When and why should nurses look in mouths?



This on-demand teaching session focuses on the bidirectional link between type two diabetes and poor oral health. It is relevant to medical professionals, particularly nurses, as it was brought about from a trust grant and is hosted by nurse, Michaela Nuttall, and diabetes specialist nurse, Judy Downy. Through their discussion, they explore the challenges and opportunities in providing better care to patients and diagnosing more people with type two diabetes from poor oral health. The session is part of a series of learn with nurses events and will be available to watch whenever attendees are interested.
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Michaeala Nuttall, RGN MSc founder of Learn With Nurses is joined by Independent Diabetes Nurse Specialist Judy Downey RGN BSc(Hons) to discuss mouth care and diabetes including:

What should nurses be looking for inside someone’s mouth?

Practical advice

Why don’t nurses look in mouths?

Challenges and opportunities Care homes, CQC and mouth care.

A missed opportunity for diabetes?

Learning objectives

Learning Objectives: 1. Explain the bidirectional link between Type 2 diabetes and poor oral health. 2. Identify the potential issues related to poor oral health in diabetes patients and what can be done to address them. 3. Describe the role of Fluoridation in managing oral health. 4. Discuss the importance of educating medical teams on the bidirectional link between Type 2 diabetes and poor oral health. 5. Apply appropriate strategies for conducting an oral health assessment for diabetes patients.
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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 sessions. My name is Michaela Nuttall. I'm a nurse and founder at LA with NSS and I'm joined by Judy Downey Judy. Do you want to say a little hello? Yes. Hi, everyone. Um I'm Judy Judy Downy and I'm a, I'm, I've been working with Michaela for years, but in the capacity of a diabetes specialist, nurse and diabetes educator. Um, so I'm really excited to be part of this project. Looking at the links between diabetes, the bidirectional links actually between type two diabetes and poor oral health. So thanks for joining us. So. Ok. Ok. So I wanna give you a little. So this is part of a series of events that is um been been brought about from a, a trust trust um, grant. Sorry, I'm being a bit at the moment. I've got a really, really, no, Judy. Can you turn your audio off? Just for a second? Let that what that is yourself at the moment. It's gone. That's better. Oh, that's ok. Just unmute when you're gonna talk, it'll be fine. It'll be fine. We've got this, we can do language. We got this, it just started crackling then. Well, this is what happens when you run things live and it learned with nurses, we run lots of stuff live and we just get on with it, don't we? This is part and I think that's part of being a nurse is we just get on with it. So as Judy says, this project, this initiative is around oral health of diabetes is by directional link. And um and so this came about and it's led by three organizations. It's by C three collaborating for health. And they are the main role within, within this project. And then we're supported by language nurses and I work for both organs, organizations and Judy and I have been doing well with nurses for, since, since the start of it in 2020. And the third organization that's involved is the Commonwealth Nurses and Midwives Federation, the CNMF. And we are supported by diabetes UK. And this is a part of a series of events we've been running, we did a few a couple of months ago looking at this bidirectional approach a bit more, but these were ones we ran with slides and things and this is part of our incon conversation sessions. So we're joined, we're running this live and you saw a little glitch at the beginning there and I can see people are joining us now, which is wonderful. But also this will be made available on demand, which means you get to watch it whenever you want to or listen to it whenever you want to. So I'm gonna hand over to Judy now for a moment just to tell us a little bit more about the project. Just a very brief bit. And then, then we're gonna have a bit of a discussion. Thanks Judy. And you're gonna have to unmute and see if it goes a bit cracky again, but we'll see how it goes. Can you all hear me guys? Anyone who can't hear, please write in, in, into chat and, and please use chat for any questions as well. Um Yeah, this is, this, this was I'm a diabetes specialist nurse, as I just said, and I have someone's, someone's put in to chat. They can good. I, I always like to know that people can hear because it's frustrating if you can't. I've been a diabetes nurse for years and years. Some of you already know that, but it's only really since I got involved in this project with trust and obviously learn with nurses, but that I've actually learned a lot myself about this, what's called a bidirectional link between poor oral health and diabetes, all types of diabetes, but especially type two diabetes. And I've learned so much and I've actually got really interested in it, which I probably, you would never would have thought I would do. But in all these years that I've been seeing diabetic patients often with very poor diabetic control because that's what we do is DSN. I often noticed that that people's teeth looked awful. They often had lots of teeth missing as well, especially the people who had really, really poor control and usually had, had diabetes for a long time. But I didn't actually look in their mouths or give them any advice regarding oral health. Um, you know, now I would change tack completely because I now know there is a strong link between, um, poor control of diabetes. But also conversely, if you have poor control of diabetes, you're much more likely to have poor oral health. And by that I'm thinking of, um, starting off with, you know, cavities, you know, where you need fillings, we've all had fillings. Well, I have and, and we're from that era where we all had a lot of fillings. Yes. Yes, we did. And it's interesting because our kids who are, who were a lot, obviously a lot younger, but they don't think that because of Fluoridation, isn't it? The, I believe they don't have nearly as many fillings, but it was common, wasn't it? But the thing is a lot of my type two patients, they usually are type two, actually don't go to the dentist and never have done. Um, and yeah, because, because of the, well, not many dentists now, see private patients. Any, sorry NHS patients, I mean, and, and, um, and now it, it, you have to wait months and months So, so if, if your cavities aren't dealt with, you can develop this thing called periodontitis, which I'm sure you've all heard of starts off with bleeding gums. I bet we, I certainly get that occasionally when I brush my teeth hard. It's, it's, um, but that leads on to bone loss eventually. It's quite scary. And that's why a lot of the people I saw had teeth missing because they'd gone way past that stage with bone, bone loss. And of course, the bone in the jaw anchors the teeth in. So I'm putting it quickly basically, and their teeth get loose and eventually fall out. It's awful really. And of course, because they've got high blood sugars and usually they do that sort of exacerbates the whole process, um or, or infection setting in, for example, and poor cir circulation. But conversely, if someone does not already have type two diabetes and they have a mouth like that, that's going to exacerbate, it is going to speed up the process to developing type two diabetes. So we do believe that if the message could be got out there and there was enough education for us, not just nurses, but the whole multidisciplinary disciplinary team, then this may slow down the total number of people that are developing type two diabetes, which as we all know is huge, isn't it? And we now understand that poor periodontitis really, I'm talking about really poor oral health actually is a contributing factor to developing type two diabetes. And that's what I've learned really. And why I now feel that if I were seeing patients, I would actually ask them about their oral health and check it out. That's what I've learned. It's, um, fascinating. Really? And I look back at night, I think, oh, my God. All those people I saw and I used to think, well, you know, he's hardly got any teeth and he's only in his forties because often that's all they were. And I didn't, I didn't actually even comment on it, let alone do anything. It, I think that's what we, that's what we end up with in some ways. And I remember when I, when I, when I used to, you know, years ago on the walls and I'd take a pulse and write down irregular on the chart and I do think I need to go look for a or something. I would just write down because that's what we did now. Yeah. And so I think we can think, you know, well, you know, we have to learn from what we've not done and then I think, move forwards with what we can do. And I mean, when I think about when I first spoke to you and said, Judy, we've got this project. What do you think about this initiative of health and diabetes? And you were a bit interested? But then you became rapidly interested, I think, because of the, the the potential, I think from both ways that are there. And I'm pondering here thinking so we know that actually we know that, you know, the diabetes epidemic and we hear more and more now from primary care, particularly since lockdown that there is more and more people with the prediabetes and diabetes being diagnosed that has ever been out there, that's ever been out there. You know, it's rocketing up, which means we're gonna have worse and worse, oral health and worse and worse teeth as we get older. But in the converse, there's probably a lot of people who didn't go to the dentist either during lockdown and are not going to the dentist now. And the challenges with the lack of NHS dentists and, and even just, you know, the cost of living being able to afford to go to the dentist. So, as well as this availability of the sugary products and all of that stuff that actually we really got, we're at the beginning of a new ticking time bomb, I suspect. And one that, that makes each other worse, I think so. Um, so I just did a couple of questions. So not just just as checkups, somebody's put in, but also the dental treatment. Absolutely. Absolutely. And, and so before we start thinking about opportunities, I just want to, um, think a bit more about the challenges. So, because what we want to do is if you were talking about being able to look in people's mouths and if you go, if you knew what you knew now back then and with people with not a lot of teeth and, and with type two diabetes or with diabetes, you do something differently and what would you know, what, you know, what would you be able to do? What, what could you do? How do you tell me? Am I making sense? Yes, you are making sense. And I'm, I'm familiar more recently working in primary care, which is so for example, all our people with, with diabetes, even type one diabetes have their annual review in primary care, um, which is actually very annoying to a lot of people with type one. I'll tell you that because they still have to go to hospital appointments as well. So I see that hospital, diabetes clinics could and should be involved in this as well. Um, but, but I suppose the logical steps, some people might say is that, that the, um, oral check should be part of the annual review along with all the other things though. And that's often the problem because of the lack of time. So with the, with the best will in the world, it's very hard to actually fit everything into an annual review. And anyone who's listened to this, who's a practice nurse in primary care will know this is true. It's really hard to fit it all in. Um, but ideally it would be one of the um, where people come from annual reviews, they usually send the questionnaires to bring along about what's been going on in the last year. And obviously what's been happening with their mouth and their teeth could be in that que questionnaire to get them thinking. But ideally, I, I would, um, because you can see if someone's got obvious problems such as a swollen face or they tell you I've got terrible toothache but, but it's often they don't really have symptoms like that. And I ideally you should actually ideally look in their mouths, have a quick look inside their mouths with using a light source. But obviously that does mean people need to be educated and actually make the rest of you a lot of times it's healthcare assistants that would be in the position to do that. And I, I, because they do the more practical parts of an annual review such as the foot check as well. So, I mean, I'm thinking back to when I was on the mouth care in the old days and I mean, I still remember the sponge on a stick. So do I, so do I on the stick and the pink stuff? And you took it all off and then it was a bit of something around your finger and all of that sort of stuff. But, but I didn't look in the mouth. I just rubbed something around it and, and I'm wondering, do we as nurses do we look in mouth, you know, do we look in mouth and certainly in primary care, would you, why would you look in the mouth unless, you know, I think most of us wouldn't look in the mouth until there's a reason to look in the mouth, which might be something that's sore and hurting. And then do we not just think? Well, that's surely that's the dentist that has to look in the mouth. So it does it take long to look in the mouth with the lights off? Does it, does it take well, having not done it yet? But I would say I would say it wouldn't take long. Um, but obviously you as the nurse, the health care assistants, because I do believe that most people who do this in primary care would be health care assistants. So, and I've done a bit of research, read a few articles and it does say that that they're trying to get some, there hasn't been any training for healthcare assistance. Excuse me, if I've got it wrong now, but up to a few years ago, you know, where they were doing their training, there wasn't anything on mouth care for health care assistance. So, you know, and, you know, I used to provide education, diabetes education in primary care. And now if I was still doing it, I would include a session for health care assistance and the practice nurses and the GPS quite frankly, you know, because ideally that take the, it's a bit like they take the opportunity to grab you for a flu flu jab. I know when I did my diabetes clinics, it was like anyone who came through the door. You know, even if they had a book, they got a flu jab, you know, whether they liked it or not actually. But saying that that makes me think about the payment side of things in primary care because that's the flu jabs. You know, of course, we, we thought people should have flu jab but they attract payment. So, yeah, so if the oral check cannot be put into a system where there's a payment attached that is a big disincentive, I'm afraid. Yeah. Yeah. And I, I was just looking at next year's cough as well and, you know, and it's, it's very long with lots to do to work through. Um, and, and, oh, I'm, I'm pausing on cough for a moment while I was thinking about what's in there. But I think there's also, you know, we know it's not in cough. We know it's not gonna be and even to get it into an annual diabetes check and get it on the table to be discussed. To think, could it go in because I'm sure there's lots of things that want to be thrown into a diabetes check, an annual, an annual review check. What else could we do? And, and it's about maybe it, nurses and health care assistants, whoever else is, we know we have a big health care team involved with, um, with caring for people with diabetes or, or without diabetes. But noticing that um, that their mouths are not looking as good as maybe they could be, but maybe what we could do is start thinking about when, when should I as a healthcare professional? Think about looking in mouth because it's not necessarily just waiting until people have got diabetes or waiting until I can see they've got teeth missing. I think there's something in the middle there to say. Is there something we can do earlier on to prevent the teeth getting bad and maybe to help prevent diabetes? I think that there's maybe a sweet spot in there and I'm almost thinking, should we be able to do it when we do a BP check? Could, is it something we could log in with a BP check? But we don't know yet, do we? But what would say? Yeah. Yeah. II, I believe that, um, it could, it could and should be as they do with flu jabs, you know, something because it should be quite quick because you as the practice nurse that and actually nurses on the wards as well can, can have a look. Of course they should. But it's, you know, it's something that sometimes you do have to be opportunistic with, with people. Um, some of the people who do have the worst oral health are people that possibly don't even come for their annual reviews. Yeah. You know, and, but they'll turn up for some other reason. So, so, you know, I'm almost thinking, you know, anywhere where we see patients surely we should make, looking in their mouth is part of, you know, we do your BP, your pulse, we do your sacs, we do your, this, you know, I know that they're very different type of measurement. But you know, we'll ask all different things, check your pressure. So I'm thinking when, you know, when you're in the hospital, all these different bits, just having an extra little bit added in and let's have a look in your mouth could be really useful, but a challenge we would have. So what do we do if we find something? And that's for another day. I say that for another day because we can't ignore the challenges that we have with getting to dentists and stuff. But is there practical stuff that you've come across in this session that people can do themselves that doesn't involve going to the dentist? Is it as simple as cleaning your teeth more frequent? Yeah, I've seen it. Um, you know, suggested that it would be a great idea and I'm also thinking of Children too, you know, because I in a perfect world, it would start in childhood learning how to clean your teeth properly, doing supervised brushing. Um, you know, but again, I'm thinking of the time constraints of doing that. It's, you know, if you had 30 minutes or 45 minutes, it'd be so enjoyable because you could really give the education you want to give properly. You know, whereas often we're in a position where we say, oh, here's a leaflet, you know, and there's loads of leaflets out there about how to look after your mouth and how to brush your teeth. There's loads of things you can find that you, but it's not the same as demonstrating it, you know. So brushing is re really important how and brushing twice a day and ideally watching how someone does it, you know. Um Yeah, but you're supposed to not spit. Are, are you, you're supposed to keep the toothpaste on your teeth? And I think, didn't, didn't we have um we have Jill doing that session um on one of so for anybody that's watching this now and you haven't been a part of the other ones. We've got, we, we've built this as a sea of different sessions and this is just having a conversation. Judy does one where she goes much more in depth about the diabetes side of things and the impact with oral health. And Judy does one a lot more about the oral health and what to look for in mouth. So if you, if you've joined a session and this is your first one, hopefully we're going to entice you to go and join some more of the others. So I think we've had a little bit of a chat about some of the opportunities that where we could do that. Um I think you've got a really, you really clear gap where you've mentioned about training, particularly when it comes to health care assistance and, and actually, I would stay with nurses as well. And part of this, um, this whole initiative with this diabetes and oral health initiative we're doing is um to um we've got a round table coming up in a couple of months which Judy's coming along to. And it really is thinking, is there a way we can influence policy, influence educators influence because we want it into nurse curriculums, any training curriculums. Just that real importance of, of looking in mouth. Yes, what we've got to do with it is another matter. But even if it's just simple advice about cleaning teeth and mouthwash, but I want to just draw your attention now to something about care home student. And we know that care homes are, you know, we are a very aging population and it came and we learnt more about this when Judy and I were at the Burdett M CD symposium A it was a couple of months ago, it was September, I think, wasn't it? It was only last month. And Judy and I were part of a cafe style discussion where we met lots of nurses and we were explaining about this project and they were, before I talk to C QC. Do you want to have a moment reflecting on that session and what, what you learned from the nurses and how keen they were? What did you think it was? It was a fantastic session. Um Yeah, so, so I'm just trying to think, I mean, the, the subject of, um you know, what do you do when, if you do that? Because we need to send refer people on and, and that came up a lot, didn't it? We do have another session where we're going to cover that in more detail with your dentist Molly. So I won't go into too much detail, but I know Zoe's mentioned it a few times that, that, you know, should people with diabetes have free dental checkups. But, you know, yeah, of course, they should. But, but how could we make that happen? And that is one of the things when we have the round table we're going to discuss, aren't we? Um you know, but, but even if they could have free dental checkups, would they go? You know, I'm not being funny, but a lot of the people who have real problems probably wouldn't go. Yeah, we're looking at who has the worst teeth and who has the worst mouths and that's the discussion that's going to be by Christine Hancock and Jill from the Commonwealth Nurses and the CNN F because we know that type two diabetes type two. Diabetes is disproportionately born by people who are less, you know, poorer socioeconomical status, ethnicity. However, we look at um however, you look at inequalities, diabetes and access to oral health care to, to dentists and maybe toothbrushes and toothpaste because all of this stuff costs money. So there's a really good session gonna come up on that one. But II I think what, what came out of it for me that round the, the, the, the, the, the Burdett session was that really the nurses there were very keen off because we had, we did the same session four times over. Do you remember when it was? That's why we like, we were absolutely blown away by it four times over. So it was a bit, we kept, we repeating ourselves, but actually the discussion kept evolving. But one of the things I think that came through is the nurses were saying, give me really simple practical stuff. It would, they really, they didn't want not, not too very fairy, which is maybe what we're doing now but that we're just having a discussion but they really want some really practical, simple implement um advice. And I think that really echoed for me the challenges that what it is to be a healthcare professional today that there is so much going on that unless something really sparks your interest, like, like you've just done with like you've just done with all health and diabetes, but that's your world, your world is diabetes and it's always been diabetes. But if it's not, your world, diabetes is in the world, how do we spark and ignite that to become your world or oral health? To become your world? And maybe that's what we're trying to do here, isn't it? Is just really raise that awareness and, and, and get people to think a little bit differently to be able to nudge people along. Oh, I hate that word nudge. But to move them along to the, to think a little, to think a little bit more. So I'm just going to spend the next few minutes now talking to you about the C QC and care homes. So, one of the people, one of the people on, on one of our round table, one of the nurses said, well, what about care homes? Shouldn't that be an opportunity? So I went and had a look for it and there's a, there's a report by the C QC called Smiling Matters. And what they did is a big overview of um, oral health in care homes. Now, when we think of care, that is not just um, people who are older, you know, we have all different types of people, maybe with learning disabilities, physical disabilities that live in care homes. So we, we're not, you know, this is the whole population that, that, that live there. And what they saw was that, um, in care homes, the majority of people. So 63% of people had care plans that only sort of touched on oral health, only sort of touched on it. And when they actually asked people, when you know, when people go round on the, on the C QC visit to say, are you aware of the nice guidelines in relation to oral health and care homes? So there's actually a nice guidelines and um only 28% have said I've heard of it and I've read about it. The majority of people have never read and nearly 40% have never heard of it. And this takes me on to the third bit, which is about do the staff and the care homes receive training. So there's a nice guidance there to say it's really important to think about um mouthcare, oral health and whether it's not just dentures, it's about the whole lot that almost half of the people had had no training in any sort of oral health and only and then about 23% had sometimes a little bit and that their staff had some and it was only less than a third that said, yeah, their staff always have oral training for mental health, which then made me think about the session that we saw with Adrian who um he's so before I come back to on that one is he's a learning disabilities nurse. And his dissertation was around one of the um service users that he cared for that had really challenging behaviors and it ended up, it was because he'd had an abscess and was unable to say he had an abscess. So I just think there's this real opportunity in care homes. If you know, if we can't start anywhere, if you can't start all over is care homes an opportunity because we've got the nice guidelines for it. Now, the C QC and this is 2019, it was written and there's still lots of opportunity for training in care homes to really help improve that. So was that I just like your thoughts on some of those elements. And what would you advise Jude? What would you think about? I, I've just learned from you. I haven't actually looked at those nice guidelines, but that's really interesting that it's mentioned, but I'm not a bit surprised that a lot of people haven't heard of it and a lot of people haven't even read it because that is true of most nice guidelines. Let's be honest, they are quite difficult to get your head round, aren't they? But it, it is a good starting point and my experience which isn't vast, but I have done some training in care homes and they're usually really keen because I think often they feel that they're left out. It's been said to me, you know, it's, they're left out. No one bothers with them, you know, doesn't. And yet we've got this huge population of people in care homes, like you say, they're not all, very elderly and they're not all demented, you know? And, and we, yeah, I mean, going into the care home to do training is, is the ideal thing because it's, that's my experience because it's very hard for them to get away, you know. But a nice little lunch time sessions are ideally with some sandwiches, you know, lunch time. We do it. Yeah, I know. So, But then I pondering on, is that a little something we could think about going forward though? Is that a bri idea? Yeah. And I think as well because, you know, care homes don't necessarily fall under the NHS. Do they? They fall with the local authorities and social care and, but then social care budgets are absolutely stretched. And what do you do when you find somebody? But I think if we can come at it from that angle of prevention and preventing diabetes, I think that's quite a powerful message. I think what we, if anybody's watching us now or on demand and you are from a care home, we'd love to hear from you or contact us. However you think of just how could we make this happen because as you say, Judy, we love to go in and do training on site in person. You can really get to, you know, we love doing our online stuff as well, but face to face is special, isn't it? Yeah. Yeah. Absolutely. And I think, I think you're right about not feeling valued and, and being given training particularly by is a way of feeling valued. That actually my, my knowledge and my, and my education is important. So I do think training is important to make, to make, to make health care professionals feel valued. Got a couple of minutes left before we wrap this up. And I wonder if, if you've got any little gems, anything you might like to ask me anything. What, what about your thoughts, Judy before we start to wind this up. But if any, I'll just have a chat chat in case we've got any questions that have come in. You want me? There you go. If you want to put something in to chat, anyone. Um I know Zoe has a, a few things but yeah, I, my thoughts are, this is a massive, massive, massive hu humongous idea to, to try and reduce the, to show an impact on the incidence of type two diabetes. And it would take many, many, I probably won't even be around by the time it did because as we know type two diabetes doesn't come on quickly. It's many, many years of metabolic changes up to 15 or even longer. And often it's to do with how family history as we all know, but also how a child, you know, the diet of the child and whether they were obese or not in childhood. So, ideally, it's really got to be in schools as well. And I think schools as far as I know, do do oral health, you know how to brush your teeth and things, but the parents need to be on board as well, don't they? You know? So can I ask you a question now? And one that I, and it's about the onset of type two diabetes. It's about that journey. Say I started the early part of that journey. So say I was 45. I mean, I wish I was 45 but let's say that and I was not exercising as much and I was piling on the palms and, and, you know, I might have, you know, genetic predisposition somewhere and I started down my journey of developing type two diabetes. How does that timeline compare as if I was 12 and started being exposed to not exercising and all of that? Does it, does it happen quicker? The younger it starts that timeline because I kind of feel that's what happens in cardio. Uh That's a good question and I believe it must do because there are teenagers being diagnosed with type two diabetes at the age of 15, 16, 17. Um, you know, actually, you know, I'd have to look for the evidence for this, but I can see what you mean because, you know, with, with older traditionally, people were in their forties or fifties or sixties even. And we used to teach, you know, the metabolic changes could be occurring up to 15 years before diagnosis. But they couldn't be, could they, if a child is diagnosed at the age of 15, 16? Yeah. Yeah. It's a really good point. And I'm not giving you clear answer because I don't think there is and the building up of blockages in the arteries and a lot of it is all to do with that inflammation that sits there or in markers, which is in people with type two diabetes. Just to say many years ago, I was in a research nurse at Oxford University and it was, it was a prospective study into childhood diabetes. So they all had type one diabetes. But we did back in those days, I used to go around getting all these bloods of Children. God, you know, and um, I had to spin and separate these blood samples. Yeah, I used to take my kids with me, you know, and they'd stand by the centrifuge. There were, there were some and they were using boys again. I can't answer why. Who, whose lipid started to be deranged in teenage years. Yeah, you could tell when you spun and separated it, you could see it in the sample. I think that they think there is a link between, you know, having type one diabetes from a very young age and, you know, not necessarily familial hypercholesteremia. But yeah, it's um, to get back to your question though. I do. I, you know. Yes, it's got, it can't be 10 or 15 years where they develop it at the age of. And it's scary to think those Children are so young. So by the time they're in their forties, they've already had diabetes for over 20 years. I know we going off on to heart attacks and stuff and women having heart attacks. So about this for shut me up just really nicely to some of our other sessions. So we have got one coming up called. What about the kids? So I think that's you and Jill, isn't it about? What about the kids? I think that will be for that one yet. Please do look because that will be another discussion really exploring this way about that relationship that's there and what can we potentially think about it? So, before we wrap up, I, I, I've seen a question. I see a comment come in so nurses could have patience placements with hygienists and dental nurses. I think that sounds very exciting, doesn't it? I think that sounds and maybe that's something we bring to our round table. Yeah. Yeah. Academics coming along because I know that people are never happy with their placements. Are they? It never, it, it's, but, but I think it sounds really good even if they just did a day or two there, that's what I was thinking. It, it didn't, wouldn't need to be a long placement, but just to see for themselves, you know and get, and I'm sure those, those lovely people who work in dental surgeries could tell some stories about what they've seen with people with diabetes and poor oral health. Yeah.