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OK. Hi, everyone. Uh Welcome to the session in the um series of programs on oral health be asking why doesn't everybody clean their teeth? And I have with me Christine Hancock, founder and director of uh C three, collaborating for Health. He'll tell you a little bit more about the, the Oral Health Series. Um But just to remind you, uh as far as the medal form is concerned that at the end of the session, you need to fill in the feedback form so that you can download your certificate and a feedback form will be sent to you on the chat. But if you don't get it on the chat, um it'll be sent to your email mail by the organizers. So to let know about the um the oral health series and um engaged with and a little bit about C three and learn with nurses. I will indeed. Thanks. Thanks, Jill. Uh Hello everybody. Um Good morning, afternoon, evening. Uh here in London, I've just finished breakfast and cleaned my teeth. So uh so the timing is uh timing is good. Um And I'm delighted to that you're joining us for this session. It's, it's one of the series um that we've been collaborating on um about oral health and diabetes, which is a grant we've received from the Burdett Trust, which is a big uh foundation um supporting nurses and nursing work um mainly in the UK but to some extent globally and some of you may have been involved with the nursing now campaign um which they, they funded um C three is a global charity headquartered in London, not very big. Um But we think making more noise and bigger than weeds look as though we are and we're about trying to prevent chronic disease. I'm a nurse by background and I couldn't believe it when I first heard that if you could support people to stop smoking, eat and drink differently and being a bit physically active, you could prevent so much ill health, including about two thirds of diabetes, type two diabetes. So we, we work in a number of ways. Um But we work with nurses a lot. Um Partly because my background is nursing and I believe nurses can do a great deal. I'm also no, there's about 28 million of us around the world. So if they all felt as strongly about preventing chronic disease as I do, we'd have our own army out there as it was. Um and the Burdett Trust for Nursing by funding um projects programs like this is very much supporting it. Learn with nurses is an amazing organization set up by one of my colleagues at the beginning of the pandemic to be able to reach nurses online for education and training opportunities. Um So we're delighted to be working with Commonwealth Nurses and Midwives Federation and I'll ask Jill to tell you more about that. Mm Thank you, Christine. Just very briefly, we're a federation of free associations in commonwealth countries and our, our role is to support those nursing and free organizations with capacity building, link them together uh provide education. Um And also do so that keeps us busy at the moment. We're, we've been really busy with the mental health legislation and with uh developing um the practice. Um and now working with C three learn with nurses and the better Trust for nursing on the oral health project uh which has been a lot of fun. Thanks Christine. Oh, thank you, John. It's good. It's great working with you though. Uh working at the other end of the world is um a little bit difficult for all of us. Um the the, the Oral Health program um and this is a part of it. C three is Oral Health Program, most of it working uh with Jill and the Commonwealth Nurses Midwives Federation is really about alerting nurses to the importance of oral health. And I have to say I'm quite embarrassed that I haven't thought about it more. So as a nurse, oral health is sort of obvious cleaning teeth of people in hospital and mouth care. One of the things we learned almost day one of our training programs. Um but the awareness which seems to be so obvious that because what you eat and drink is so key to your health and to the um chronic disease, especially um obesity and diabetes. I had never really associated it with oral health. And yet I knew that somehow I managed to forget. I think that when the World Health Organization came out with its very strong messages about sugar. And most of us interpreted that as being about obesity. Actually, the originally, it was about oral health and tooth decay. So oral health is really important. It is after all, the gateway to everything for us, it's also important in terms of speaking, if I wasn't smiling, I'd be a bit different to listen to and you wouldn't, I hope you're warning to me, but you wouldn't warn to me if I wasn't smiling and looking cheerful and a nice person to talk to if I couldn't open my mouth because I was so embarrassed about my teeth. Um So we've um been working particularly at the moment in, in Africa and Asia with J and colleagues and with the support particularly of Colgate. But Burdett Trust has been running a series of grant proposals linked to chronic disease, what globally are called non communicable diseases. NCD in the jargon. Well, certainly in the UK, we tend to call chronic disease or long term conditions. And from c three point of view, what we're so aware of is how almost easy it is to prevent them if people could just adjust those simple steps, except they're not simple, especially for the most disadvantaged people. So, oral health is crucial um because it's where, where we, everything we eat, um and drink and drink, perhaps particularly important because of the impact of sugary drinks and the widespread availability. And when the Burdett Trust recently put out a proposal um for grants linked to diabetes. And because from ac three point of view, preventing diabetes is a very core message, we submitted a proposal and been uh great to be funded um to look at with nurses, the impact of oral health on the prevalence of diabetes. And again, I thought I knew a lot about diabetes, but I didn't know about what's called the bidirectional links between diabetes and oral health. So this is part of our overwhelming oral health work. Um And we're gonna chat to each other. Um And hopefully you'll hear and um, almost join in. Um, and I'm going to start off linked to the title of what we're talking about today as, as I said, someone who's just come down from cleaning her teeth after breakfast, Jill, why doesn't everybody clean their teeth? It's a very good question, Christine. And there's, there's quite a few reasons I think first of all, there's a lack of education and reinforcement about the importance of oral health uh for parents and Children and even health workers. And that, you know, parents, um, those who were responsible for Children unless they have been in the habit of cleaning them, their teeth themselves. Unless they know why they should be t cleaning their teeth regularly every day, twice a day, two minutes. Um, they're not going to reinforce that with that with their Children either. So I think this lack of understanding and a commitment um to developing healthy daily oral hygiene routines stems from early childhood. So if you're not taught those routines as a child, you're not going to continue them as an adult and then you're not gonna teach them to your Children. So we need to be able to stop that cycle, that negative cycle and turn it around so that it's a positive cycle so that Children are taught to the um daily oral hygiene routines. It is so they can reinforce it to Children. And then as those Children go up to be adults, then they can teach their Children also. I also think there's a lack of commitment by governments to oral health. You very rarely see public health programs um targeting oral health. Uh you see them about other things. Um But making that like, as you said earlier, making the link between sugar and oral health um is really important or you talk about uh you know programs about nutrition, but that doesn't make the link to oral health and how important your teeth are to have good nutrition, to be able to chew your food and to be able to digest your food. Also, some reasons why people don't clean their teeth are outside of control. It may well be that there's a lack of oral health professionals um in some, you know, across the world, uh there's uh there's not a great deal of emphasis on or training oral health professionals. They have dentists, they don't have oral hygienists or um dental nurses. A implements quite often don't publicly fund oral health professionals. And so going to see an oral health professional, the private sector can be quite expensive, also cost of living profe um pressures, you know, they, they sometimes people have to make choices about what they spend their money on. Um But one of the things that I, I try to get across is that cleaning your t um is really costeffective active because it is so much cheaper to go to the dentist to have teeth filled or teeth pulled out or teeth replaced or having gum disease. It's really important that uh we get this message across but saying all that the UK is a high income country. Um So why uh surely everybody in the UK cleans their teeth and store and oral helping. What do, what do you think? Yeah. Well, so, so we should um there's almost no excuse. Um but the reality is not good and it's not good in many high income countries. Um particularly those that have big gaps uh between the health of the wealthiest and the most privileged people and the health of or the poor health of those um who have the lowest incomes and the most challenges in so many ways. And I think the the dilemma is that when your family budget is really stretched and your priority is to try and make sure everybody gets food and that you're able to, as we approach the winter that you're able to eat uh your homes that while the cost of toothbrush and toothpaste doesn't seem enormous. Um It's something that when you're trying to scrimp and save some people, sadly, um feel that it's something that they can leave off. And I was really shocked the other day. Um so a few weeks ago and some people listening from the UK may have seen it, but there was a survey done of teachers and 80% said they were bringing toothbrushes and toothpaste to school because their kids were not able to clean clean their teeth themselves. And there were some really, really sad anecdotes. The one that happening really with tears um was a little boy who was wearing a mask and the teacher thought he was anxious about COVID. Um and he said, no, his teeth were so awful um that he couldn't bear for people to look at them. So he wore a mask and that's just so terrible. And the cost of a toothbrush and toothpaste and if you've got, you know, three Children and two parents, that's, that's quite a frequent cost if you buy a cheap toothbrush and its uh replacing toothpaste. Well, you don't need a great deal, you know, five people in the household and you can get through a tube of toothpaste quickly. I think when you're in the supermarket shopping and the bill is hitting your limit, then toothpaste may be one of the things you feel you can leave behind. And it really is um as Jill says in, in this country, um there's much more support and incentive for um having your eyes or your ears tested than there are for looking after your teeth. We've also here in this country had a lot of problems getting access to dentists, um difficult to get uh what we would call NHS access, the National Health Service and having free dentistry. So dentists are more and more moving into private practice. I'm told there are complicated issues about their contract and the way they are paid. But the result for people in this country is that getting to see a dentist is incredibly difficult. And I have to say if you get toothache, you go rushing to a dentist, there is almost no pain like toothache, but there can be a lot wrong with your teeth and there isn't then then the sort of incentive um to go to, go to the dentist, I think. Mm. Well, if it's, if you're not having that, yeah, if you're having that problem in the UK, you can imagine what it must be like then for people in, in, um, low or low, middle income countries. Yeah. Um, can you talk a little bit more about your, you started off saying, talking about, um, the link between oral health and diabetes and, um, I wonder if you'd talk a little bit um effect of oral health on a person's general health. Yeah. So there is a lot of evidence now which again, I come back to my sort of confession at the beginning. I don't think I'd ever thought of, I thought of oral health as really staying there, you know, cleaning your teeth. So they look good, they didn't get diseased. Your breath was good. II never saw it going much past the front of my mouth really. Um But it's the poor oral health has a very close link to developing diabetes, which is particularly what our current piece of work is about. But there's also very clear evidence about links to cardiovascular disease, respiratory disease and dementia. So these are the major, you add diabetes to that. These are the major killers and the major causes of serious ill health. And in most of our countries at the moment, they're also the major cause of pressure on our health service, hospital services, perhaps particularly, but primary care services as well. If you could wipe out diabetes, hypertension, cardiovascular disease, respiratory ill health and, and Alzheimer's disease, blame me. We nurses wouldn't have much work to do. Um And clearly, sadly, that's not gonna happen quickly, but this is an important area to stop. So you can talk to people about their teeth. And actually, I think that, that people listen to that because most people know it was better to have nice teeth, nice smile, clean breath. Um, but I think very few people understand or have ever heard that it might be a link to diabetes, to heart disease, to Alzheimer's. So it is, it's bigger than just your teeth. Um It's a real impact on your overall health and that's why nurses are so important and why it's not just something even if you had easy access to the dentist, even if you went every six months to the dentist. Um and the dentist hopefully might tell you about all this. But actually, nurses see people at all sorts of times for different reasons and they have that great opportunity to say by the way, while I'm taking your BP, can I remind you, do you clean your teeth regularly? Do you know it's as important as keeping your BP under control and having that sort of conversation with people that you might be talking to and let alone your neighbor or the person in the shop if an opportunity arises to talk about the importance of oral health. We, nurses should take it. I think. So. What do you think, Jill, do you think I'm right. Could nurses and midwives do more to help people's oral health? And could they do more most of all for Children? Because, as you said, right at the beginning, if people get used to cleaning their teeth, it's, it's a habit and it will continue. Mm. Yeah, I'd, I'd reinforce what you just said that, uh, nurses have great opportunity, nurses and midwives, they have great opportunity. Um, generally they're well respected. Um, the, the information that they provide is trusted. Um, I think it's, uh, you've confessed yourself that you weren't particularly well informed. Um, and that, that's one of the II think that's a personal responsibility. Nurses have to make sure that they're informed and an opportunity like this where you've got, you're going to be talking about, um, uh, oral health, um, is to make sure that you keep informed. You know, you've, we, we did a survey of nurses and we did a survey of nurse educators and overwhelmingly almost, you know, 85% hadn't done any updated education on oral health in the last three years and such a lot is happening. So to, to not keep yourself informed is really quite, uh, is quite negligent apart from that you're not looking after your own oral health if you're not keeping yourself up to date, uh, or your children's oral health. So you have to look after your own or oral health. You have to look after the or you have to keep yourself informed, provide or effect you have with a patient. There was a study done that showed that the incidence of uh pneumonia in aged care homes could be reduced by 60% if the care workers made sure that the residents cleaned their teeth twice a day, um and made sure they did it. I mean, didn't just hand them the toothbrush or, or, or whatever, but helped them, you know, particularly in aged care homes, um, or, or homes for people with disabilities, particularly intellectual disabilities, they sometimes need assistance with things like that. So not just stuck, sticking the toothbrush and mug on the, on the table and expecting them to look after bells, but support them with it and looking inside people's mouths, you know, nurses, nurses don't have to offer treatment, but they can, they've got an fantastic opportunity to look inside people's mouths and give them some advice about what they need to do. Um You can easily see dental caries, they, they stand out because they're dark particularly. You look a lot al along the gum line. You look at a person's tongue, you look at their gums to see if there's any recession around the teeth. Um You can also pick up and, and for the early detection of oral cancers. Um it's, it's probably uh three or four minutes to look inside somebody's mouth and to give them some advice. Um, one of the things that always upset me is, is, uh, when you do a patient admission or you're checking someone off before they go to the theater or something, all you usually ask them on the admission form is whether they have dentures or implants or whatever. You never ask them really about their oral health. You never ask them the last time they went to the dentist, you don't ask them if they've got toothache. I mean, that's the uh or, or their gums bleed. Um These are the things that nurses can do and, and, and probably as much as possible with the associations um for more oral health personnel. Um and, and more um more respect generally for the, the contribution that nurses can make the link to general health, the link in reducing the burden of disease. Um making the link between oral health and general health. You know, ii think these are all things that um that nurses and midwives can do. Um midwives, maternal and child health nurses, you know, it's, it uh it's really important. Yeah, I mean, I think the issue of pregnancy is, is one that's very important. Um dental decay periodontitis in pregnancy can lead to gestational diabetes, it can lead to um premature babies, it can lead to stillbirth. Um and I think it can also lead to your own teeth pulling out. Indeed. Indeed. Which isn't very pleasant. Yeah. Absolutely. No. No. Um, and I think, I think there are a lot of myths as well about, um, how first teeth don't matter and you can wait until you've got your secondary teeth, but that's too late. And therefore, you know, your baby can't clean their own teeth. But the mum can wipe, gently wipe and keep clean the gums and then as soon as possible learn to clean their teeth and make it fun and something you always do. Um, it's wonderful when you i toddlers sort of wanting to clean their teeth because some of their mother or their father has made it a fun thing to do. And that's really important. Yeah. The other things that are important to remember, you only need a tiny, little bit of toothpaste, pea size amount of toothpaste. You see pictures of people slathering toothpaste and their mouths all fluff with froth and bubble, but you only need a small amount which also helps with costs. Um and, and uh you know, one of the questions I'm frequently asked is about, um, what should you do about sugary foods? You know, Children love to have something sweet. Should you be depriving them of sugary foods? You know, occasionally sugary foods are fine. But it's a real good idea if kids rinse their mouth after they've had something sweet, you know, instead of leaving all the, the chocolate and the, and the sugar packed around their teeth, you know, give their mouth a wrist, a rinse and get rid of it. I notice that there's been a couple of comments on the chat. Um One suggestion is that or question is, should, should we be seeking donations, toothbrushes and toothpaste to food banks? Um I don't know about the uh the UK but in Australia, the number of people going to food banks um this in this last 12 months um has risen by about 60% and people who'd never been to food banks before are now going to food banks um just for um you know, really essentials. Um And yeah, the comment is um should we be seeking donations of toothbrushes and new toothbrushes? Of course, and toothpaste to food banks, I think the answer is absolutely yes, shocking and and in a way it links to food. Um So if you're so hard up that you need food from a food bank, you absolutely be sure that you're not getting um a diet that's full of fresh vegetables and fresh fruit because that's too expensive. Um So people who are using food banks are likely to be eating um and their Children are likely to be eating disproportionate amount of food that is high in sugar. And so toothpaste, toothbrush is really important. Um And we've had that debate in this country around um sanitary products and this is very similar in a way they are and they're expensive and people who are trying to make sure they can have food and warmth come top of everybody's list. Um but helping people access um tooth toothbrush and toothpaste is really really important toothpaste. Of course, in in most countries where toothpaste is available and is used increasingly contains fluoride as well, which is really important. Um so having fluoride, lots of places have fluoride in their water but not everywhere. Having fluoride on your teeth through toothpaste is really important. Mm. Yeah. And one of the, one of the latest pieces of research that I read said that the external application of fluoride is beneficial than internal application, which is, you know, um, Fluoridation of water and which only works if you've got a central water system. Another one of the questions on the chat box, Christine is it best to brush teeth for breakfast or after? Um, there's two answers to this first uh last thing at night. Um, is the best time to brush your teeth. Nothing else after you've except water after you've brushed your teeth at night. So don't have a, as Michaela said, you'd see a nice glass of apple juice after you've cleaned your teeth before you go to bed. No, no, only water. Um The recommendation is that you clean your teeth first thing in the morning before break all of that saliva and um uh around build up around your teeth during the night. Um So it's best to clean your teeth as soon as you, uh, as soon as you wake, if you to, um, clean your teeth after, at breakfast, you need to wait about 30 minutes after eat dinner as well. You need to wait about 30 minutes before you clean your teeth. But after breakfast, all you really need to do is rinse your mouth, um, clean your teeth when a, uh, you've got enough fresh breath to um, reach your Children, you greet your partner, um, and then have your breakfast and then rinse your mouth um, quickly so that you get rid of all of the, I feel that that's not sufficient. Um Then it's, it's, you can certainly, um, so long as you clean them twice a day for two minutes, um, you'll be fine. Yeah. And the other question is, um, there's a couple of questions really, one is about uh um teaching people to clean their teeth with when they have an intellectual disability or a lending disability. Um And of course, there's the thing with, um teaching people to uh clean their teeth is having the same routine, having the same routine. It's the same with Children doing the same routine. Um making sure that they have the all of the steps. Um, and, and supporting them, assisting them, you mentioned that um uh kids, little kids, little toddlers, like clean teeth, but they actually should be supported to clean their teeth until they're about eight years age. Um because before then they don't sing mechanism. They tend to swab their toothpaste so they shouldn't be swallowing their tooth out. You know, I remember, uh, when I was working as a school nurse, we did this program, um, which we did on a, an annual basis with, uh, all of the classes and we called it a circle scrubs and flicks. And, uh, they were provided, what, what did you call this? Circles? Circles scrubs and then flicks and that was them spitting out. And, uh, they, they, uh, cleaned their teeth themselves and they were pro toothbrush or toothpaste. They cleaned their teeth and then they rinsed their mouth with this um solution and it stained their teeth pink and that, and they could look in their, their big mirrors and they could see where they'd missed, which was teaching them where they'd missed and then they could circle their teeth and then go and it could spit out their thing. Yeah, they, or, or the clicking was cleaning between their teeth, but they're not and not rinsing, rinsing, rinsing was one of the things that we're always taught to do toothpaste. They say don't rinse. Um Yeah, don't leave, leave it there. The question for you. Um Someone made a comment that it's very hard, the NHS because most of them prefer to the private sector because they can earn more money. I mean, what's your, what's your answer? That that's true. Sadly. Um And I think it's really important to try and get a, an NHS dentist for Children. Um, but I think it is really, really difficult. So, keeping your general oral health good is even more important if there's a shortage of dentists. Um, and that's true around the world. Um, not only is there a shortage in many countries. Um, but often they're working in private practice, often they're concentrated in the wealthier areas of the country. Um, so in, in some of the areas in um I think it's uh Sierra Leone where the figures were awful, something like 10 dentists in the whole country, but eight of them are in the capital city now. It's not like that in England, but there still is um a concentration of dentists in areas where people are well off and those people are less likely to have poor teeth because they're more likely to have had a good diet to be able to afford and use toothbrush and toothpaste for most of their, their lives. So if, if you can't get a dentist, then you're looking at your oral health is even more important. Um And sadly, some people end up having to go to um emergency accident, emergency departments with toothache. And that often does get them some sort of emergency dental care, but that's terrible because that really is the opposite of trying to prevent ill health. That really is leaving it until it's terrible. And then the NHS will, will do something. But um needing to lobby for better dentists, better dental care. Um, access to dental hygienists or dental therapists is sometimes available and much less expensive than going to a dentist. Um, so it's worth asking those questions of your local dentist. Ok. It's difficult to get to see a dentist. All the charges are likely to be more than you can afford. But do they have direct access to a dental hygienist? Um, who would at least keep an eye on a professional eye on your teeth, make some good suggestions. Um And tell you if you have serious problems before they get too bad. Yeah, but do you think that perhaps the governments don't appreciate um for making public uh dental care available? And there we have the same problem we have, we don't have uh in Australia very most, most people have to go to the dentist privately and it's not covered under our medical benefits scheme. Um unless you've got private health insurance, um which I'm ideologically opposed to um you have to pay the full cost yourself. So why, why don't governments realize that they could save so much money on chronic, putting more money into oral health disease? It's, I think, isn't it? Absolutely. I think um we have a real job to do to explain that link that we're talking about today between oral health and general health. Um II just so at least two of our political parties and we in the UK are running up to elections. So people are making all sorts of noises promises. Um At least two have been talking about oral health recently, but they've talked about quite rightly, they talked about dentists, having more dentists, having access to dentists. But I don't think many people are pointing out the impact of oral health far more generally, both on health but also on other things. I've, um I, until recently been a trustee of a charity that works with homeless people, um, working to help them get into work um with a, um, a structured, very good, um supportive work placement program. And I don't think the people including me had ever thought about oral health until we realized that we talked about, we did, they did fantastic work finding access to smart clothes. So if somebody goes for an interview job, somebody's been living in a homeless hostel. Um, so that they have smart clothes and then we realize they couldn't, if you've got bad teeth, you don't smile. If you don't smile, look like someone anybody wants to employ. Um If you do smile and your teeth are horrible, you also look like somebody. So we in this country and I think many others are really in theory trying to work to help people get into work. But I don't think many people think about oral health in that context either. Mhm. Oh, Christine, we've had, we've had really, uh a really great chat but we've just about run out of. Um, it, it's gone very quickly. I'm usually not a good talker but it's uh, it has gone really quickly. Um, just summing up in, in, in a few short sentences. Um What's the message about why people, why don't people clean their teeth? What's your message about that? Sum up our chat. People need to think about how important cleaning your teeth is for your overall health and preventing you getting diabetes and other health conditions and work and try really hard to get access to toothpaste and toothbrush. Um and we so called professionals need to try and get that message across much more widely. Yes. Uh Just, just listening to what you said, then I thought of something something it's really important that people understand that they shouldn't because the bacteria passing the bacteria from one person's mouth to another, even if you sit in between um you know, is not a good thing at all. So that's something else to, to remember that. Yeah. Yeah. Well, thank you very much for your company. Um I hope you've enjoyed our conversation. I hope you've learned something you um and it's inspired you your teeth and make sure that your family clean it, but that you raise this issue with um uh every possible opportunity with clients and patients and don't forget you need to fill in the feedback form. Um The feedback form is on the chart. Um And uh it will also if you don't pick it up. It'll also be emailed to you by the organizers of the in Conversation series. So, thank you very much for joining us. Thank you very much Christine. I'd love to have a bit more time to explore a few more things. But, um, it's been really great.