Oral Health - Should we leave it all to the dentists?



This on-demand teaching session will bring together medical professionals and discuss the relationship between oral health and diabetes. The session, facilitated by Michaela Nil and Molly Gal, will explore the bidirectional link between these two conditions and focus on the initiatives in place to help healthcare professionals. The session will cover the difference between gingivitis and periodontitis and explain the signs to look out for in a patient's mouth in order to make a diagnosis. Molly will explain why it is important for healthcare professionals to be involved in screening for oral health diseases as well as the reasons why it is important to take a preventive approach. This session is part of a series which is funded by the Burdett Trust for Nursing grant, and provides education and training programs available for healthcare professionals.
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Diabetes Nurse Specialist Judy Downey RGN BSc(Hons) and Molly Agarwal, Public Health Professional and Dental Care Professional talk about oral health - Should we leave it all to the dentists? This LWN in Conversation style webinar will discuss:

Haven’t nurses got enough to do?

Should dentists look for diabetes?

A 40-minute live webinar that will be recorded and made available on demand.

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. Recognize the importance of the bidirectional link between diabetes and oral health. 2. Describe the signs and symptoms of periodontitis. 3. Identify patients at high risk for oral health diseases. 4. Apply screening measures for identifying periodontitis in patients with diabetes. 5. Understand the role that nurses can play in screening and early identification of oral health issues in patients with diabetes.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

So welcome everybody to another of our learn with nurses collaboration sessions about oral health and diabetes. Now, the Eagle eyes of you will notice that I am not Judy Downy. Unfortunately, Judy Downy is quite unwell today and we thought rather than um rather than postponing that I will just be a stand in because I've been a part of the program for a while now. And actually, a lot of our discussion today is really about the dentists. Uh and we've got Molly here with us. So a little bit about um what we're gonna do and uh and then I'm gonna ask Molly to introduce herself. So this is another of our learn with nurses sessions done collaboratively with um C three, collaborating for health and the CN MF, the Commonwealth Nurses and Midwifery Federation. And this was all done and was enabled by a grant from the Burdett Trust for Nursing. This is a what part of a series of education and training programs available for healthcare professionals. Really looking at that bidirectional link between diabetes and oral health. And we've done a series of different webinars. We've done some of these in conversation sessions and if you haven't watched any of the others yet, they are all available on demand. Now, we do have people joining us live. Uh And that is wonderful to see, but also this one will also be available on demand. Now, when you are watching it on demand, you won't be able to see the chat box. So if we do say, oh, there's a question that's come in, we will read it out aloud that way, you'll know what we're answering cos you won't know what that is there. So, as I said, my name is Michaela Nil, I'm the founder here at L Nurses, but I also work for C three, collaborating for health too. I'm a nursing associate in nursing there and I worked very closely with C three for many years. So I'm delighted that we are here together today. But what is the last live version of this diabetes and oral health project? So I'm gonna ask Molly now to say uh uh a little bit about who she is and what she does. Uh Molly tell us who you are and what you do. Thank you, Michaela. Um So, uh and thank you for having me over for this conversation. I couldn't be more happier because I'm really very passionate about uh advocating for the, the impact of oral diseases on systemic diseases as well and not just on your mouth. So, uh like I, like I said, my name is Molly Gal. I am a registered dental therapist, been practicing for many years now. Um I also am a public health practitioner and uh alongside my clinical dentistry, I work for the NHS Improve the NHS England Improvement Team. And my role is currently as the health improvement advisor and I'm working on two different projects. One is for oral health actually across Northwest London and the other one is on obesity. So quite the uh touching uh uh almost um touching base on how oral health impacts, you know, diabetes, your obesity levels, and uh BP and so on and so forth. So, yeah, really looking forward to an exciting conversation and folding this afternoon. Yeah, brilliant. And I must say that um since we've been involved in this project and it, it, before I got, you know, before this came about, I hadn't really thought much about oral health and what it meant apart from, you know, I go for my checkups and stuff and what I've learned from engaging with other nurses and other D and dentists and all the different people involved was how much they didn't realize either. And so it's great to hear Molly that you actually are on the ground doing initiatives. It's not just about, oh, is there a connection? It's actually uh well, there is and there's initiatives going on and I might, I might even ask you a little bit more about those initiatives and what sort of things you're doing cos I it's really good to have those practical examples. But the theme of today's session is really about, shouldn't we just leave it all to the dentist? You know, this is oral health, this space inside here, that oral cavity, that's more your territory than my territory. That's often what we, we hear back from nurses, you know. Um So, so let's imagine, first of all, Molly that, that, that we've got nurses and they attended maybe some training, maybe they have, maybe they haven't, but they might have to start looking in people's mouths, particularly for people with diabetes. Do you, what do we think about that? What do you think about nurses performing oral oral examinations on dentists on, on, on patients? Yeah, on patients. Sorry. Yes. Uh well, whilst there is no dispute in the fact that nurses are inundated with uh a lot of work, a lot of stress, a lot of pressure already. Uh but I II just, I just like to think that the various screening, validated screening factors that's out there for every clinical set up where nurses are doing the screening. Uh It really gives us a very good rich port there to identify patients at high risks for um oral health diseases. So for example, for example, if a patient in the medical, his if a patient walks in and they have a medical history of um familial uh history of diabetes or say a high BP or uh a high, high cholesterol or if they are overweight or obese, then they are likely to, they're likely to have periodontitis. And, uh, before I, before I go on talking more about, uh, the bidirectional relationship between diabetes and periodontitis, I'd just like to, uh, you know, give a bit of a summary on what periodontitis actually is. So, basically the, yeah, the, basically there are two, diseases, uh, two sorts of main oral health diseases. One is the gingivitis and the other one is uh you know, very much going to talk about on periodontitis. So, gingivitis is reversible. And as the name suggests, it's basically the swelling of your gingiva, you know, the bank, um the layer that you see or whilst um whilst smiling or speaking. Ok, I call that my gums. Yeah, I call my gums. Yeah, that, that's the gums really. Exactly. Uh and the second one is periodontitis, which is when, you know, when gingivitis it has been um it, it's been ignored for long and you're not. And you've reached a point where, you know, your, your oral health is really poor. Uh your gums are bleeding often almost uh almost daily. Uh you have dryness in your mouth and you have mobile teeth, some of your teeth are mobile, that means you, the, your gingivitis has now progressed to periodontitis. And sadly, this is irreversible and that's where it gets a bit more serious. So that's where the infection comes in. And now you have an established mouth infection. Um, and, and yes, uh, research suggests that if you have periodontitis, you're more likely to have diabetes, mellitus and vice versa. Um, and that is the relationship, bidirectional relationship between periodontitis and diabetes. And would we expect nurses then to look in, let's imagine, is a nurse looking in the mouth? And I'm a nurse and I might look in her mouth. Am I expected to know the difference between gingivitis and periodontitis? That's should I um how would I know the difference? That's a, that's an excellent question actually, because whilst all of this may sound very daunting that you, oh my goodness. It's a, it's a meticulous examination and you know, you would need all of those typical dentist probes and a mouth mirror to exactly go back and everything, you know? Yeah. Well, II, I'd like to highlight that actually. Uh it can be simplified down really. Um So the signs to look out for, like I said, uh earlier was uh you know, mobile teeth. So if your, if your teeth are a bit mobile, uh and there are three types of mobility uh to go into more further details. And then if you could, you could ask the patient if they have a history of bleeding, how often their gums bleed. Um and they may answer it bleeds rarely or occasionally or almost every other day when they're brushing their teeth. And thirdly, they've experienced something called as dry mouth or xerostomia. So, these are the three typical cardinal signs of periodontitis. And yeah, of course, if they have missing teeth as well owing to the mobility of teeth and they've lost their teeth. Um you know, because of prolonged mobility, that's also one of the signs. So really, these 3 to 4 signs are quite uh classical of having established periodontitis in your mouth. So it's almost saying we shouldn't be scared of looking in mas. It, it, it, it's not, it's not a big huge thing. It, it's not something totally unknown. They were, they were quite straightforward, but there'll be the cynics out there that say, are, are we as nurses and maybe health care assistants and, uh, pharmacist who've got whole different teams out there that are involved in care along along with GPS and stuff. Are we not just being asked to do it because there's not enough dentists and shouldn't we leave it all to the dentists? Isn't that, isn't that, isn't that space? The dentists space? Well, I mean, that stands true for almost every speciality that's out there. Uh, called, uh, a heart surgeon is meant to be looking at heart diseases and, you know, re related factors. Um, a urologist is meant to look at, you know, uh tho those, those kind of, uh diseases and areas and it goes nothing changes for dentistry as well. But lo I mean, now there is a growing there, there's growing evidence to suggest that, you know, everything is linked in the body. Um uh I if, if you have obesity, you're more likely to have diabetes because you know, there are, there's something called as common risk factors, you know, such as sugar and cholesterol and high BP. So in II, in that case, it really helps and it gives you that preventive approach to public health. So if, if we just leave it all to the dentist, so I just feel it's, it's uh it's a bit uh almost unfair because uh dentists like uh other healthcare professionals are also inundated with a lot of clinical work stress. And uh not to forget the backlog, we're still, we're still sort of facing from the pandemic. Um So it's, it's really uh I ii it, it would be of definitely uh of massive health if there are nurses pitching in to just sort of screen the patients and suggest, OK, you know, you're more pro prone to have uh uh to be having periodontitis. Um because, you know, your history suggests you are you're diabetic and um and the, the these got little signs in your mouth. So it, it, it would be a good idea to just get yourself checked and sort of take that preventive approach. So while this may look daunting, uh I'd still like to just highlight the, the fact that the there definitely there is meticulous examination and high specialty training to be able to really get to the, the nitty gritty of the, the oral health disease you have in, in your mouth, but simply to just screen a patient, uh as to whether, you know, you're more likely to have periodontitis or not, that would work one dose for a clinical set for the oral health set up. And, uh, you know, lay foundations for just preventing more complications from diabetes and um preventing oral health diseases at large at a population level. Yeah. And I think you've hit on the word though. It is about prevention and, and we, we both are very fond of the word prevention and not just the word, but actually the whole concept and really well well invested into it. And ii like the way that we know, we think we, we don't just leave heart attacks to be a cardiologist in your card. So it is about trying to prevent that periodontitis and that we all have a role to play and that, you know, preventing gingivitis to start with. I think we all and particularly as nurses um do have that role to play and the wider health care professionals. And while you were talking, I suddenly thought that, you know, it is a, it is a screening tool. It's those questions are simple screenings and actually we have pathways for people with diabetes. So or, or, or say people who we think might have hypertension. So if the BP is 1 40 or 90 then we don't diagnose anything there and then we, then unless it's really high and then we might do, then we, ok. So now we'll go down this process. We might send you off somewhere and, and have a, a BP monitor, finished fitted or something. The same with screening for diabetes. We do a, we do a, you know, we might use AQ diabetes tool. We might use thresholds at which we then do an HBA one C and a follow up HBA1C. And it is, it's maybe about seeing those three questions that you just said um about thinking, OK, do I need to move that person forward? So and so when would we say I've looked in the mouth? I've asked those three questions. When do I think actually I II think I need to say you might need to see a dentist quite urgently. Is there ever an urgent if there's no pain or even if there is pain? When should, when should I advise? I almost want to think pass the clinical baton on to somebody else when, when, when should I do that? So um there's, there's definitely a fine line between gingivitis and periodontitis owing to the fact that the former is reversible. So uh there's nothing to be more uh there's nothing very urgent out there, but in the latter, in the case of periodontitis, I think that's when nurses definitely need to refer uh the patients uh to dentist and highlight the importance of definitely visiting that uh having having regular checkups and reviews by your dental care team. So it's really when periodontitis is there, when you can see those, you know, those uh few cardinal signs of periodontitis, it's, it's absolutely essential that nurses make a reference straight away. Yeah. Yeah. And we do get a lot of pushback saying the wait for dentists is quite long. Even finding a dentist can be a big challenge for a lot of people. But we know that um particularly particularly when in this um in the, the, the the cost of living crisis that we're in the middle of and all of that, that it, that actually spending time and money on dentists or even, or even on toothpaste and toothbrushes sometimes can be a real challenge for people. And that was certainly discussed at um at one of the, the sessions recently between Christie and Hancock and Jill that um they were starting to talk about actually, maybe we should be asking people to donate toothbrushes and toothpaste to food banks because um brushing teeth is just as important as eating in a lot of ways, you know, um even respect to flossing and all of that sort of stuff, but even that basic flushing flushing brushing that's there. So uh given I've asked you some a couple of questions here, have you any thoughts about, you know, coming thinking as it from the dental perspective to the nursing perspective. Is there anything you'd like to ask me? Maybe? So, I mean, as a dental care professional, uh, I'd like, I mean, I'd like to know more about, you know, what, what in your mind, uh, would you suggest there that there is the potential role for nurses to get involved with oral health education and prevention and really, uh, just general oral health advice in general on a day to day basis? Yeah. Yeah. And that's, and you know, and I, that, that's a great question and it's something I've been obviously thinking about for quite some time now since being involved in this project. And what we do know is that for nurses and well, nurses and healthcare professionals to attend training, we have some training that is mandatory you have to do and you have to attend that training and you can't do your job unless you've done that mandatory training. Now, sometimes that can be not very exciting because, you know, it's that fire training and all of those elements of it. So I'm not sure it should be, you know, should it be there? Is that one place? Is that something there? Um Also, it's not probably part of any of our core curriculum when we are training. So whether we're training as nurses, uh healthcare assistants, doctors in the same way as what it would be. So there's an opportunity there to influence, I would say, um you know, universities and care kills that. Maybe there's, there's a role for training and education, but that's done with people who have not yet trained. And so then, of course, we've got many, many nurses, um, around the world who, who are all trained and who could start to look more in people's mouths and, and I think that then comes to accessibility of training. Um, is it, is it something their employers say you must do? And if an employer says, well, you must do it, then they're more likely to get time off to be able to do it rather than having to do it in your own time. So a bit like the sessions we run now people are doing it in their own time. But if it was made, actually, we want everybody to be able to attend some form of training about a good oral health, then I think that would work really, really nicely as like a, as a core bit of work. Somehow. I also think that training, um it, it needs to not be scary. This feels like something more that you're adding into my day, something more that I should be doing. And haven't we got enough to do without another task that we've got to do. And um, and I, and I think that, you know, there's, there's, there's, there's ways of systematizing, systematizing, getting things put systematically into what we do. And if we, if we think about patients with type two with with diabetes, then they do have their annual review and that does have specific things that we have to do within it. So whether that's checking BP, checking, eyes, checking feet, you know, that is there and we know even for those things, they're not always done all the time. You know, there's a significant proportion that miss out on that. So that, but if we add it into the annual review, then maybe that's more likely to get it into people wanting to attend training and, and you know, in the, in the type two diabetes guidelines, nice guidelines. In 2022 there's a whole section, there's a new section about parodontitis. So it's making its way in, I would say it's making its way in. But I think we've, we've almost got a win over the hearts and minds of this is a good thing to do. This isn't an extra thing to do. Well, of course, it is an extra thing to do. But, um, but it, but, but it doesn't have to be huge and arduous and actually it will make a big difference to our patients and, and it will make a big difference into prevention, particularly with thinking about that link between diabetes and diabetes control and to do with your gums and inflammation. And even we're seeing stuff emerging now about heart attacks that, you know, it's really, we are really at the beginning of this, uh another massive risk factor that's out there and it's getting bigger and bigger, particularly as you mentioned about obesity and you mentioned about sugar and, and all of that and we know that people, well, I say they're probably cleaning their teeth less but I suspect, you know, cost of living is making a big difference. So I think, than it is about um, only lobbying more as well for, I actually I II want to be trained on this. I want to. Um and it's not courses. It's, it's little things of just having a, it feels like it needs to be added into care plans added into, you know, a lot of things have been digitalized now. So adding into templates, it's, there's a, there's a way of systematizing is that a word of, of making sure that's how we make sure things happen I would suggest in healthcare now. So we kind of have to get to that root of it and change our Absolutely. I mean, uh this just reminds me of the famous uh uh sentence uh the dental care profession, dental care team often use uh that the mouth is the gateway to the, to your entire body. And if you have a healthy mouth, you have, you're more likely to have a healthy body and it's not just so put the mouth back weekly or for the change. Uh We, we are constantly lobbying for, you know, put the mouth back in the body, it's not separate to your body. So, yeah, unless you do not really address the preventive factors for taking good care of your oral health. You are never going to achieve that perfect state of wellbeing in your body. Be it? Diabetes or obesity? Yeah. Yeah. Yeah. No, II like that. Putting the mouth back in the body because it is, and we see it over there. It's a dentist thing. It's not a, it's not a, it's not a medical thing. It's not a nursing thing. It's a dentist thing. And then, and, and wherever possible, we should do that. Now, I've just seen a really good question. Um come into the chat and I'm going to read it out so that anyone watching on demand was there. And, and so said, I think I could definitely ask about oral hygiene routine and dental checkups, which could ask as a prompt. And also would it be helpful to know about people's gum health before starting treatment? And she was thinking about something called calcium channel blockers, CCB S now calcium channel blockers. Um They're used a lot in people with hypertension, they're used in people who are over 55. And we know your prevalence of diabetes goes up as we get older and particularly in people who are black. That's also where we would also use that first line as well where we know there's more diabetes. So, so what do you think is that could act as a prompt? Do you think that that, do you think? What am I saying? Could we use it as is there ways of having prompts in there? Definitely ask about oral health. Definitely. What would the little prompts be? What was your top prompts? Those three things? Definitely. I think uh the key question here is to ask, simply ask how many times do you brush in a day and you'd be really surprised to, to hear answers like, uh you know, sometimes none like it, you're not even the people who are not even brushing once a day because again, cost of living crisis, lack of time, uh lack of awareness really. And uh ii ignorance for oral health. Um So really, that gives you a very good insight into what the rest of the body, I mean, what the general health as well for the patient is like, so a simple question, like how many times do you brush in a day can give you a whole lot of insight into what uh is out there further? I mean, uh you know, um and then, you know, really uh uh advising the patient if that's the answer or say if it's say less frequently or less than once a day or maybe just uh once a day, it's, it's, it's, it's a great way to just touch base on the fact that uh you know, it's really good to brush your teeth teeth twice with a fluoridated toothpaste and it doesn't cost you an arm and a leg. But it's really about just getting that awareness and prioritizing oral health as, as much as the rest of your health, um can, can work one dose for your wellbeing. And actually, um a lot of just thinking about it now, if people have got an NHS dentist and they're worried about the cost of toothpaste, then you can actually get it prescribed. You can get the fluoridated toothpaste prescribed. That's what that, yeah, we have, well, I pay for mine but that's what we do. I get it prescribed. Yeah. Well, um that's, that's also a very good uh uh suggestion, Mila and I just like my uh like the listeners to know. So the UK has uh uh I mean, the whole, the whole of UK uses floated toothpaste and the amount of flu fluoride in every toothpaste in the UK for adults. Uh toothpaste for adults is 14 50 to 1500 PPM. Uh And that's the general recommendation by nice uh for everybody to use unless you are on the way to get periodontitis or you have uh you, you, you are on the list for special needs. Uh uh It is not until then that you need uh something as high as a, as something called a high chlorid toothpaste. And it's only then that you need a prescription from the dentist, but really you can just get a regular fluoridated toothpaste from over the counter and that is also almost equally good in the sense that it's still better than not having any fluoride in your mouth from, from not brushing at all in a day. So, um, e even if you, it's because you know that there are lots of patients who are not registered with the dentist and uh, I, if you cannot get access to a prescription for a toothpaste, you can just get it over the counter and, yeah, yeah, it nice things like that. I was just thinking then, yeah, and I actually, I get it because um I've lost a lot of enamel. My enamel is, is and every time I see my dentist she says, oh, your teeth are so thin and they, you know, the enamel is really, really disappearing quite rapidly, but that's for different reasons. But um yeah, but uh yeah, so um I think we might be thinking about wrapping this up a little bit and I, and I just have you got any, any ideas going forwards? I mean, are you going to challenge anybody who watches this or takes part in this to ask a patient how many times a day to clean your teeth? It could be just, I mean, I uh one other question I'd like to ask is, I mean, this is something very widely discussed in the whole of health sector and the NHS and uh everywhere. What are the barriers for people being referred to dentists? And what, how can we, how can we improve that? Um Because even despite the event, sometimes it's the lack of accessibility and it, it, it, it then really then goes on to the system change. I'm not to do the clinical set up. Yeah, I think you're right. And it is, and it's one of those things that feels like it's getting harder and harder and the discussions and, and I mean, many of us are on local, I mean, my little road whatsapp group and the, and the Facebook groups for communities and there's always people saying, do you know of a dentist that's accepting, do you know of a dentist? So, I mean, and, and, and we're just talking about England and the UK and other countries. It's, it's much worse, it's much worse. The proportion of dentists per head of the population is, is better any. Um, and, and I, and I think, I think we don't see that as a, as a reason to not ask about oral health. We don't say just because there's not enough dentists or there's not enough dental practices or technicians or, or, you know, hygienists, what that whole dental nurses, that whole team approach doesn't mean we don't do it. We don't ask the questions. I think that's my first bit to think about. The second bit is we almost need to though, if we are going to raise the issue, where do we, and how do we then sign post people on. And I think that is a big barrier that people might be nervous about asking about or, you know, healthcare professionals be nervous about asking about oral health because you're left holding the bat. And what do I do if there's no NHS dentists or there's no dentists? And, and so that asking the question leads to something that you can't move forwards on and, and I think that then leads into that wider issue, which is that much more, um it's a much more global issue of a of a shortage of any sort of health, dental, nursing staff. You know, we really do have those great big issues and maybe there is something about, um you know, I'm always saying about lobbying and stuff, but we have to have that whole approach, don't we, we have to have this much different approach to how we structure health care, how we think about because actually it isn't always about going, seeing the dentist. It may not be I go and see AAA Dental. They could go and see you molly, they could go and see, II see a lovely hygienist regularly. So it's not nece and, and, and I know that she keeps an eye on my gums and I see her more frequently than I see my dentist, you know, so I think, I think it's not just about seeing, it's only the dentist that we have to see. Um It's a bit like saying when you go to primary care. You can only want to see the GP yet we know. Now in primary care we've got GPS, nurses, advanced nurse practitioners, um, advanced practitioners, paramedics, pharmacy technicians, we're pharmacists. We've got this whole range and I think maybe what we need to start doing is seeing dental practice as this as a whole team approach which, which it is a whole team approach and maybe, and maybe that's instead of thing. Oh, it's not enough dentists, maybe we just need to think a bit more. I don't know, am I, am I barking up the wrong tree then? No, that, that that's an excellent message actually Michaela because this is this is something which can be sustainable in the long run. So instead of having to just simply bank on your dentist alone who is uh already uh you know, I is available for a very long waiting time. It, it, it it's still better than otherwise to go visit the rest of the dental care team. For example, like you very rightly mentioned hygienist therapists and dental nurses and they could at least shine light on, on the fact that, you know, you are are at a high risk of uh you know, developing further oral diseases and uh you're more likely to lose your teeth in the future. So why not come and get yourself reviewed more, more regularly, more often? So that gives you some sort of uh direction in in the pathway for your oral health care. Yeah. Yeah. Absolutely. And I think, and, and I think if I, if I think back to some of the, uh, well, the issues in oral health and diabetes, uh, you know, my world is more heart attacks and strokes and cholesterol and BP. The issues are still the same there, we know there's a massive inequity. So whether that's socioeconomical status, whether that's ethnicity, whether that's even geography in your postcode makes a difference to how um how people are able to access services, whether we think about health literacy. But it, it, it's just, and again, I think we see no different here than what we would see in, in whatever access of, of the world of health and prevention that we look at. So I feel like we've gone around the world today. She says in lots of ways and I'm not sure we've come up with many solutions, but really this is about having that conversation and having that wide way and, and discussing some of the issues. But I'm really liking those simple questions that you said, you know, how often do you clean your teeth? What a great question just to slip in and, and find out what people say. I might start asking all my friends just to do a little survey. Can I just find out and, and I learned something on this cos II, no, don't, don't get cross with me molly. But um I used to get up and then go downstairs and have a couple of cups of black coffee, which was really bad for my teeth and then have, you know, have a, and it was only, and I'd have a shower and then I'd clean my teeth and as opposed to now what I do, as soon as I get out of bed, I go and clean my teeth. And that's what I've learned is that cleaning your teeth straight away as soon as you wake up is better than doing my pattern that I've been doing for. I mean, which is better than not cleaning it at all. But I've changed my behavior as a result of being involved in, in this diabetes and oral health um initiative by just switching to clean my teeth as soon as I wake up and I do add, I don't want that nice guideline suggest that brushing should be done twice as minimum. Um Last thing in the mor uh last thing in the night before going to bed and at any other time of the day. So mi I'm not quite cross with you actually. So if you manage, if you actually manage to brush your teeth, last thing before bedtime, you absolutely. You're more than welcome to brush any other time of the day based on the nice recommendations. Ok. Thank you. I feel so bad. I won't tell you then about the apple juice. I used to give my daughter before she went to bed after she brushed her teeth when she was little. Yeah. I know. I don't really know. No, that's absolutely. Absolutely. But I luckily, yeah, we did, we didn't do that for longer. But, yeah. But, you know, and you don't realize I'm a nurse and I didn't realize, you know, she's 27 now. She was only, I don't know, two or something. She was only little. I was trying to get her off the bottle and onto a sippy cup. One n she thought, well, I, and that whole box, a whole lot of other conversations, the sippy cups and, uh, the sugar filled, uh, drinks for these kids and toddlers, uh, uh, conversation for another time probably. Exactly. And actually, well, Jill and I did one of those conversations if anybody is enticed about that. Now of hearing this, you can watch that one on demand. It's called, what about the kids? And it felt like I was just being the world's worst mother, um, as, as we were talking about it. So, um, so I think we'll wrap up. Have you got any last, last summaries that you'd like people to take away from this session? Well, it's really, I II couldn't reinforce the message more. It's prevention and prevention is the cornerstone of uh, wellbeing your general health. So, a simple, a simple behavior change, uh such as brushing your teeth twice daily to begin. Ee even if you're not brushing on uh twice daily, even if it's once a day before bedtime, that can work one dose for your teeth in the long run. Um And just, just ensuring you're not rinsing your mouth after brushing. Now, that's also something, uh that sort of, you know, makes people, you know, really, really surprised, like, OK, am I not to rinse my teeth with water after brushing my teeth? And that's the, that, that's when the other nice guideline comes in which says which, which says you're not to rinse your mouth right after, but probably 30 minutes later or so, because you want the fluoride in your teeth um to sort of start uh affecting the enamel change and making it more sturdier. So a a simple behavior cha change which is brushing your teeth every single day and then slowly building it up to twice daily or more than twice daily. Can, can be the best way to look after your oral health. Brilliant, brilliant. And we've just had somebody put in the chat that they're going to ask people from now on about how often they clean their teeth. So, a huge thank you, Molly to joining me today, Judy. You missed out. I hope you're feeling a lot better, but I've certainly enjoyed being your standing. Um Oh, we've had something else coming for a very interesting session. I feel comfortable about asking patients about their oral hygiene when at work and she's water. So that's Natalie and is ward based and always offered to those that need it. Uh, particularly cleaning dentures, et cetera. And patient education is also as important. Absolutely. Natalie. And I'm, I'm really pleased that you've enjoyed this session too. And I think we, you know, if I think back to when I was to be a nurse on the ward, you did involved with teeth a little bit more. But it, but it was cleaning, it wasn't really looking in the mouth, you know. Um, but I guess cleaning was better, better than other stuff. But we, I think there's something about something about, I think that we need to loop back to our, our title. Should we leave it all to the dentist? And I think the answer is no, no. And, and you, you actually put it very succinctly. We put the mouth back in the body and it is about that holistic tear, isn't it? And that's that we, you know, we look after every bit, not just an arm or a leg or an eye or that's where specialists are at. But for most of us, we want to have that holistic approach. So a huge thank you, uh, to anybody that's watched us today and also for anybody who's watching on demand, I'm gonna pop the feedback in the chat now, for anybody that wants to or hopefully you all want to be able to do some feedback for those of you that have joined us. Um I'm gonna say this afternoon it's this afternoon for Molly and I, but you might be joining from a different country and for anybody else who is watching um is watching on demand, please do your evaluation as well. Thank you very much and look out for some of the other sessions we've done too. Thank you, Molly. Thank you, Michaela.