Want to know more

ORAL HEALTHCARE IN AGING

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

 

Overview

 

  • Poor oral health is associated with malnutrition, dehydration, brain abscesses, valvular heart disease, joint infections, cardiovascular disease, pneumonia, aspiration pneumonia, and poor glycemic control in type I and II diabetes.1,2
  • Oral health also affects nutritional status, ability to speak, self-esteem, mental wellness, and overall well-being.
  • The mouth reflects the culmination of multiple stressors over the years and as the mouth ages it is less able to tolerate these stressors. With an increase in chronic disease and medication usage as a person ages, the prevalence of root caries, tooth loss, oral cancers, soft tissue lesions, and periodontal problems increases significantly.3,4 Many of the oral health problems in the elderly could be avoided with routine preventive care.
  • Many oral diseases are not part of the natural aging process but side effects of medical treatment and medications.
  • Despite oral health being essential to overall health status and quality of life, more than a quarter of older adults have not seen a dental professional in the past five years.5

 

 
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Definitions

Oral: refers to the mouth (natural teeth, gingival and supporting tissues, hard and soft palate, mucosal lining of mouth and throat, tongue, salivary glands, chewing muscles, upper and lower jaw, lips).

Oral Cavity: consists of the cheeks and the hard and soft palate.

Oral hygiene: the prevention of plaque related disease through the disruption of plaque through the mechanical action of tooth brushing and flossing or use of other oral hygiene aides.
Edentulous: toothless.

 
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Background

Tooth Loss

  • Tooth loss is attributed to two major etiologic processes: dental caries and periodontal disease.
  • The presence of dentures and edentulousness are associated with:
    • Poor masticatory (chewing) efficiency
    • Altered phonation (vocal sounds)
    • Social inhibition
    • Dietary restrictions
    • Lower intake of vegetables and fruits
    • Less dietary fiber
    • Greater carbohydrate intake
  • Dentate compared to edentulous older adults have higher intake of:
    • Proteins
    • Fibers
    • Calcium
    • Iron
    • Thiamin
    • Riboflavin
    • Niacin
    • Vitamin B2
    • Vitamins C and E
  • Treatment
    • Fixed and removable prostheses
    • Implant supported prosthesis
  • Prevention
    • Maintenance of oral health
    • Regular dental visits
    • Well-balanced and nutritionally acceptable diet

 

Dental Caries

  • New and recurrent coronal and root surface caries are prevalent among the older population.
  • More than half of the elderly dentate population have new or recurrent dental caries.
  • Etiology and risk factors:
    • Dry mouth
    • Gingival recession
    • Impaired oral hygiene
    • Oral microbial infections
    • Multiple restorations
    • Inadequate fluoride
  • Life-long exposure to fluoride has been associated with diminished tooth loss and lower caries rates.
  • Treatment
    • Restorations (amalgam, composite resins, glass ionomers)
    • Crowns
    • Endodontic therapy (root canal treatment)
    • Extractions
  • Prevention
    • Fluoride therapy
    • Frequent recall to the dentist
    • Good oral hygiene

 

Periodontal Diseases

  • Plaque, calculus, and gingival bleeding increase with age, even in healthy persons (gingivitis). More than 2/3 of the older dentate population has evidence of gingivitis.
  • Attachment loss and gum recession increase with age (periodontitis). More than 3/4 of the older dentate population has experienced some form of periodontal attachment loss.
  • Medications causing gingival problems:
    • Calcium channel blockers
    • Cancer chemotherapy
    • Cyclosporine
    • Dilantin
    • Immunosupressants (e.g., Azathioprine, Methotrexate)
      • Common medical problems associated with periodontal diseases due to an inability to perform adequate oral hygiene
      • Alzheimer's disease
      • Parkinson's disease
      • CVA (stroke)
    • Common medical problems associated with periodontal diseases due to direct deleterious effects on gingival, periodontal, and alveolar health
      • Anemia
      • Bleeding disorders
      • Diabetes (uncontrolled)
    • Etiology and Risk factors
      • Numerous medical problems, medications
      • Oral neglect
      • Improper and insufficient hygiene
      • Restorations
      • Partial dentures
      • Cigarette smoking
      • Poor nutrition
    • Treatment
      • Improved oral hygiene
      • Prophylaxis and scaling/root planing (treatments provided by dentists and dental hygienists)
      • Periodontal surgery
      • Extractions
    • Prevention
      • Regular personal hygiene with manual or powered toothbrushes
      • Daily use of interproximal cleaners including dental floss
      • Antiplaque dentrifices (toothpastes)
      • Maintenance of removable partial prostheses (partial dentures)
      • Frequent recall to the dentist

 

Oral Mucosal Diseases

  • Traumatic lesions
    • Salivary dysfunction causes desiccated and friable tissues
    • Poorly fitting prostheses cause ulcerations, candidiasis (oral fungal infection), masses
  • Common infections of mucosal tissues
    • Candidiasis
    • Herpes Simplex (herpes labialis or cold sores, intraoral herpes)
    • Herpes Zoster Virus (Shingles)
    • Staph aureus
  • Common Ulcerative and Vesiculobullous (blister-like lesions) Conditions
    • Angular cheilitis- red and white cracked lesions in the corners of the mouth, caused by inflammation and a fungal infection.
    • Cicatricial Pemphigoid- an autoimmune connective tissue disease that affects skin, and many mucosal tissues including the mouth; untreated, it can lead to permanent scarring of the affected tissue. It produces red, inflamed lesions on the gingival, palate, tongue, and cheek tissues. Mild trauma to tissues produces bleeding and painful ulcers.
    • Denture stomatitis- red inflamed tissue beneath dentures, caused by fungal infections and insufficient oral hygiene.
    • Lichen planus- an autoimmune connective disease affecting skin and oral mucosal tissues. The most common form is visualized as a lacy white appearance on the tongue and/or cheeks. A less common but more painful form produces red and white ulcerated lesions.
    • Pemphigus vulgaris- an autoimmune connective tissue disease, similar to Cicatricial pemphigus, affecting multiple skin and mucosal tissues including the mouth. Red, bleeding tissues result from trauma, but heal without scarring. Untreated lesions can develop into large, infected regions which require immediate medical attention.
    • Recurrent aphthous stomatitis (canker sores) - an autoimmune local tissue disease that is associated with stressful circumstances, as well as nutritional deficiencies and several diseases. Well-circumscribed lesions develop under the tongue, inside the lips and cheeks, and most commonly heal within 7-10 days.
  • Malignant Neoplasms
    • Head and neck cancers comprise approximately 3% of all cancers
      • Basal cell carcinoma
      • Malignant melanoma
      • Salivary gland neoplasms
      • Squamous cell carcinoma
  • Oral Mucosal Disease Treatment and Prevention
    • Treatment
      • Drugs (antimicrobials, immunosuppressants, analgesics)
      • Removal of lesions
      • New prostheses
      • Cancer treatments
  • Prevention
    • Maintain good denture fit
    • Good oral hygiene
    • Frequent recall to dentist
    • Reduction of cancer risk

 

Xerostomia (dry mouth)

  • Prevalence in elderly 25 - 40+ %
  • Complaints of dry mouth and objective evidence of salivary dysfunction are probably not the result of the aging process and require intervention and prevention.
  • Causes: many medications, many medical conditions, head and neck radiation, chemotherapy
  • Common medical problems associated with salivary dysfunction:
    • Alzheimer's disease
    • Parkinson's disease
    • Dehydration
    • Diabetes
    • Sjogren's syndrome
    • Stroke
  • Common medications associated with salivary dysfunction
    • Ant anxiety agents
    • Anticholinergics
    • Antihistamines
    • Antihypertensives
    • Antiparkinson agents
    • Antipsychotics
    • Chemotherapy drugs
  • Salivary Dysfunction increases the risk for:
    • Dental caries
    • Candidiasis
    • Dysgeusia (decrease in taste)
    • Mucosal desiccation (dried and cracked lips and oral tissues)
    • Poor denture retention
    • Dysphagia (difficulty swallowing)
    • Difficulty chewing
    • Gingivitis
    • Poor nutrition/weight loss
  • Treatment
    • Sugar free gums, mints, rinses
    • Fluoride formulations
    • Saliva substitutes, lubricants
    • Prescription drugs to enhance salivation
    • Frequent oral care
  • Prevention
    • Reduce polypharmacy
    • Salivary-sparing radiotherapy used for head and neck cancers
    • Good hydration
    • Fluorides and good oral hygiene

 

 
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Assessment/Screening Tools

 

Past oral health history

  • Past medical history
  • Past history of oral diseases or infections
  • Current medications (OTC, prescribed, herbal, home remedies)
  • Current diet
  • History of smoking
  • Past dental treatments
  • Last dental visit
  • How many times a year does the patient have routine dental care
  • Assess knowledge and practice of oral care and dental care
  • Assess level of assistance patient needs with oral care
  • Current insurance coverage for dental care

 

Physical Exam of the Oral Cavity

The RN conducts an assessment/evaluation of the oral cavity on admission and every shift. The RN notifies the physician and dentist of any abnormalities present in the oral cavity. The areas included in the assessment are:

  • Condition of the oral cavity
    • Lips: pink, moist, dry, intact, swollen, sores/ulcers, etc.
    • Oral mucosa: pink, moist, dry, intact, swollen, sores/ulcers, bleeding, painful
    • Tongue: pink, red, moist, dry, swollen, sores/ulcers, bleeding, white patches
  • Presence or absence of natural teeth or dentures
    • Natural teeth: intact, broken or decayed, food particles, halitosis
    • Dentures: upper, lower, partial, fit of dentures
    • Ability to function with or without natural teeth or dentures
    • Speaking, chewing, swallowing ability

 

 
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Nursing Care Strategies for Oral Hygiene Plan of Care

Dependent mouth care- edentulous patient with dentures

1. Assist patient to sit out of bed to chair or sit-up with HOB 45 degrees or higher.
2. Remove dentures using tissues or gauze as a barrier. Clean gloves may be worn.
3. Pull the lower plate down and lift forward and out. Pull the upper plate up and forward to dislodge and remove it. Place dentures in emesis basin and proceed to the sink.
4. Scrub dentures with toothbrush/toothette using up and down motion.
5. Clean the grooved area, which fits against the gum with the toothbrush. Rinse with cool water.
6. Brush patient's tongue.
7. Use toothette to clean mouth, lips and tongue.
8. Re-insert dentures.
9. Dry area around mouth and face of any excess solution.
10. Apply lip moisturizer.
11. Oral care is provided during morning care, evening care, and PRN.
12. Patient will receive oral hygiene a minimum of once every 8 hours while in the acute care or long term care or home setting.
13. Patients with gastrostomy tubes, and are not unresponsive, will receive mouth care a minimum of every 4 hours while awake.
14. Patients with gastrostomy tubes, and are unresponsive, will receive mouth care a minimum of every 4 hours.
15. Observe aspiration precautions while providing oral care

Dependent mouth care - patient with teeth or partial dentures

1. Assist patient to set out of bed to chair or sit-up with HOB 45 degrees or higher.
2. After positioning patient, place soft toothbrush/toothette at an angle against the gum line. Gently brush teeth in an up and down motion with short strokes using toothbrush/toothette.
3. Brush patient's tongue.
4. Dry circum-oral area and face of any excess solution.
5. Apply lip moisturizer.
6. For partial dentures, follow procedure for full denture cleaning and insertion.
7. Oral care is provided during morning care, evening care, and PRN.
8. Patient will receive oral hygiene a minimum of once every 8 hours while in the acute care or long term care or home setting.
9. Patients with gastrostomy tubes, and are not unresponsive, will receive mouth care a minimum of every 4 hours while awake.
10. Patients with Gastrostomy tubes, and are unresponsive, will receive mouth care a minimum of every 4 hours.
11. Observe aspiration precautions while providing oral care.

Assisted/Supervised Care

1. Assess what patient can do independently.
2. Set up necessary items.
3. If needed, offer mouth rinse to patient to expectorate and cleanse mouth and assist with emesis basin for expectoration.
4. Oral care is provided during morning care, evening care, and PRN.

 
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Evaluation/Outcomes

Patient:

  • Patient will receive oral hygiene a minimum of once every 8 hours while in the acute care or long term care or home setting.
  • Patients with gastrostomy tubes, and are not unresponsive, will receive mouth care a minimum of every 4 hours while awake.
  • Patients with gastrostomy tubes, and are unresponsive, will receive mouth care a minimum of every 4 hours.
  • Patients and families will be referred to dental services for follow-up treatment.
  • Patients and families will be educated on the importance of good oral hygiene and follow-up dental services a minimum of twice a year.

 

Professional Caregiver

  • The RN will conduct an assessment/evaluation of the oral cavity on admission and every shift.
  • The RN will notify the physician and dentist of any abnormalities present in the oral cavity.
  • Will assess what each patient can do independently.
  • Will observe aspiration precautions while providing care.
  • Will provide oral care and dental care education to patients and families.

 

Institution

  • Will provide access to dental services as appropriate.
  • Will provide on-going education to healthcare providers.
  • Will provide a yearly oral health and dental care in-service to healthcare providers.

 

 
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References

1. Coleman, P. (2002). Improving oral health care for the frail elderly: A review of widespread problems and best practices. Geriatric Nursing, 23(4), 189-199.

2. Taylor, G.W., Loesche, W.J., & Terpenning, M.S. (2000). Impact of oral diseases on systemic health in the elderly: diabetes mellitus and aspiration pneumonia. Journal of Public Health Dentistry, 60(4), 313-320.

3. Persson, R.E., Persson, G., Kiyak, H.A., & Powell, V. (1998). Oral health and medical status in dentate low-income older persons. Special Care in Dentistry, 18(2), 70-7.

4. Kiyak, H.A. (1996). Measuring psychosocial variables that predict older persons oral health behavior. Gerodontology, 13(2), 69-75.

5. Ship, J. (2002). Improving oral health in older people. JAGS, 50, 1454-55.

6. Ship, J.A. (2004). Mouth and Dental Disorders. In Beers, M.H., Jones, T.V., Berkwits, M., Kaplan, J.L., & Porter, R. (Eds.). (2004). The Merck manual of health and aging (1st ed.,pp. 495-506). Whitehouse Station, NJ: Merck & Co., Inc.

7. Ship, J.A., Phelan, J.A., & Kerr, A.R. (2003). Biology and Pathology of the Oral Mucosa. In Freedberg, I.M., Eisen, A.Z., Wolff, K., Austen, K.F., Goldsmith, L.A., & Katz, S.I. (Eds.). Fitzpatrick's dermatology in general medicine (6th ed., pp.1077-1090). New York, NY: McGraw-Hill.

8. Ship, J.A. & Ghezzi, E.M. (2005). Oral manifestations of systemic disease. In Cummings, C.W.,Flint, P.W. & Harker. L.A., et al. (Eds.). Cummings: otolaryngology head and neck surgery (4th ed., pp. 1493-1510). Philadelphia, PA: Elsevier Mosby.

9. Ship, J.A. (2005, in press) The oral cavity. In Hazzard, W.R., Blass, J.P., Halter, J.B., Ouslander,J.G. & Tinetti, M.E. (Eds.). Principles of geriatric medicine and gerontology (5th ed.). New York, NY: McGraw-Hill.

 

Last updated - September 2005

 
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