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ORAL HEALTHCARE IN AGING

Nursing Standard of Practice Protocol: Providing Oral Health Care to Older Adults

Linda J. O’Connor

This standard of care protocol is based on evidence in multicomponent oral health care studies. 1, 2, 3, 4 , 5, 6, 7 

I. Overview: The promotion of oral health through good oral hygiene is an essential of nursing care. The RN or designee provides regular oral care for functionally dependent and cognitively impaired older adults.

II. Background 8, 9, 10, 11, 12, 13, 14, 15, 16

A.  Oral hygiene is directly linked with systemic infections, cardiac disease, CVA, acute MI, glucose control in diabetes, nutritional intake, comfort, ability to speak, and a patient’s self-esteem and overall well-being.

B.   Statistics 17, 18, 19, 20  

1.       More than one-half of the elderly dentate population has new or recurrent dental caries.

2.       More than two-thirds of the older dentate population has evidence of gingivitis.

3.       More than three-quarters of the older dentate population has experienced some form of periodontal attachment loss.

C.  Definitions

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

2.   Oral cavity: includes cheeks, hard and soft palate.

3.   Oral hygiene: the prevention of plaque-related disease, the destruction of plaque through the mechanical action of tooth brushing and flossing or use of other oral hygiene aides.

4.   Edentulous: natural teeth removed.

III. Patient Assessment 21

A.  An RN conducts an oral assessment/evaluation on admission and every shift.

A nurse assesses the condition of:

1.      The oral cavity (lips, oral mucosa, and tongue): The oral cavity should be pink, moist, and intact.

2.   The presence or absence of natural teeth and/or dentures: Natural teeth should be intact and dentures (partial or full) should fit comfortably and not be moving when the older adult is speaking.

3.   Ability to function with or without natural teeth and/or dentures.

4.   Patient’s ability to speak, chew, and swallow.

5.   Any abnormal findings, such as dryness, swelling, sores, ulcers, bleeding, white patches, broken or decayed teeth, halitosis, ill-fitting dentures, difficulty swallowing, signs of aspiration, and pain are documented by the nurse and the health care team is informed.

B.   Assessment Tool: The Oral Health Assessment Tool (OHAT). See the Resources for information about this tool.

IV. Nursing-Care Strategies 22, 23, 24

 A. Oral Hygiene Plan of Care:  Dependent Mouth Care of the Edentulous Patient

1.      Oral care is provided during morning care, evening care, and PRN.

2.      Wash hands and don gloves.

3.      Remove dentures by pulling 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.      Brush dentures with toothbrush/toothpaste using up and down motion.

5.      Clean the grooved area, which fits against the gum with the toothbrush.  Rinse

      with cool water.

6.   Brush the patient’s tongue.

7.   Reinsert dentures.

8.   Apply lip moisturizer.

B.   Dependent Mouth Care:  Patient with Teeth or Partial Dentures*

1.      Oral care is provided during morning care, evening care, and PRN.

2.      Wash hands and don gloves.

3.      Place soft toothbrush at an angle against the gum line.  Gently brush teeth in an up and down motion with short strokes using the toothbrush.

4.      Brush the patient’s tongue.

5.      Apply lip moisturizer.

* For partial dentures, follow procedure for full denture cleaning and insertion.

C. Assisted/Supervised Care

1.      Oral care is provided during morning care, evening care, and PRN.

2.      Assess what a patient can do and provide assistance as needed.

3.      Set up necessary items.

V. Evaluation of Expected Outcomes

A.  Patient

1.      Will receive oral hygiene a minimum of once every 8 hours while in the acute-care, long-term-care, or home setting.

2.      With gastrostomy tubes and is not unresponsive, will receive mouth care a minimum of every 4 hours while awake.

3.      With gastrostomy tubes and is unresponsive, will receive mouth care a minimum of every 4 hours.

4.      Patients and families will be referred to dental services for follow-up treatment.

5.      Patients and families will be educated on the importance of good oral hygiene and follow-up dental services.

B.   Professional Caregiver/RN will:

1.      Conduct an assessment/evaluation of the oral cavity on admission and every shift.

2.      Notify the physician and dentist of any abnormalities present in the oral cavity.

3.      Assess what each a patient can do independently.

4.      Observe aspiration precautions while providing care.

5.      Provide oral care and dental care education to patients and families.

C.  Institution

1.      Will provide access to dental services as appropriate.

2.      Will provide ongoing education to health care providers.

3.      Will provide a yearly oral health and dental care in-service to health care providers.

VI. Other Clinical Guidelines

A. Johnson, V., Chalmers, J., & Titler, M. (2002). Evidence-based protocol: Oral hygiene for functionally dependent and cognitively impaired older adults. Iowa: University of Iowa Gerontological Nursing Interventions Research Center. www.nursing.uiowa.edu/centers/gnirc/protocols.htm

References

1.  Chalmers, J. M., & Pearson, A. (2005). A systemic review of oral health assessment by nurses and carers for residents with dementia in residential care facilities.  Special Care Dentistry, 25(5), 227–233. Evidence Level III: Quasi-experimental

2.  Coleman, P., & Watson, N. W. (2006). Oral care provided by certified nursing assistants in nursing homes. Journal of the American Geriatrics Association, 54(1), 138–143. Evidence Level IV: Nonexperimental Study.

3.  Fitch, J., Munro, C., Glass, C., & Pelligrini, J. (1999). Oral care in the adult intensive care unit. American Journal of Critical Care, 8(5), 314–318. Evidence Level V: Program Evaluation.

4.  Frenkel, H., Harvey, I., & Newcombe, R. G. (2001). Improving oral health in institutionalized elderly people by educating caregivers: A randomized controlled trial. Community Dentistry and Oral Epidemiology, 29, 289–297. Evidence Level II: RCT.

5.  Isaksson, D., Paulsson, G., Fridlund, B., & Nederferos, T. (2000). Evaluation of an oral health education program for nursing personnel in special housing facilities for the elderly, Part II. Special Care Dentistry, 20(3), 173–180. Evidence Level III: Quasi-experimental Study.

6.  Nicol, R., Sweeney, M. P., McHugh, S., & Bagg, J. (2005). Effectiveness of health care worker training on oral health of elderly residents of nursing homes. Community Dentistry and Oral Epidemiology, 33, 115–124. Evidence Level V: Program Evaluation.

7.  Stiefel, K., Damron, S., Sowers, N., & Velez, L. (2000). Improving oral hygiene for the seriously ill patient: Implementing research-based practice. MedSurg Nursing, 9(1), 40–46. Evidence Level V: Program Evaluation.

8.  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. Evidence Level III: Quasi-experimental Study.

9.  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. Evidence Level IV: Nonexperimental Study.

10. Imsand, M., Janssens, J. P., Auckenthaler, R., Mojon, P., & Budtz-Jorgensen, E. (2002). Bronchopneumonia and oral health in hospitalized older patients: A pilot study. Gerodontology, 19(2), 66–72. Evidence Level V: Review.

11. Terpenning, M. S., Taylor, G. W., Lopatin, D. E., Kerr, C. K., Dominguez, L., & Loesche, W. J. (2001). Aspiration pneumonia: Dental and oral risk factors in an older veteran population. Journal of the American Geriatrics Society, 49(5), 557–563. Evidence Level IV: Nonexperimental Study.

12.Yoneyama, T., Yoshida, M., Ohrui, T., Mukaiyama, H., Okamoto, H., & Hoshiba, K., et al. (2002). Oral care reduces pneumonia in older patients in nursing homes. Journal of the American Geriatrics Society, 50(3), 430–433. Evidence Level II: Individual Experimental Study.

13. Abe, S., Ishihara, K., & Okuda, K. (2001). Prevalence of potential respiratory pathogens in the mouths of elderly patients and effects of professional oral care. Archives of Gerontology and Geriatrics, 32(1), 45–55. Evidence Level IV: Nonexperimental Study.

14. Mojon, P. (2002). Oral health and respiratory infection. Journal of the Canadian Dental Association, 68(6), 340–345. Evidence Level V: Literature Review.

15. Scannapieco, F. A. (1999). Role of bacteria in respiratory infection. Journal of Periodontology, 70(7), 793–802. Evidence Level V: Literature Review.

16. Fowler, E. B. (2001). Peridontal disease and its association with systemic disease. Military Medicine, 166(1), 85–89. Evidence Level V: Literature Review.

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

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

19. Ship, J. A., & Ghezzi, E. M. (2005). Oral manifestations of systemic disease. In C. W. Cummings, P. W. Flint, & L. A. Harker, et al. (Eds.), Cummings: Otolaryngology head and neck surgery (4th ed., pp. 1493–1510). Philadelphia: Elsevier Mosby. Evidence Level VI: Expert Opinion.

20. Ship, J. A., Phelan, J. A., & Kerr, A. R. (2003). Biology and pathology of the oral mucosa. In I. M. Freedberg, A. Z. Eisen, K. Wolff, K. F. Austen, L. A. Goldsmith, & S. I. Katz. (Eds.), Fitzpatrick’s dermatology in general medicine (6th ed., pp. 1077–1090). New York: McGraw-Hill. Evidence Level VI: Expert Opinion.

21. Chalmers, J. M., King, P. L., Spencer, A. J., Wright, F. A. C., & Carter, K. D. (2005). The oral health assessment tool: Validity and reliability. Australian Dental Journal, 50(3), 191–199. Evidence Level III: Quasi-experimental Study.

22. Fischman, S. L. (1997). The history of oral hygiene products: How far have we come in 6,000 years? Periodontology, 15, 7–14. Evidence Level V: Literature Review.

23. Meurman, J. H., Sorvari, R., Peltari, A., Rytomaa, I., Franssila, S., & Kroon, L. (1996).  Hospital mouth-cleaning aids may cause dental erosion. Special Care in Dentistry, 16(6), 247–250. Evidence Level II: Experimental Study.

24. Pearson, L. S., & Hutton, J. L. (2002). A controlled trial to compare the ability of foam swabs and toothbrushes to remove dental plaque. Journal of Advanced Nursing, 39(5), 480–489. Evidence Level II: RCT.