This article focuses on the role of the oral health educator. It gives background information on oral health and the role that the trained dental nurse can play in prevention and treatment of problems.
The need for an oral health educator
Some practices do not see the need to have an oral health educator, and persuading them to support a nurse through the training or to fill an appointment book for a nurse who is already qualified can be challenging. If this is a role you want to pursue, it is vital that you get the whole dental team on board and ensure that all staff know why this role is so important. Hopefully you will have regular staff meetings, and these are ideal times to inform everyone of what you can offer to your patients and also how you can support the rest of the team.
The main role of the oral health educator is obviously oral health education! But what does this mean, and which patients can benefit from this service? If you have a hygienist at your practice, many of your patients will be having regular hygiene appointments – but that does not mean you cannot add to this existing service. It is often the case that a hygienist is booking quite far in advance, so if a patient needs an appointment to tie in with another appointment (a restoration fit, for example) it can often be easier to book in with an oral health educator. In addition, the patient may not be due for their routine hygiene appointment and may only need to book for oral health education. Being able to offer an oral health education service as an alternative to appointments with the hygienist (where appropriate) means less waiting time for the patient and also frees up time in the hygienist's book, thus reducing their waiting list.
If your practice offers large treatment plans and has cases where patients have had a number of new restorations, an oral health education appointment at the end of their treatment is essential. It can add value for your patients as it can make them feel cared about and looked after. It also decreases the likelihood of problems with the restorations in the future. If patients know how to care for their mouths, they are less likely to need to contact you about problems – this will often mean they are happier with their treatment and more likely to recommend your practice to others. Fewer problems will also mean more space in the dentist's book to see these newly recommended patients!
I used to work at a practice which had a large number of patients undergoing orthodontic treatment. All patients with fixed appliances need to be shown how to clean around them, so a minimum of one oral health education appointment should be booked – but I found that regular appointments to reinforce good oral health messages were often needed. There were a number of younger patients who I saw at every adjustment visit as they needed constant motivation to care for their mouths while undergoing this treatment.
The role of the oral health educator
During my time as an oral health educator, I have found that one of my main roles is simply chatting with patients. It sounds simple, but taking the time to have an informal chat with your patients is a great way to build rapport with them and will make them want to stay as a patient of your practice. As I am sure we have all experienced, patients are often more honest with a nurse than they are with a dentist. Building rapport with them means they will feel they can talk to you about any concerns they have and will feel more comfortable choosing the right treatment options. Having an oral health education appointment at the end of a treatment plan gives patients an opportunity to discuss any concerns they may have that they did not want to raise with the dentist. This could also lead to a discussion about any further treatment options that are available to the patient, which could result in the patient taking up treatment that they would not have considered otherwise. The key here is making your patients feel like you have time for them and want to listen to them. Patients really do appreciate this and it goes a long way towards keeping them as patients of your practice and gaining more patients through recommendation.
A large part of the role of the oral health educator is offering advice to patients. This will mainly be recommending appropriate oral hygiene products and offering dietary advice but will also extend to the treatment options available. It is essential that an oral health educator is fully aware of all options available to patients – both at your practice and on referral if necessary. Another type of advice an oral health educator can give is smoking cessation advice. Unless you are trained in this, patients should be signposted to an NHS Stop Smoking service – but simply having the conversation can improve a patient's chances of quitting as they may not be aware of the effect smoking has on their oral health.
Understanding of oral diseases
The oral health education qualification equips nurses with more in-depth knowledge of oral diseases than their initial dental nursing qualification. This enables us to be able to discuss these issues more confidently with our patients. Patients who are referred to the oral health educator will often be patients who are at higher risk of caries or periodontal disease – the oral health educator should be able to tailor their advice to the individual.
For patients with a high caries risk, advice should focus around their diet. Demineralisation occurs when the pH of the mouth is below the critical level of 5.5. Remineralisation occurs when the pH of the mouth returns to its normal level of 7. Returning to its resting pH takes around one hour. If periods of demineralisation are longer than remineralisation, caries occurs. This can be understood more easily using the visual representation known as the Stephan curve. Messages for patients at high caries risk should focus on keeping demineralisation episodes to a minimum so that the mouth can have more remineralisation episodes. Patients often think that it is the amount of sugar they consume that is the issue, when really it is the frequency. I was once told by a patient that he had one can of cola per day, which he did not think was excessive. Through further discussion, I found that he sipped it over the course of around three hours. This shows the importance of developing good questioning technique when assessing your patients!
For patients at risk of periodontal disease, advice should focus on oral hygiene instruction. The most common improvement to make to a patient's oral hygiene is the positioning of their toothbrush. Plaque begins to form at the gingival margin and so patients should be encouraged to brush there rather than focus on the tooth surface. I once worked with a dentist who said he wished they were called gumbrushes rather than toothbrushes! If plaque is left at the gingival margin, it hardens to become supragingival calculus and also spreads down the gingival crevice where it again hardens and becomes subgingival calculus. The calculus then attracts more plaque and the gingivae is constantly irritated. Patients with gingivitis or periodontitis must be shown how to clean interdentally. I lose count of the number of patients who tell me they do not clean interdentally because it makes their gums bleed. You should explain to them that their gums are bleeding because they are irritated, and stress that with daily interdental cleaning the bleeding will stop.
As an oral health educator, you may see orthodontic patients. These patients are at higher risk of both gingivitis and periodontitis, so it is essential to equip them with the knowledge and skills to keep their mouths healthy whilst undergoing orthodontic treatment.
Best practice for oral health education
The nine principles set out in the GDC Standards must always be adhered to. The Standards are available on the GDC's website, along with guidance on how to put them into practice. It goes without saying that you should always be professional when speaking with your patients. Oral health education can often come across as patronising, particularly if you are much younger than the patient you are caring for. When seeing older patients, I often make a point of explaining near the start of the appointment that the oral health advice we give now has changed since I was taught as a child and that advice can move on as technology and research advances. Whatever the age of your patient, you should ensure they do not see your appointment as a “telling-off”. They may not be doing everything they should, but it is important that they know you are advising rather than criticising. I often say things along the lines of "tweaking your routine to make it a little more effective". If they leave feeling that the appointment was a negative experience, they are less likely to carry out your instructions, and it may also give them a poor opinion of your practice. Similarly, if you are seeing patients for a series of appointments, always make sure you praise them for any improvements. Always make sure you listen to your patients. There may be a reason their oral health is poor and there may be a simple solution if you know what the reason is. If you are giving hygiene instruction to a patient with mobility problems, pay attention to what they tell you. They may know what works for them and it is far better for the two of you to work together and share your ideas. Improving a patient's oral health is always a team effort!
If you do find that you are out of your depth, do not be afraid to ask other members of the team for help. You should never try to do something that you know you are unable to do. Other members of your team should always be open to offering help and advice, and asking for help is a great way to improve your knowledge and skills.
Suitable health promotion activities
It can sometimes be difficult to think of activities to reinforce good oral health messages, but there are a wide variety of ways you can do this. To promote general messages to all of your patients, it is a great idea to be aware of national campaigns such as the British Dental Health Foundation's National Smile Month, as they have promotional materials available and this can give you a good reason to have a display in your waiting room. If your practice has a social media page, you can also use this to promote the event and share information with patients.
For oral hygiene instruction, patients should be encouraged to attend their appointments with their own oral hygiene aids. This enables the oral health educator to demonstrate the use of the products in the patient's mouth and is often more effective than demonstrating on a model. The patient can then try using the products themselves, which means that the oral health educator can check that the patient has understood the instructions. It also means that the patient is more likely to remember what to do than if they are just shown but are not given the chance to practise for themselves. Another advantage of patients attending with their own oral hygiene aids is that potential improvements can be spotted quite easily; there have been many occasions when I have found that a patient is using a toothbrush or toothbrush head that should have been replaced some time previously. Obviously, some patients forget to bring their own products with them, and sometimes they are not told to by the referring dentist. Although using a patient’s own products in their own mouth is preferable, demonstrating on a mouth model is adequate if this is not possible. I always ask the patient to repeat the demonstration after me to check their understanding of what I have shown them. Another way to promote good oral hygiene is to use disclosing tablets or solutions. This is a great thing to do when treating children, but if you use them with adult patients, ensure your patient is happy for you to do so. Adults are often going straight back to work after their appointments and will not have time to remove all of the stain. If you are giving patients disclosing tablets to take home, make sure you inform them that they can stain fabric so that they know to be careful. When seeing patients with fixed orthodontic appliances, I often recommend disclosing once per week – it is vital to maintain excellent oral hygiene when wearing a fixed appliance. I usually recommend disclosing after brushing so that patients can see where they have missed. It is often the same or a similar place every time, so this method means that patients can easily see the areas they need to work on.
Dietary advice can often be quite difficult to give, but – like oral hygiene instruction – can be made interactive. Diet sheets are the best way of identifying your patient's current diet and ways it can be improved. I always prefer to give these to patients to take home and fill in for their next visit, as things are often missed if a patient tries to complete a diet sheet at their appointment. I often ask patients to highlight demineralisation episodes themselves, and then I transfer this information to a graph. It is essential that patients write down the time of eating or drinking for this to work, so use a diet sheet that includes space to write the time. I then go on to explain the Stephan curve and use graphs to show their demineralisation and remineralisation. Some patients struggle with this, so explain it simply for them and use lots of examples. Patients may not identify all of their demineralisation episodes because of hidden sugars. I used to keep a lot of labels and food packets to show patients how to identify hidden sugars. This works well as a game with younger patients, together with working out how many teaspoons of sugar are in a food or drink. I also use laminated cards with images of different foods and drinks so that patients can select healthy snack options for themselves. They are much more likely to be able to recall information if you have provided them with ways to find it for themselves rather than if you have just told them, so it is great to find little games like this to use during sessions. These often work better with younger patients but can be adapted to work with older patients. I am sometimes surprised by what people think is a healthy snack!
Summary
You will see a wide range of patients when offering an oral health education service. Some are more difficult to deal with than others, and some will be more grateful for your help than others. In my experience, some of the more difficult cases have been the most rewarding, but helping to improve a patient's health is always a great experience. If you are struggling to explain to your team how important oral health education is, point out how much patients appreciate it and how this can increase loyalty to your practice. Remind the clinicians that they are less likely to encounter problems if their patients are looking after their oral health well, and let your boss know how both of these points can increase the financial turnover of the practice! It is a very rewarding job role for a nurse, but it is a great extra treatment available to patients and can be essential for some – so it is well worth the work for yourself and your practice.
Katie Booth, RDN