiologist will provide the
prescription for HFTP/FV for DTs
and DNs respectively
• If you see any soft tissue lesions
that you are concerned about:
refer on (see later slides)
• DTs: if you see something that is
beyond your Scope, refer to the
dentist
• DNs: if you see something that is
beyond your Scope, refer
upwards to the DT in the team
(unless beyond their Scope)

39. Direct Access
• 'Direct Access' means that DTs
can diagnose, treatment plan
undertake their full scope of
practice without patients seeing a
dentist first
• In the context of the SENIOR trial,
residents will be examined first by
a dentist from your CDS
• The purpose of this is to complete
a baseline assessment for the
purposes of the research
• This also enables the PGD and
PSD to be issued
• DTs will be required to undertake
an examination and conduct
treatment, as if this was the first
time they had seen the resident
• DTs should not refer to the
dentist that has undertaken the
baseline assessment
• However, there is no problem if
the DT wishes to discuss the
resident with another dentist in
the CDS
• Clinical care by DTs within the
CDS falls within Crown Indemnity

40. Clinical records (for DTs and DNs)
• GDC Standards 4.1.1 “you MUST
keep complete and accurate
[clinical] records, including an up-
to-date medical history each time
that you treat patients”
• GCP also requires you to
complete the research records for
SENIOR
• The proforma for this is called a
Case Report Form and will be
kept by the care-home manager
• You must ensure that the
resident's ID is on the record
If it hasn’t been written down
it hasn’t happened
In breach of GCP too!

41. Contemporaneous notes
“Be a fair written reflection about
what was seen on examination and
discussed with the patient…
…Detail of what decisions were made
and what the justification was, at
each and every patient visit…
…This should be able to be fully
understood by a third party who was
not present at that time”
[Dental Protection]
“The time of treatment whilst the
patient is seated in the dental chair
for a consultation, as well as when
specific treatment is being provided"
“Records made at the end of a
session, or at the end of the day, are
not considered to be
contemporaneous”
“Date and time stamp"
[DPL Newsmatters June 2014]

42. Medical history
• The medical history helps to
prevent medical complications
and thus minimise detrimental
effects to the patient and the
possibility of medico-legal
complications
• Failure to obtain, update, and
investigate the patient’s medical
history have all been alleged in
professional liability claims
against dentists
• At each and every visit, review
the written medical history and
current medications for your
clinical notes
• History of rheumatic fever/murmur
• Heart disease/heart condition
• Bronchitis/asthma/breathing problems
• High/low blood pressure
• Abnormal/excessive bleeding/bruising
• History of any allergic reactions
• History of jaundice/liver disorders
• Diabetes
• History of hepatitis/bloodborne diseases
• Epilepsy/dizziness/fainting/blackouts
• Digestive problems
• Organ transplant/artificial joints/implants
• Any hospitalisation
• Exposure to CJD
• History of mental illnesses
• Current medication (any warning cards)

43. Dental history/presenting complaint
• Patients should be asked about
previous patterns of care
• Try and question residents with
respect to:
– previous periodontal treatment
– previous oral surgery procedures
– previous orthodontic treatment
– any other treatment
• Patients should also be asked
about any presenting complaint
• Site
• Type of pain
– Sharp/stabbing vs dull/throbbing
– Intermittent vs continuous
– Spontaneous vs triggered
• Duration
• Radiation
• Anything that aggravates/eases it
• Analgesia
• Loss of sleep

44. Routine examination
• The face and neck should be
examined at each appointment
with any new abnormalities or
changes recorded:
– TMJ
– Soft tissues
– Lymph nodes
• The soft tissues of the mouth and
tongue should be examined at
each appointment with new
abnormalities recorded:
– Mucosa
– Tongue & Floor of mouth
– Palate
The soft tissues of the mouth and
tongue should be examined at
each appt with new abnormalities
recorded
The teeth and restorations should
be examined at each appt
recording any changes
If there are no abnormalities, then
document this also

45. Extra-oral: TMJ
• Palpate the lateral aspect of joint
with mouth closed, during
opening and closing
• With the patient’s mouth fully
open, move your fingers behind
the condyle to palpate the
posterior aspect of the joint
• Palpation may reveal pain and
irregularities during condylar
movement, described as clicking
or crepitus
• Record findings in patient records

46. Extra-oral: Soft Tissues
• Begin examination by observing
the lips with the patient's mouth
both closed and open
• Note the colour, texture and any
surface abnormalities of the
upper and lower vermillion
borders

47. Extra-oral: Lymph Nodes
• Normal lymph nodes are either
not palpable, or may feel like a
pea or lentil, and are not tender
when touched
• Abnormal lymph nodes are
generally larger, may be tender,
and can be an indication of an
inflammation or that drainage of
infection has occurred
• A non-tender enlargement may
indicate cancer or lymphoma
https://www.youtube.com/watch?v=PTLC4275-Q4

48. Intra-oral: Labial and Buccal Mucosa
• With the patient's mouth partially
open, visually examine the labial
mucosa and its sulcus
• Retract the buccal mucosa and
examine first one-side and then
the other from the labial
commissure to the anterior
tonsillar pillar
• Note any change in pigmentation,
colour, texture, swelling and/or
other abnormalities

49. Intra-oral: Tongue
• Inspect the dorsum of the
tongue, the papillae and the tip
• Ask the resident to protrude the
tongue to assess any deviation
• With the aid of mouth mirrors,
inspect the right and left lateral
margins of the tongue
• Examine the ventral surface and
palpate the tongue (bimanually)
• Check for any changes in colour,
texture, swellings, or other
surface abnormalities
• Note in the clinical records

50. Intra-oral: Palate
• With the mouth wide open and
the patient's head tilted back,
gently depress the base of the
tongue with a mouth mirror
• First inspect the hard and then
the soft palate
• Examine all soft palate and
oropharyngeal tissues
• Check for any changes in colour,
texture, swellings, or other
surface abnormalities
• Note in the clinical records

51. Lesions you might see (benign)

52. Lesions you might see (PMD)

53. Lesions you might see (oral cancer)

54. Oral cancer
• The prevalence of oral cancer in
the UK is relatively low
• Survival has not improved
significantly, so early detection is
key
• Oral cancer can arise within
Potentially Malignant Disorders
(leukoplakia is the commonest) or
de novo
• Common risk factors: smoking
and use of tobacco, alcohol,
exposure to sunlight and age
• More common in older men
• If in doubt, don't hesitate to refer
on, making note where possible
of:
– Duration of lesion
– Effect of lesion
– Size & shape
– Any changes in size and shape
– Raised or flat
– Colour
– Margins; ill-defined / well-
defined
– Fixed or mobile
– Where does it originate from?

55. Hard tissue examination
• A full dental charting should be
recorded, detailing:
– Teeth present
– Current restorations
– Dental caries (coronal and root)
– Mobility
– Missing teeth
– Prostheses
– Tooth wear
• Record any provisional or
definitive diagnoses

56. Periodontal examination
• Where possible it is important to
determine:
• Periodontal status
• Extent of disease
• Type of disease
• Stage
• Grade

57. Prostheses
• If patients are wearing removable
prosthesis these should be
examined
• An assessment of the dentures
should include:
– Problems with speech
– Retention and extension
– Stability
– Articulation
– Premature contacts
– Displacement/centric relations
– Periodontal considerations

58. Treatment planning
• Following examination and
discussion with the patient, a
written treatment plan should be
made in the clinical notes
• This should set out in logical
sequence the resident’s dental
needs and the proposed care
• Alternative treatment plans
should be discussed, if
appropriate
• Ideally, the agreed treatment plan
needs to be signed by the
resident and the clinician, if
possible

59. Capacity and consent
• Capacity is the ability to
understand, assimilate and
acknowledge the information and
make a decision
• Capacity is assumed in an adult
unless proven otherwise
• However, with some residents,
capacity may be diminished
• They have consented to take part
in the study, so the number of
these cases is likely to be limited
• But we must follow the Mental
Capacity Act 2005
• Consent can be implied or
expressed
• Implied consent is generally
sufficient for dental examinations
• Expressed consent involves an
explanation of the proposed
treatment
• Most dental treatment is based
on expressed verbal consent
• All consent must be recorded

60. Mental Capacity Act 2005

61. Working with older patients

62. Promoting positive behaviours
• Time and Place
– Work with the carer to develop a routine for oral care
– Sometimes it may be helpful to have more than one care assistant
helping, but the resident may respond better to known staff
– Carry out the task in a quiet distraction-free environment with
sufficient light, where the resident is comfortable (location should be
as private as possible to preserve respect and dignity)
• Communication Strategies
– Be caring, calm, friendly and smile
– Talk clearly at the residents pace and explain in simple terms what you
are doing
– Be gentle and remain positive
– Refrain from showing any frustration

63. Dealing with care-resistant behaviours
• Bridging: describe and show the toothbrush to the resident,
mimic brushing your own teeth, give a spare toothbrush to
the resident and the resident may mirror your behaviour
• Chaining: lightly bring the residents hand to their mouth while
describing the activity (enable resident to continue if able)
• Hand over hand: gently place your hand over the residents
hand and gently brush the teeth together
• Distraction: distract the resident by placing a familiar item in
the resident’s hand while you brush the resident’s teeth
• Rescuing: if attempts are not going well, changing the person
delivering care may bring a fresh perspective and encourage
cooperation

64. Dementia and cognitive decline
• Early Stages: many residents will be able to carry out their
own oral care, but may need reminders to brush or might
need a prompt (e.g. toothbrush with toothpaste applied)
• Later Stages: residents may become disinterested or resistant
to care, so you may need to work with their carer/family
• Dentures: it is important that residents wear their dentures
for as long as possible and that these dentures are cared for,
but they may start to take their dentures out (making new
dentures fall out of the scope of the study)
• Natural Teeth: many dementia patients are on multiple
medications which can lead to a decrease in the amount of
saliva (use of a high fluoride toothpaste is indicated here)

65. Dysphagia
• One in ten people over the age of 65 have swallowing
problems (dysphagia)
• Mild dysphagia: routine oral care should be continued as
normal
• Moderate to severe dysphagia: oral care for people with
severe swallowing difficulties should be discussed with a
dentist in your Community Dental Service
– Reduce or eliminate the use of water
– Unremoved food and liquid may enter the lungs and this may cause
harmful bacteria to grow (aspiration pneumonia)

66. Ulcers and/or dry mouths
• Mouth ulcers: can occur for a variety of reasons (denture
trauma, a reaction to drugs, underlying disease or oral cancer)
- it is important to seek advice from a dentist, even if painless
• Dry Mouth: this condition often goes undetected, especially in
people with dementia. It is a very common side effect of many
medications and can be unpleasant and uncomfortable. It
leads to an increase in tooth decay and can make wearing
dentures difficult. Symptoms can be relieved by encouraging
regular sips of water through the day. A variety of products
that may help are available through consultation with the
dentist.

67. Online resource
https://awfdcp.ac.uk/

68. Accounting for !COVID!

69. Accounting for !COVID!
• Everyone entering the care-home
environment needs to be mindful
of the impact that the COVID
pandemic has had on care-homes
• Given this, all members of the
study team and those delivering
the epidemiological element and
the intervention should actively
seek to reduce the burden that
care-homes have already
experienced
• The COVID risk assessment tool
should be completed prior to any
face-to-face contact with
residents

70. Where to find materials?
https://awfdcp.ac.uk/

71. Diolch yn fawr iawn
i chi am wrando
p.brocklehurst@bangor.ac.uk