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Nurses discuss diabetes, oral health and general health relationship

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Summary

In this session, Judy Downey and Jill Isla will discuss the importance of oral health and its link to general health, including diabetes. They will examine associations between oral health and general health, explanations for these associations, how healthcare professionals can implement this knowledge, and the link between oral health and diabetes. The session is sponsored by the Burdett Trust, Learn with Nurses, and C three Organization. This session is an invaluable opportunity for medical professionals to learn about the bidirectional link between oral health and type two diabetes.
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Description

Diabetes and Oral Health Series:

Jill Iliffe from the Commonwealth Nurses and Midwifery Federation joins Diabetes Nurse Specialist Judy Downey to discuss and highlight the links between diabetes, oral health and general health.

Nurses and midwives are in a unique position to raise awareness about the importance of oral health and provide oral health education to individuals, families and communities. Implementing preventive measures early will alleviate individual pain, discomfort and disfigurement and reduce the economic burden of oral diseases on individuals and the health system.

A collaboration between C3 Collaborating for Health, the Commonwealth of Nurses and Midwifery Federation and Learn With Nurses.

Funded by Burdett Trust for Nursing.

Learning objectives

Learning objectives: 1. Identify the associations between oral health and general health 2. Explain the three mechanisms linking oral health and general health 3. Describe the risks associated with periodontitis and its effects on the body 4. Analyze the bidirectional link between oral health and type 2 diabetes 5. Discuss how preventing periodontitis may prevent type 2 diabetes from progressing.
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Right then. So I don't, don't know if any of you guys that are here so far have ever sat in on Learn Sa Sarah's here. Hi, Sarah. Sarah. Hi. Uh, uh, any of you? Uh, we're just kicking off. So you haven't missed anything. Um. Oh, yeah, that's right, Mary. The names are going in, in a random order. So it's not necessarily on the bottom. So I did, I missed you, Mary. Hi, Mary. I know you sat in on the last one. So, thanks for joining us. Pop into the chat where you work, can you? And I'll have a look in a minute and all of you. So, yeah, I'm joined today. I'm Judy Downey and some of you sat in on my talks before with Learned with Nurses, haven't you? Which I've been doing for three years now since the beginning of the pandemic. And I, I'm, I've been a diabetes specialist nurse for a long time actually since 1995 which is a long time, isn't it? And I've worked in primary care mainly, but also in hospitals too. Started off in hospitals. That's where I cut my teeth. I suppose you could say on the diabetes, working in hospitals. And Good morning Mary, you're, you're in occupational health, very relevant to this topic. And Jess, you're a practice nurse. Brilliant, brilliant. We've got quite a few people joining in. So that, so, so in the last several, six years or so I've been independent. So that means, um, I'm self employed basically and I've worked in general practice running diabetes clinics, but mainly what I do is actually um education for healthcare professionals. So a lot of that's online now, as you know, that's really changed, it needs to be all face to face. But as this is online, but I do actually work for New Uni as an associate lecturer as well. And even there, we're doing blended, they call it blended learning where some of it's online and some of it's face to face and actually we love face to face, don't we? But we'll just have to make do with being online today. So, um I'm joined today by my colleague from Australia. Um Jill who's probably worked all day in, but have you not been working all day now? You're doing this? So would you like to introduce yourself, Jil? Sure, welcome everybody. It's really great to see um those, those people who have joined us this morning. Um My name's Jill Isla. I'm a nurse and midwife. I'm currently the executive Director of the Commonwealth Nurses and Midwives Federation. Um The CNMF is a network of uh national nursing and midwifery associations and individuals in commonwealth countries. And we do a lot of uh education work, leadership, uh networking, um education and a lot of regulatory work. So that's um and I've had a very varied nursing and mid career. I've been very fortunate, I've worked across the world um and had a, a wonderful time and I'm looking forward to sharing um oral health with you today. Thanks, Judy. Thank you very much. So, so, yes. Um So we'll crack on now. We've got quite a few people. So that's lovely because it is early in the morning, isn't it several, several more practice nurses? Um So, so yeah, we've introduced ourselves. Um we, we are offering these sessions on behalf of the Burdett Trust who actually gave us funding to actually put on this initiative all around oral health and the importance of oral health. It's not just to do with diabetes, it's to do with general health as well. Although, as you know, I'm here specifically on the diabetes aspect. So we're working with the Burdett Trust on this. We're also working with, learn with nurses who who, as you know, I've been part of learn with nurses for three years. And then obviously, Jill's just just mentioned her organization, you're also involved with this, which is brilliant and also the c three organization. So that's new to me, but basically, we're trying to raise awareness of the importance of oral health and its link to general health, not only diabetes, but actually many aspects of general health. So I'm here to discuss its link with diabetes, but don't think it's only diabetes. Ok, a lot more to it than that. What we want to talk about today is this link between oral health and general health, as I've just mentioned and some just brief theories about why this is the case and also in the link between diabetes and oral health. So it goes two ways and I'll discuss that more later on for you guys. What can you do for your patients? Um whether you're practice nurses or whether you're hospital nurses or whether you work in a care home, what can you actually, how can you implement the knowledge that perhaps you're learning today in the care of your patients or education of your patients? How can you actually do that and why is it so important to do so? And obviously we talk about all health regimes and I know you'll probably tell me um that that there's a lack of dental care in this country. I know you probably will. I obviously I'm so conscious of that, but we will talk about it. So that's what we're gonna cover today. Um Have I missed anything out, Jill? I don't think so. Um So yeah, Jill, you were going to um ask me something to kick off? Yeah. Um No, I thought I thought I might start first of all, Judy by talking about the associations that have been found. Yeah, go on. Yeah, the associations that have been found between oral health and general health just to put everything in perspective and what the general theories are that explain that association. So I thought if I started off of that, then I could move on to asking you more about um the the link with um with diabetes. Yeah. So simplistically and I stress simplistically. Um there are three mechanisms. So the first is that um is linked with periodontitis in your, in your mouth. So if you have dental caries that are left untreated, um that can lead to infection in your gums, gingivitis and that can then lead to periodontitis, which is much more serious and it's irreversible, gingivitis is reversible. But when you get to periodontitis, it's irreversible. So once you get to that stage, you've got local infection and you've got local inflammation that, that local um infection and inflammation can progress to systemic bacteremia and systemic inflammation. There's also um which which systemic bacteria and systemic inflammation can affect all organs of your body. So your heart, your lungs, your pancreas, your brain, any organ, once you've got something in the system that's carried around by the blood stream and, and every part of you is at risk. But then you get ascending and descending micro and macro aspiration of the bacteria in the changed oral microbiome. So that, that um travels through the pharynx, the na up to the nasopharynx, down to the um to the oropharynx, the la laryngopharynx and then to the larynx and, and, and esophagus that micro or macro aspiration. And it's very interesting that some of the um studies there's been a huge amount of research done in the last few years on uh the links with um oral disease, particularly periodontitis and other diseases. Um and that changed microbiome have been uh located, have been identified um in people's lungs. And so as far as the link with general health is concerned, um the period periodontitis has um associations with all types of diabetes, including gestational diabetes, type one, type two cardiovascular disease, respiratory diseases such as cod and pneumonia, stroke, um other cerebrovascular diseases, particularly Alzheimer's disease and dementia. And there's been very recent uh 2023 studies that have demonstrated that link. So as you can appreciate, um you know, oral health is critically important, having a healthy mouth and avoiding um infection such as periodontitis. It's really important for general health and wellbeing. And I I was wondering Judy if you would, if you wouldn't mind, um just enlarging on the bidirectional link between oral disease and type two diabetes and how prevention of type two diabetes may be possible with improved oral health. Thanks very much. Yes, that, that's, you know, anyone who knows me knows that I'm passionate about prevention of type two diabetes. And we are talking specifically about type two diabetes here, which affects over 90% of people with, with diabetes. You all know that don't, you can it be prevented with improved oral health? Well, as you know, it, there's, there's a whole array of different factors that come into play where one develops type two diabetes. And you, if you've heard me talk before, you know that this metabolic changes can go on for up to 15 years, maybe even longer before we can have a diagnosis. In other words, where we can do an HBA one C and it's risen to 48 bearing in mind that normal HBA one C is only about 32. I don't know if you knew that, but by the time it's got to 48 it, things have been going on for years. So you have your insulin resistance as you know, your other metabolic changes. But if you do develop periodontitis, which is very common, isn't it, Jill? It's not like, you know, it's very common in the population. I'm not sure what percentage of the general population have periodontitis, but it's quite a high percentage, isn't it? Yeah, I believe it is. So, so, um, and as Jill pointed out it's an inflammatory process. Now we believe that type two diabetes in itself is an inflammatory process too. And, um, so, and as Jill pointed out, it's not just one part of the body, it's the, it's the whole, whole, whole body is affected by inflammatory processes. And if one has periodontitis, it's going to actually affect the progression to developing type two diabetes. In other words, it's going to speed it up. That's the way I would put it. So a person would probably be on the path to developing type two diabetes already because they probably, well, they're going to have insulin resistance, probably central obesity as well as obesity type a family history. If they then develop periodontitis while all this is going on, it's going to actually speed up the progression. If, if this periodontitis could be, as JLL said, it can't really be reversed, can it or needs to get in there before a person develops periodontitis. Ideally, they may have gingivitis where, where you have bleeding gums. And I think most of us have had bleeding gums at some point. That's a common thing. But if that goes on, it goes into periodontitis, it will affect the blood sugars actually because you've got an inflammatory process going on. So the blood sugars will be slightly higher. They still may not be at a diabetic range, but they will be slightly high because of the inflammatory process. And one has to remember the cardiovascular links to this as well. Have you ever heard the term diabetes is a cardiovascular disease? Has anyone ever heard that? Because I first heard it years and years ago because the two things are linked like that. If you then have periodontitis on top of it, that's going to, to actually increase the risk even more. So, in theory, type two diabetes could be prevented if a person's oral health was improved. And that's a theory, there's so many people developing type two diabetes. You all know that you've all seen it in your work, haven't you? More and more and more people are developing type two diabetes. And as I said earlier, it's multifactorial. But we now know, and we are realizing and I've been doing diabetes good, not so long, you know, and we didn't pay attention to oral health really at all. We just didn't. And now we are and you will start to see more, more, you'll hear more about it and it's not irrelevant. It's totally, totally relevant. And obviously, if one develops, if one already has type two diabetes, your risk of developing periodontitis increases. So this is the bidirectional thing. So, so you've got inflammation going on, you will know, don't you that? Well, there's inflammation anywhere in the body. Um, it could be a, a slow healing wound, it could be um COPD blood sugars increase and that affects healing. It's going to make periodontitis progression faster. So it's basically, it means that the diabetes is much harder to manage, to keep the blood sugars under control. So we're looking at it from two angles trying to prevent diabetes. That's the perfect world. That's what we would hope. And, but if a person already has type two diabetes then trying to manage the oral health, improve it so that it's easy to manage their diabetes. Does that make sense? Everyone? I hope so. There's questions at the end. By the way, this is the way we're running this that if you were wondering, I hope you can wait for another 15 minutes and then we'll throw in some questions. Is that ok, Jill? Does that answer your questions? Yeah. How do you think that as far as diabetes goes, um, nurses can, um, advise patients in relation to, um, or alert them to the, the, the importance of, uh, oral health in relation to their diabetes. What would be recommendation? Yeah, I mean, I, I've thought about this since I've been involved in this project because I, I'm honest, I didn't really think about this much before, but I, I know as a diabetes specialist nurse, I so often saw patients in my clinic because I worked in you guys that practice nurses. You might have noticed it as well. People with poorly controlled diabetes who often had, had, had their diabetes for a long time. Often you could see just to look at them that they had teeth missing often. And I'm talking about people here in their forties. I'm not talking about very elderly people. They might have had the diabetes since they were Children. And you know, in a diabetes annual review guys. And those of you who see patients in hospital as well, we do have to fit in your practice nurses here will know only too well, how many things, how many checks some people call it diabetes checks. But we do have to fit in a lot of things into only often, only 20 minutes. It should be longer. That, that will set me off, it should be longer. But basically, we're under such pressure to do as much, see as many patients as we can and often in not enough time. And obviously, we would like to now encourage everybody to patients that are able to take the information in, obviously about improving their oral health. How could we fit this in if I was thinking of a diabetes, an review, I'd like to say we would be able to, to speak to the person about ask them, have they got any symptoms for example of, um, gingivitis or, or periodontitis? And, and um, I do have some great handouts that one could one could refer to and also give to patients about the symptoms and what to watch out for bearing in mind. We've probably only got a couple of minutes if we're lucky, but I'm so conscious of that, you know. Um, so backing up what we say with some educational material and failing that if we don't have time to actually even look in the person's mouth, at least give them some information to take away with. And especially in general practice where people are having their annual reviews with you. That's type ones and type twos, isn't it? And you may see a lady with gestational diabetes as well. So it's important though to raise people's awareness of oral health and you know, to ask for help if they need it. So, yeah, that's is, does that answer the question? Ji Yeah. Yeah. Yeah, that's right. So, um we'll talk, we'll talk later on about, you know, how someone should look after their teeth. I think most of you will know that and also the problems of getting dental input. We'll talk about that later on, shall we? Because that's an issue, isn't it? Is it in Australia too? Um, not, not too much. Um, I don't, I don't think we've got a fairly good ratio of dental uh professionals and, and quite a broad range. Um, you know, dentists, technicians, dental, dental associates. But, um, as far as the oral health regime, um for individuals and families, um, I there's some very interesting statistics that are coming out about our oral health regimes. And, um, and of course, a lot of debate still about, um, Fluoridation, Fluoridation, Fluoridation because I can never get that word, right? Fluoridation of water. Um And, and recent recent research has demonstrated that um, a, a topical application of fluoride is actually as effective if not more effective of protecting your teeth than systemic fluoride. It, it, it does emphasize how important having an adequate intake of fluoride is So the recommended regime of course is a, an annual check, annual dental checkup. Um, nice daily cleaning of your teeth, preferably with a fluoride toothpaste uh for two minutes. But one of the other things that, that I notice that most people do is that they rinse their mouth and then they s wash all the tooth. Yeah, because you, which you're not meant to do, you're meant to just spit but not. Yeah, but that is, that's sort of an incorrect thing to do because the, the toothpaste, the the remaining fluoride that remains in your mouth on your teeth after you've cleaned your teeth provides protection. So the message is um annual checkup, uh brush your teeth twice a day with a f preferably with a fluoride toothpaste. And for two minutes before your evening, morning and evening are the best times. Um evening before the evening brush floss or use a dental brush to get between your teeth up and down motion so that you clean the very ins the sides of your teeth. Yeah. And, and then brush your teeth again. Spit, don't rinse um and make sure you cover all surfaces. So the front with the circular motion, the back, um biting edges, ones at the back as well and then sort of in between your teeth and your tongue gently brush your tongue. But, but the other message is not, not to be too vigorous to be quite gentle. Um because being vigorous if you, when you're brushing along the gumline, you can actually, you know, damage the tissues. So you need to do that. Uh, you need to be gentle but you need to be thorough. Mm. So that's, that's really what the recommended, um, oral health regime is. And, uh, uh, another thing that, um, that, uh, the, the science is showing at the moment is that up until the, uh, age really of eight, Children should be supervised when they're cleaning their teeth because Children don't actually have, they tend to swallow. Um rather than spit and swallowing the toothpaste isn't a good idea. So they need to be supervised and taught to spit but not swallow. And, and they only need a pea size amount of, of toothpaste on their brush. Um and for a baby just to smear. So when a pea size, you know, you see these pictures of, you know, a whole strip of toothpaste along your toothbrush. No, no, you just need a pea size that's sufficient for cleaning your teeth. Um and a and supervising your Children. So that um you teach them to spit and not swallow. Yeah. So that's really the, you know, the recommended um regime and, and one of the things that, you know, we've been trying to get across to nurses and not just, you know, in the diabetic situation. Um although this initiative of course, is linking oral health and diabetes, but as you said earlier, it's an opportunity to talk about the general health as well. And it's one of the things that looking back over my own career, you know, we were always fairly good to uh do um handout um toothbrushes and toothpaste and make sure that our patients clean their teeth, but we didn't ever inside their mouths. And what we're trying to encourage nurses to do is two things. One is to talk about oral health to ask people about their oral ho um health reg regime, ask them if they have any problems with their mouth or their teeth and take the opportunity to give them um some health promotion and your handouts. Um I suppose they might be specific to um diabetes, but having handouts that you can give people about um their oral hygiene regime, but also look inside people's mouth and you know, it takes, if you look inside your own mouth, it doesn't take long to have a look, see people got clean teeth, uh see what their tongue looks like, see what their gums look like, see if you can see any cavities and, and not necessarily focus is not to diagnose the focus is to assess and then advise and refer. So that's what we're hoping that um you know, this, this uh initiative will uh will do. We really um encourage nurses to be more alert about um about the need to talk about oral health. But anyhow enough of that, that um you started to talk about um, assessments, diabetes assessments and, and the difficulty in incorporating something else into the time to do the annual assessment. But shouldn't oral health, really considering the link, the bi directional link between diabetes and periodontitis, shouldn't oral an oral health assessment be an integral part of the um assessment for the diabetes nurse when they're doing their annual check. How, how can that, how can that be managed to you? Um, it's a good point and bear in mind that most, nearly everybody who's doing the diabetes annual review isn't actually a diabetes nurse. They, they're practice nurses who are generalists, although some practice nurses do not exactly specialize, but you guys that are practice nurses know what I'm talking about. So, so, so, um, as far as finding the time, what one of on the chat, someone's already commented on that, um, not sure how to discuss it concisely within an annual review appointment. Um So there's two things, it's the time which in my, in my own, I don't know about the rest of you guys that practice nurses, but my time was cut down. It was just dreadful really because you could seriously, you could hardly get any education at all because all you were doing was ticking boxes and, and the quality outcomes framework bearing in mind that all annual reviews are done in primary care, not in hospitals, they're never done in hospitals. So the quality outcomes framework is a method for generating income for the practice. And the practice is very keen on reaching targets that belong to the quality outcome framework. So until oral checks are given that accreditation, if you like, it's going to be very difficult for a practice nurse to actually justify why she's going to take more time because it would take more time to do an oral check. Believe me, it would. So we talked yesterday about brief interventions, didn't we? Where you don't have much time? But you do want to raise awareness. So if you can't do a proper an oral check because of time constraints, you can at least ask have these handouts. And by the way, the handout isn't specific to diabetes. It could be for anyone else as well. It's, it's, it's not specifically for people with diabetes. And, um, just, just say, um, ask them, have they had any, any bleeding for one thing when they brush their teeth? Um, and if they say, you know, um, raise, have you been to a dentist recently? And everyone here I think is from the UK will know it's so difficult to get a dental appointment on the NHS. And a lot of our patients who do have serious problems often don't, cannot afford to go to private dentists. It's really expensive and, and they, they want to see the dentist on the NHS if you like. And I believe the waiting list is something like six months and seven months if you, if you can get it. So that's a huge problem. So, although we would recommend that people have a dental check at least once a year. Everybody, not just our diabetic patients, actually, I think most people don't have that Dun Gill in this, in this country because this huge issue around getting a dental appointment. So that's where as nurses are in a position to at least raise awareness and yes, maybe give a handout, you know, there's, um, gosh, yeah, it's, it's a huge issue to do that. Although we know in a perfect world that is what should be happening. We have to think outside the box and think of other ways of dealing with it, I guess if a person not able to go to a dentist. Yeah. Yeah, I just noticed that Sarah. Sarah asked about the thoughts on the use of mouth use of the and I, I'm happy to, um, share what I've, I've read about that. Um, there's a, as I mentioned earlier, the, um, the current research is showing that the use of a fluoride toothpaste, um, is as effective as if you didn't use that and you just had um, flu, a Fluoridation of um, water, milk or salt. So using a fluoride toothpaste is really important. There are also um, mouth washes and there are also, they can be either fluoridated, um, or not. They can be antibacterial mouthwashes are fine. Uh, they're, they're recommended um, if you can have one that's got fluoride added, that's really good. But it's very important that you, um, that you spit the mouthwash out, you don't swallow it. And it's also also very important that, um, you only have AAA tiny bit that you don't, you know, have a great big s squishing around your mouth because some of it's going to obviously, um, you're gonna swallow some of it. So just a small amount to rinse your mouth. Um And then spit out the rest. There are also um fluoride varnishes that your the dentists are, they're very effective. Um But they need to be applied by um ad a dentist or a dental technician or a dental nurse. Um because they're much, much stronger. Yeah, they painted on your teeth, but it's much stronger than the fluoride toothpaste. It's much stronger than the mouthwashes. Um And they're also gels. So if the dentist thinks that your teeth, uh your enamel is starting to thin, they may recommend a flu gel and you just put massage that on your teeth. That that is much, that's not as strong as the varnish. Um But the varnish, they recommend varnishes at least twice a year for people who have thinning enamel on their teeth. Um But it's something that needs to be applied by a dentist and it's um and you know, diagnose that you need it um by a dentist. It's not something that you can go into the pharmacy and buy yourself and start painting on your own teeth. It's, that's not recommended at all. Hm. One of the o yeah, one of the other things in addition to all this, it's not much point in looking after your teeth. If you're going to stuff yourself with a whole lot of sugar and then leave that sugar in on your mouth around your, have a, have a chocolate after lunch and, or instead of lunch and then leave it sitting on your teeth for hours at a time. If you do have sweet stuff, it's really important to rinse your mouth and get rid of the sweet stuff so that it's not, um, it's not sticking to your teeth and it's not staying there because the damage is not just the sugar but the length of time that the sugar is in, um, contact with your teeth. Really interesting. Yeah. Yeah. Actually this is fantastic. I mean, we're getting near the end now, but there's a few thoughts have come in on the chat Jill, um, which was, um, you've answered the one about mouthwashes and I've learnt about dental. What's it called again? I didn't, I didn't even know about that. So I, I've never actually even heard of it. So, thank you very much. And my dentist has never offered me anything like that. But um, Diana very, it's interesting. You have said a shame. We can't refer to dentists at like we can for foot care. For example, we can't, we can't, we just have to say to people go and make yourself an appointment. Um We, we, we can't do those types of referrals in the UK. And then, um Sarah has mentioned it is an issue trying to see dentists with the payment and we are like, Sarah thinks we're like to see more or problems going forward now. Yes, we probably are partly because there's more and more people with poor metabolic health, not only type two diabetes, but in those years leading up to the diagnosis as well, which as I said earlier, you know how long that goes on for at least 10 years? And Sarah, thank you for saying it's an interesting and important issue. Thank you for saying that because that's one of the points of us running this initiative, wasn't it? Jill was to raise awareness and then Nicola where the ward you work in a is medical and a diabetes ward. Ok. And, and you think when it comes to our patients with diabetes, we are conditioned, this is so it's true. We, we are conditioned to think about foot health because that is part of one of the um co points where you get payment is doing a foot check and don't set me off about how long that takes if you have to fit it into your annual review, which often was the case for me. Um, and more often than not forget about their oral health. It's true. And that's what we're here for today to try and raise this awareness. And I think we have, um, and, and Nico is definitely going to be taking more interest in her patient's mouths. That's good to hear, isn't it? So, yeah. Yeah. Um, you know, has anyone else got anything they want to add? Um, is there anything else you want to add Jill to this in the UK that um that you aren't able to refer to dentists? No, but I think that and, and that oral health isn't included um as an item in your annual review, one of the other functions of this initiative is to identify areas for policy development. And so, you know, nurses in the UK need to start lobbying so that you, you can refer to a dentist assessment is included um in the tick boxes for your annual check. And that's something that we'll be taking forward to the committee um to start lobbying as far as policy is concerned to make these changes. It's, there's got to be a lot of changes in not only in diabetes and your review, but the whole system with, with these points and heading for targets, no matter what often that means throwing drugs at people where if they made lifestyle changes, they wouldn't need the drugs, for example, but you can get to your target which triggers payment more quickly by giving drugs. It's, it's a huge change in policy, but we so hope that we will be able to influence and you guys can as well, you know, you can influence as well. Um Certainly, I hope you when you go back to your wards or back to your practice, when you have a practice meeting or award meeting, please bring up this subject with, with your colleagues. That's a good start, isn't it? Jill? So, yeah. Yeah. So we have actually taken our time, haven't we? We're up to our time. Has anyone got? Yeah, it's gone really well, thank you so much for joining us. Um, 15 people, Jill. So that's wonderful. I haven't said hello to all of you, but I'm saying it now. Hi, everybody. So do take, take it. You know, I found it fascinating. I'm learning so much about this myself and I'm always going to be including this in my teaching. Certainly. That's what I'm gonna do, you know? And when I teach at the university, it's not in there. You probably know that some of the way we're supposed to teach, misses out a lot of stuff actually. But I'm going to make sure that they get some information because these are nurses who are doing diabetes management course modules. I'm going to make sure they, I certainly let them know about it and any of you guys that teach any of your colleagues, you can do the same thing, can't you? So, as regards getting the handout as long as we've got your email addresses, then I can, um, I can certainly um make sure you get that. I did find, find it um myself online. So, and I can give you the reference for the guys. I can't remember the name. It's to do with Periodontitis Gill, the European group and this is in the public domain. So, and they've got some great stuff that you can print off and give to your patients if you have to do a brief intervention or any intervention. Yeah, someone put Nicola. Thank you. I, I'm glad you enjoyed this. It's so nice to hear that, isn't it, Jill? So, anything else, Jill to add? What we really thanks for participating. Yeah. And I, and I, yes, yes, there, we're doing a podcast as well now that's new to me. But I do sometimes listen to podcasts and it always starts off with all this music at the beginning. So I don't know if we going to have music on our as it will be. They always do. So I've stuck up in the chat. The um the feedback. Can you see it um to provide feedback? But if you can't see it, don't worry, you'll be getting an email um with, to provide feedback. Um It's important you do obviously because we'd like to know what you thought and, and good and bad and um, and then when you do the feedback, you'll get your certificates. Ok? And I'll, I'll just check about how I can make sure you get the link for this. This, it, it's a start, isn't it? I, I certainly haven't ever given a patient any, any leaflets or any sh a sheet on oral health. I've never done it. So, and I will be in the future. Oh, thank you, Jenny. It's a great session. Oh, this is lovely. Thank you guys. We've had some great feedback there, Jill. Thank. It's wonderful. So it's just going off to brush your teeth. I'm going to go and do mine now as well after hearing you, Jill. Ok. So feedback forms, then you'll get your certificate and watch out for our podcast coming up. Yeah, take care. Thank you. Thank you. Bye. Thank you. Have a good day. Bye bye.