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Well, welcome. Uh My name's Jill Elif and I'm the Executive Secretary of the Commonwealth Nurses and Midwives Federation. And I'll be presenting the webinar um this morning. So welcome to the first, you know, series of webinars in conversations and podcasts about oral health. And it's important in staying healthy and preventing disease, particularly diabetes and other um NC DS. Uh The diabetes and oral health initiative is a program of C three, collaborating for health in partnership with loan with Nurses and the Commonwealth Nurses and Midwives Federation. And it's funded by the Burdett Trust uh for nursing. This webinar is being brought to you by uh learn with nurses hosted on the medal platform. And I think most of you are familiar with the medal platform. At the end of the presentation, you'll be asked for your feedback, be able to request a copy of the presentation and generate your continuing professional development certificate. This is my first time using the metal platform. So I'm a little bit nervous. I hope everything goes well for us this morning. Um And this is just to remind you that your feedback is important to us. So this presentation focuses on the why, how and when of oral health assessment for nurses and midwives. And these are the objectives uh for the session. Uh to provide current information on the importance of oral health to general health and wellbeing, to motivate nurses and midwives, to engage in oral health, uh health, oral health promotion and disease prevention. And to encourage nurses and midwives to incorporate oral health assessment into routine care for all clients and patients. So I thought we'd start with just a, a quick quiz. So which health issue has the highest estimated global prevalence? So the answer is oral diseases. Second question, which health condition has been the most dominant condition globally since 1990 regardless of country income level. And the answer is oral diseases is oral health considered to be one of the NC DS. Yes. The World Health Organization considers oral health to be a noncommunicable disease. How many primary teeth do humans usually have? We have 20 in full child dentition and how many permanent teeth do humans usually have to add a um permanent teeth do humans usually have? So the answer is 32 permanent teeth in full adult dentition. I hope you got all of those right. So the first part of the presentation is the Why of oral health assessment for nurses and midwives. As I said, there's three parts. Why, how and when? So oral health is the state of the mouth teeth and orofacial structures that enable individuals to perform essential functions such as eating, breathing and speaking. Oral health also encompasses psychosocial dimensions such as appearance, self confidence, wellbeing, and the ability to socialize and learn and work without pain, discomfort or embarrassment. Oral diseases encompass a range of diseases and conditions that include dental caries, periodontal disease, tooth loss, oral cancers, um oral uh um trauma and congenital malformations such as cleft lip and palate. Ok. So the World Health Organization and one of the reasons that there's a current focus on oral he oral health is that the World Health Organization has established a program focusing on oral health and its strong link to other ncds such as diabetes, heart disease, respiratory diseases, uh cerebrovascular disease and mental health. And the vision of who member states is universal health coverage for oral health for all individuals and communities. By 2013, there's been um historic resolutions at both the 2021 and the 2022 World Health Assemblies and at the 2023 World Health Assembly, who member states have agreed to develop National Oral Health Action Plans and together with monitoring frameworks targets and indicators to consider oral health alongside other ncds to include oral health in universal health coverage initiatives and to include oral health in essential health care service packages. As you can appreciate none of these actions at a country level will be achieved without considerable input from nurses and midwives. And it's one of the really important reasons why nurses and midwives need to be um fully aware of what's going on at a global level so that it can be transferred to action at a country level. This diagram from the World Health Organization compares the estimated global case numbers for selected ncds and demonstrates that oral diseases have by far the highest case numbers globally. As you can see, the size of the circle represents the um the case numbers and oral health is quite is by far the largest of those circles. Another diagram from the World Health Organization shows that oral diseases have had the highest prevalence in all countries globally, regardless of the country's income level for the last 30 plus years. And yet oral health has been a very neglected um area of uh health care service globally. Oral diseases are the most widespread conditions that affect humanity. Oral diseases have remained the most dominant conditions globally. Since 1990 the first year of oral disease data available from the global burden of disease. Data set. The number of cases of oral disease globally is significantly higher than all five main NTD S combined untreated carers of permanent teeth is the most prevalent. Severe periodontal disease is the second most prevalent and edentulous which is tooth loss without natural teeth is the third most prevalent. The sad thing is that the major oral diseases can be prevented using cost effective strategies. So this diagram um shows the prevalence rate of the four major oral diseases over the life course. Uh The blue line is caries of primary teeth. Um the red line that sort of like an orangey colored line. Um it carries a permanent teeth. The purple line is periodontal disease and the green line is edentulous. So you can see that there are particular peaks for each of the um four major oral diseases over the life course, both oral diseases and other NCDs disproportionately affect the most vulnerable and disadvantaged populations. People of low socioeconomic status carry a higher burden of oral disease and this association remains across the life course from early childhood to older age, regardless of the country's overall income level. The who note that poor oral hygiene is a major risk factor for periodontal disease. Severe periodontal disease is closely interlinked with major NCD S. There is strong and consistent evidence of an association between severe periodontal disease and unmanaged type two diabetes, cardiovascular disease, lung diseases such as pneumonia and to a lesser extent, cerebrovascular disease, especially Alzheimer's disease. The who also notes that poor oral health shares the same risk factors as other ncds such as poor diet with high sugar intake, tobacco use and harmful levels of alcohol consumption. This slide demonstrates uh the likely pathway between periodontitis and other ncds such as type two diabetes and cardiovascular disease, which starts with dysbiosis of the oral microbiome and a local inflammatory response. And if left untreated leads to bacteremia and systemic inflammation. And this diagram illustrates the potential pathways between periodontitis and lung disease. So, our next section looks at the how of oral health assessment. So, just a quick update of the gross anatomy of the oral cavity. Um the the gums, hard palate, the soft palate uvula, tonsils, oropharynx, and the tongue. And you can see that the center in sizes the canines and the molars and premolar are also identified in that diagram. So, just a quick update for that and a, a quick update also of the anatomy of the toes. Um you can see the three sections, the crown, neck and the root and then the tooth structure, the enamel, dentin pulp cavity, root canal, gums, bone, uh the thin layer of cementum which it encloses the pulp cavity and the nerves and the blood vessels. And finally a refresher on child and adult dentition. So, in full child dentition, uh there are 20 primary teeth, uh four in sizes, two canine and four molars on in each jaw. And in full adult dentition, you have 32 permanent teeth, um four in sizes, two canine, four premolars and six molars in each jaw. So, I the question is, how often do you look inside the mouth of a patient or a client? Nurses and midwives are in a unique position to be able to provide oral health promotion and education and undertake oral health assessments. The purpose of an oral health assessment is not to diagnose or treat but to educate, identify issues and refer. Oral health assessments are generally neglected by health professionals. Yet, our oral health is so important for our overall general health and wellbeing. So before commencing a visual inspection of mouth and teeth, ask about the individuals daily oral health regime. The last time they visited a dentist, whether they have any oral health questions or concerns and whether they have any pain related to their mouth or teeth. If the person has dentures, the oral cavity should be inspected both with dentures in place and when dentures have been removed and a bright pen light and a disposable wooden tongue depressor should be used. A small dental mirror can be useful but it's not essential and gloves should be worn and the procedure should be explained and consent obtained uh to proceed. So when conducting an oral health assessment, this is what you are looking at and for uh lips should be smooth pink. It's a moist surface including corners of the mouth that there are no cracks in corners of the mouth. Teeth should be clean with no debris, no coating plaque, tarar or discoloration present, no decay worn down or broken teeth, no tooth loss, no halitosis, gums and other tissues should be smooth pink and moist without any bleeding. And the saliva should be moist, watery and free flowing tongue should be moist pink with normal roughness. I can appreciate that it doesn't take long to have a look inside. Um somebody's uh mouth, a quick check of lymph nodes completes the assessment. Any issues of concern should be noted shared with the client or patient and referred to a dentist or doctor. And finally, when is an oral health assessment indicated? Nurses and midwives have a five general responsibilities in relation to oral health care. First of all, a responsibility to maintain own knowledge and skill, to provide oral health information, education about oral health selfcare, conducting oral health assessments and oral health advocacy. So they are the five key uh nursing and wiry responsibilities in relation to oral health. And when you consider um it going back to the earlier slides at how prevalent oral disease is. Um and how frequently um nurses and midwives have contact with um patients and clients of all ages. Um there is a lot that nurses and midwives can do to improve oral health outcomes. So, roles and responsibilities, oral diseases are largely preventable or require only simple interventions if diagnosed and addressed at early stages. Every nurse or midwife clinician has the opportunity when interacting with clients and patients to reinforce effective oral health self-care practices or support or provide appropriate oral health care. Educators have a responsibility to ensure that adequate oral health education is incorporated into initial and ongoing nursing and midwifery education managers can provide direction, support and resources. So clinicians can incorporate oral health care into their everyday practices and all nurses and midwives have a responsibility to stay informed about oral health and its importance to general health and regularly update their knowledge through continuous professional development roles and responsibilities in relation to health promotion. Um Information education should include addressing risk factors, uh smoking, avoiding harmful use of alcohol, having a healthy diet and reducing sugar intake and taking precautions to avoid facial injuries. It's particularly important with uh with young people and Children. They do the most amazing things um and never consider, you know what the risk might be and promoting a daily oral hygiene rou routine cleaning between teeth and brushing teeth twice a day. Preferably with the fluoride toothpaste and roles and responsibilities in relation to oral health assessment and oral health care including oral health as an integral part of nursing and midwifery care. And I wanted to um particularly um alert you to this study by manager Ed Al um who did and there's been quite a few studies done in residential um aged care uh that came up with similar findings that bra toothbrushing reduces the incidence duration and mortality from pneumonia both in the community and in hospitalized patients. Um which is an important message for nurses and midwives because it's usually nurses and midwives who are responsible for that um that intimate care, making sure that uh patients and clients have um their oral health, their oral oral hygiene are attended to while it's not our role to diagnose or treat. Nurses and midwives can play an important part in the early diagnosis of oral disease by incorporating oral health assessment into their interactions with clients and patients and in relation to advocacy um roles and responsibilities with your own sphere of influence. Uh for oral health to be included in universal health coverage initiatives. Um Oral health to be included in essential healthcare service packages, support for nurses and midwives to be able to provide oral health assessments and better oral health care and additional oral health care practitioners. Um One of the one of the reasons it's so important for nurses and midwives to be aware of what's happening globally is that governments including the UK government has made this commitment to um universal oral health care for communities and individuals by 2030. Um and nurses need to know how they're going to achieve that. Um And make sure that the that they enable um he health practitioners uh to be able to contribute to uh reaching that um milestone. And I just thought I would show you the figures for um oral health uh practitioners globally and it's apart from the Europe region, um it's pretty appalling. Um The global average for um oral health workforce per 10,000 population is only 4.69 in you the re region. It's 10.72. Um dentist per, per, per 10,005 0.64 in the Europe region. Um Globally, it's 3.28. But in the Africa region, it's only 0.33. Um Despite that, despite the fact that the Europe region has the highest, by far, their oral health outcomes remain extremely poor, particularly for people on low incomes or who are otherwise socially disadvantaged or marginalized. And so a challenge for you um after the after the webinar and you um and you uh get your copy of this, this presentation, I thought you might like to do your own oral health assessment. Uh So using the um oral health assessment table from a previous uh slide and using a mirror and a bright pen light, conduct an assessment of your own mouth and teeth. Give yourself a mark of three for healthy, two for minor issues and zero for major issues. Add five, if you've seen a dentist in the last 12 months and then give yourself a score out of 20. There is an abundance of literature linking oral health to overall health and wellbeing, particularly to diabetes, coronary, heart disease, respiratory disease, and dementia. This slide and the next list, some useful articles if you want to explore further. And one of the articles that you might want to look at is one by, I'm just looking to see where it is, it might be on the next slide. Um I'll just go to the next slide because it was done in the UK. Um Yeah. Right Anderson, the one at the top uh good in providing oral care, but we could do better. That's an article that's well worth uh reading and all of the links are there um where you can access the article. So that comes to the end of the presentation. Um I hope that um you've enjoyed it and you found it useful. Um And if you have any questions, uh then I'd be, I'd be pleased to try to um uh to answer them. So just going back to the, to the um the main uh the main message, um the main message is that oral diseases are the have the greatest prevalence globally. And in your country that low socio socioeconomic and disadvantaged and marginalized people have poorer oral health outcomes that oral diseases can be prevented with a good daily oral hygiene regime that the health professional that ha has the most contact um with individuals and communities um uh nurses and midwives. And so if we want to improve oral health outcomes, um nurses and midwives should take the opportunity to do so. And it's fairly simple. It's fairly simple. It's just a matter of when you have the first contact with a, with a um uh with um patient or a client that you raise oral health with them as part of that as well as taking their BP, look inside their mouth. It doesn't take long um talk about a, a daily oral hygiene regime and the importance of that in preventing other diseases. Um It's something that we can do and something, something that as nurses and midwives, we can take the opportunity to improve the health of our populations. There are um there are a couple of questions. Um We have care assistants in the UK and carers. Can they look into mouths also? M my, my response to that is yes. Um I think that that's, that's quite reasonable. Um We have uh uh community health workers um looking into mouths but they need education. Y you know, it's a, you could see from the slides on tooth, anatomy and gross anatomy of the mouth. It's, it, they're not complex structures that we have inside our mouths. Um but providing that carers um and uh um care assistants are, are given the proper education uh to know what to look for and it's, and it's really not difficult for them to do that. However, as they need to know what to do once they find something, you know, if they find, is it just if they find dirty teeth but no caries. Um do they have the education to be able to advise the person on how to um how to properly brush their teeth? You know, I er, in, in one of the programs that I did when I was working in schools as a, as a community nursing school, we did education with the primary school, Children um on oral hygiene and there's a solution that you can get, which um allows you to um clean your teeth and then rinse your mouth and the solution shows you, it, it shows up pink where you haven't cleaned your teeth. If you're working in a school, you know, these are really interesting uh programs that you can do to assist Children to develop healthy oral hygiene habits. So it doesn't have to be a registered nurse. Um but anyone that looks into people's mouths um must have the proper education um to know what to look for and also to then know what to do about what they see. Um Another question is that um many people in the UK struggle to access NHS D NHS dentists. Um That's true. A and er other countries, they uh struggle to access dentists at all or if they can access dentists there. The cost is really out of their reach. I think that's one of the areas where nursing nurses, midwives, nurse and midwife associations need to start um being quite vocal in their advocacy for improved um oral health practitioners. You know, it, it, as I said earlier countries have committed um to the vision of universal oral health um coverage um for communities and individuals by 2030 they governments need to be held to account and nurses and midwives can hold them to account um by raising these issues and, and what needs to be done. Not only do nurses and midwives need to be supported to conduct oral health assessments but they have to in, in, er, increase the number of, um, dentists who are available. Um, and one of the ways of course they can do that is, is for, um, uh, dentists in private practice to take on NHS patients. I suppose that they do that now. But the government needs to, to support, um, an increase in the number of NHS patients that dentists can see. And there's a final question. Um oh, there's another question um about the, the link between pneumonia and brushing teeth. Uh that people didn't realize there was a link between pneumonia and brushing teeth. The there you really um need to look up the, the um uh literature. There's a lot of literature that supports the link between um periodontitis and you can understand of course, because if you've got inflammation, local inflammation, uh increase in bacteria, you get bacteria in the blood stream around the oral health and then you get bacteremia and systemic inflammation, but also you get micro and macro aspiration. Um So the, you know, the micro aspiration from the bacteria in the mouth um making its way down um into the lung and there's a really close link with um with the um pleural haren periodontitis and um yeah, and uh pneumonia particularly. Um There's another question. Um It's just as important to look after gums when dentures are worn and what is the best way to provide these in elderly patients with dementia. Um, yeah, that's a, that's a really, um, a difficult question. Um, and there's no, there's, there really isn't any, uh, strong answer for that. It's, it's, it's just that you have to be, uh, um, providing the care for the gums and, you know, massaging gums. There's really good, um, creams that you can mass massage into people's gums with a person with dementia if they really can't do that themselves, it has to be done. Um, two or three ti they're two or three times a day, um, by carers. And there, there is also, um, some really good, um, cream which has a, has, um, some, uh, fluoride in it as well which protects the, um, the bone structure. Um, a and yeah, just, just looking after the gums. Uh, and yeah, it's a constant thing for people with dementia. Um, I, I appreciate that. It's, uh, I appreciate that it's difficult. I've worked in age care myself. Um, sometimes finding the dentures is as much an issue as looking after the gums. Um, there's a, there was a question about the meaning behind the different color of the tongue. Uh, the tongue should normally be pink. Um, of course, tongues can be also stained by different foods that you eat over a long period of time, but the, the tongue should normally be pink and sort of rough. Um, a, a tongue that is smooth or that is red. Um, or if there's any bleeding around the edges. Um, then that's something that needs to be referred. But, um, I said normally the, the only, um, the only difference is is when people have been eating foods that have stained their tongue, but otherwise it should be pink and rough. Um, and without any bleeding, without any fissures or not smooth and without any, uh, sores around the perimeter of the tongue. Um, I think that that was the um there's a comment here that um yeah, that uh come here for someone who's um in occupational health, in the food industry and just emphasizing um that we should all be um addressing oral hygiene and, you know, I, I couldn't um um I couldn't agree more. There's another comment that oral thrush is a common problem for elderly patients. So conducting oral hygiene five times a day enough. Um or should this be applied more often? It's actually enough if um um if the person's uh general h other general hygiene and their nutritional intake is sufficient. Um People are a bit like roses. You know, if you don't, if they don't get the proper nourishment, they get fungus. Um And it's the same with people if you don't get the proper nourishment so that you stay everything, all your tissues stay healthy. Um then you're prone to um to fungal diseases. Um So it should be if, if the person is eating properly, the, the oral hygiene, five times a day should be sufficient. Um And, and you may have to increase it until the, the thrush is cleared. Um And then drop back down again, but um most, most um facilities only manage to do um oral hygiene three times a day. So if you're doing it five times a day, you're doing really, really well and really looking after um the people. So we've just about reached our time. Um I don't know if there's any other questions. So, so takeaway message when you get your slides, do have a look inside your own mouth. Um And, and do um do please take the opportunity to um particularly when you're doing an initial assessment um or you're talking to mums and, and um pregnant mums or if you're talking to young mothers with school age Children, um Do take the opportunity to raise the oral health issue. Um Most people will be um surprised at the link between oral health and common conditions like diabetes and that it can be avoided with good oral health. Um I hope you'll join with the other sessions that uh we're going to have in this series with um uh oral health and the diabetes and oral health initiative, other webinars um in conversations and podcasts. Um And I know to learn with nurses will also have some oral health CPD um at the conclusion of these um uh all of these sessions. So, uh thank you very much for your attention Thank you for the questions. Don't forget to join us on social media um and have the rest of a good day. Thank you. And the feedback link is on the chat. Bye for now.