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Improving oral health care for the frail elderly: A review of widespread problems and best practices
CE Article
Improving Oral Health Care FOR THE FRAIL ELDERLY:
A Review of Widespread Problems AND Best Practices
Patricia Coleman, PhD, RN, APRN, BC Instructions to CE enrollees: The closed-book, multiple-choice examination that follows this article is designed to test your understanding of the educational objectives listed below. The answer form is on page198. On completion of this article, the reader should be able to: 1. Describe the prevalence of poor oral health care among institutionalized elders 2. Discuss oral disease prevention 3. Review and recommend interventions for oral hygiene
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Abstract Oral health is an important component of overall health, wellbeing, and quality of life for institutionalized elders. Despite reports by nurses of the importance of oral hygiene, empirical evidence shows that daily oral care interventions have not been effective in safeguarding the oral and general health of this vulnerable population. Effective practice must involve not only recognizing its importance but also ensuring that daily oral hygiene receives the same priority as other care practices. (Geriatr Nurs 2002;23:189-97) 189
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aintaining oral health in elderly individuals is essential to ensure comfort, health, and well-being. Poor oral health in geriatric populations can lead to lifethreatening conditions, including malnutrition and dehydration,1 brain absesses,2 valvular heart disease,3 joint infections,4 cardiovascular disease,5 and pneumonia.6 Epidemiologic prevalence studies, however, reveal that the oral health status of the institutionalized elderly is poor. Studies in the United States,7-10 Canada,11 Great Britian,12 and Europe13 have demonstrated high prevalence rates of caries, poor oral hygiene and denture care, gingival inflammation, dry mouth, bleeding gums, and periodontal disease among nursing home elders. Indeed, a survey11 of 1063 residents in 31 nursing homes throughout Washington indicated that the greatest single need among the dentate elderly was routine oral hygiene. The seriousness of poor oral health in institutionalized elders is not generally recognized by nursing home staff, and thus attention to oral hygiene is afforded low priority by nurses.14 The purpose of this article is to describe the prevalence and consequences of poor oral health care for the institutionalized elderly, discuss the prevention of oral disease conditions, review the evidence base for selected care interventions used for oral hygiene, and recommend ways that health practitioners can facilitate best practices for oral health care in institutionalized elders.
THE IMPORTANCE OF ORAL HEALTH Oral care neglect occurs at significant levels in longterm care (LTC) settings. One of the earliest investigations, which analyzed 442 institutionalized elderly in Edinburgh, Scotland, revealed that 65% of the sample wearing dentures had visible soft debris, calculus, and stains that would not wash off; 53% had denture-induced pathology requiring treatment about which staff were unaware.15 In a stratified random sample of 41 LTC facilities in Vancouver, British Columbia, researchers explored the oral health needs of 653 residents and found similar problems.11 More than a third of the sample had denture stomatitis or other mucosal lesions associated with dentures that had been used for more than 15 years. Hygiene and structure of the dentures were very poor, with thick layers of plaque found in more than 50% of those with dentures, and 20% were using dentures with missing parts, fractures, and other structural defects. Fifty-five percent of the dentate subjects had evidence of tooth decay, and 11% had severe periodontal disease, resulting in extremely mobile teeth. Vigild13 examined the oral hygiene status of 201 dentate elderly subjects in eight randomly selected nursing homes in Denmark. More than two-thirds of the sample had abundant plaque on remaining teeth, and abundant calculus was observed on almost a third of the sample’s remaining teeth. Severe gingivitis, ulceration, and/or spontaneous bleeding was found in 25%. Interestingly, the el-
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ders who depended on nursing home staff members for oral hygiene care had significantly more abundant plaque and gingivitis than those who cleaned their own teeth. Similar findings emerged in studies conducted in England and the United States. Simons and colleagues12 assessed the oral health of 1041 residents in a random sample of 55 nursing homes in England. They found 51% of the sample had root caries, which were significantly related to high plaque accumulation and gingival conditions. Other clinically significant oral problems were angular cheilitis, oral ulcerations, glossitis, xerostomia, fissured/sore tongue, and denture stomatitis. Similar findings of poor oral hygiene in nursing home samples were found in U.S. studies as well. Poor oral hygiene, broken/loose dentures, dry mouth, bleeding gums, and periodontal disease are commonly reported.8,9,16
NEGATIVE IMPACTS OF POOR ORAL HEALTH Poor oral hygiene can have serious adverse effects on the psychosocial and systemic health of institutionalized elders. The mouth plays important roles in appearance, speech and communication, and intimacy. The impact of poor oral health (eg, pain, xerostomia, halitosis, unattractive dentition) on these oral functions can lead to poor self-esteem, social isolation, and depression.17 Moreover, adults who are depressed or disengaged may neglect oral hygiene and thus contribute to poor oral status. Thus, preserving oral health is an important yet underrecognized way to enhance the psychosocial well-being of institutionalized elders. Poor oral health affects systemic health in several ways. First, poor oral hygiene can result in malnutrition, pain, and serious dentally derived infections (eg, pneumonia, bacteremia).18 Second, poor oral hygiene can complicate the management of systemic illnesses. For example, periodontal disease adversely affects glycemic control in diabetics.19 Third, the presence of systemic illnesses (eg, Parkinson’s disease, Alzheimer disease, stroke, arthritis, psychiatric illness) and the drugs used to treat them can complicate oral health care.18 Multiple medications may produce adverse effects on oral health (dry mouth, movement disorders) that complicate effective oral hygiene care.
SPECIFIC CONDITIONS RESULTING FROM POOR ORAL HYGIENE Tooth loss. Most tooth loss is caused by two preventable diseases: dental caries (tooth decay) and periodontal disease.1 Missing teeth can have a profound effect on both oral and systemic health. Uncompensated tooth loss leads to food impaction, risk for periodontal disease, difficulty chewing, and further tooth loss.1 Tooth loss alters food selection, resulting in a carbohydrate-rich diet lacking fiber and protein, putting the elder at risk for malnutrition.18 Tactile and textural perceptions of food may become impaired, altering swallowing ability and increasing the risk of aspiration. Tooth loss, even when replacement
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prostheses are worn, can affect an individual’s quality of life, as dental prostheses are imperfect replacements for teeth and may affect an elder’s social interactions, facial aesthetics, chewing, swallowing, and speaking.1 Dental caries. The incidence and prevalence of dental caries are increasing in older adults.20 Untreated caries can result in pain, tooth loss, abscess formation, cellulitis, and bacteremia. Caries-causing bacteria residing in dental plaque destroy the tooth structure. Because elders form plaque more rapidly than younger individuals,1 lapses in daily oral hygiene can increase the risk of developing new and recurrent tooth decay. Periodontal disease. Periodontal disease is an inflammatory disease of the gingival and supporting tissues caused by bacteria residing in dental plaque.18 Periodontal conditions are associated with tooth loss and mobility, halitosis, bleeding gums, chewing difficulty, and choking—outcomes that influence self-esteem, social relationships, and nutritional intake. Furthermore, periodontal infections increase elders’ susceptibility to pneumonia,6 brain abscesses, uncontrolled blood glucose levels, and infective endocarditis.1 Medication use and chronic diseases associated with aging increase the morbidity associated with periodontal disease. Denture stomatitis. Denture-induced stomatitis is a chronic inflammation of the mucous membranes under the dentures, producing red, inflamed tissue from the presence of yeast and bacteria.21 Prevalent in surveys of institutionalized older adults, the condition is associated with continuous denture-wearing or poor or nonexistent oral and denture hygiene and may result in significant alterations in nutrition, mood, and behavior.22 Tingling, burning pain, and taste disturbances may be reported, although the condition is often asymptomatic.1 Some medical conditions also may contribute to tissue susceptibility to inflammation, such as broad-spectrum antibiotic use, impaired salivary flow, corticosteroid inhalers, and immunocompromised states.1 Xerostomia. Prevalence increases with age, and recent estimates suggest that at least 30% of adults 65 and older report xerostomia.23 Reduction in salivary flow is attributed to systemic conditions and medication use rather than the aging process itself.18 More than 500 drugs in 42 categories contribute to xerostomia; some of the major categories are listed in Table 1. Other major causes of dry mouth are Sjogren’s syndrome, diabetes mellitus, Alzheimer disease, sarcoidosis, chronic anxiety and depression, oxygen therapy, oral suctioning, and NPO status. 23 Salivary gland hyposecretion increases the adherence of dental plaque and thus the frequency and severity of dental caries and periodontal disease.1 Xerostomia may cause taste abnormalities, problems with denture retention, pain, diminished food enjoyment, reduced medication compliance, and difficulty swallowing, speaking, or sleeping. All these make the oral cavity more vulnerable to infection. Although xerostomia is one of the most common undesirable effects of drugs on an elder’s oral health,
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Table 1. Common Drugs Contributing to Xerostomia Anxiolytics Anticholinergics/antireflux Anticonvulsants Antidepressants Antihypertensives Antipsychotics Antihistamines/decongestants Cytotoxics Diuretics Opiates
nurses’ knowledge about the impact of drug therapy on oral health is limited.24
Oral Hygiene and Systemic Disease The oral cavity is a refuge for a large variety of microbes that have the potential to cause both oral and systemic disease. Oral bacteria have been implicated in bacteremias after dental manipulation, flossing, and toothbrushing. Recent reports have been made of associations among severe periodontal diseases, oral hygiene, and coronary heart disease.25 Bacteria commonly associated with pneumonia have been found to colonize the dental plaque of older hospitalized patients26 and residents in nursing homes,27 two groups who often demonstrate poor oral hygiene. Increased dental plaque load from poor hygiene promotes oral colonization by respiratory pathogens and increases the risk of pneumonia in susceptible individuals. Moreover, recent data demonstrate that providing regular oral hygiene care to elderly nursing home residents reduces the incidence of pneumonia in this population.28 These studies provide compelling support for attention to good oral hygiene in frail elders.
THE IMPORTANCE OF PREVENTION General preventive measures are essential to promoting good oral and general health in the elderly, including daily oral hygiene practices with specific attention to control of dental plaque and xerostomia,20 regular oral health assessment,22 and dietary awareness.29 Table 2 illustrates these principles.
ORAL CARE INTERVENTIONS Selected oral care interventions that have particular relevance to these oral hygiene goals will be reviewed, with specific attention to these practices in the nursing home setting. Toothbrushing. A small, soft toothbrush is considered the most effective mechanical method to control dental
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Table 2. General Oral Health Prevention Practices Daily Oral Hygiene to Reduce Plaque Accumulation on Teeth and Dentures
• Mechanically remove plaque from natural teeth with small, soft toothbrush (or electric toothbrush) and fluoride dentifrice twice a day; gently brush teeth, tongue, and gums daily. Facilitate flossing as appropriate. Consider oral or topical fluoride or antiplaque agents in consultation with dental professional.
• Clean dental prostheses with denture brush twice a day; remove and soak them at night whenever possible. Regularly inspect prostheses for cracks, sharp edges, missing teeth. Regularly clean denture storage container, and initiate denture identification program.
• Alleviate/prevent xerostomia: routinely ask elder if mouth feels dry or uncomfortable. Give fluids, such as water-based mouth rinses, frequently. Use artificial saliva or lip lubricants. Have elder chew sugar-free gum or suck on sugar-free candy as appropriate. Periodically review xerostomia-inducing medications for reduction of drug levels/alternate drugs.
• Seek assistance from dental team for communication/behavioral strategies for cognitively impaired and behaviorally difficult residents. Use modified physical or chemical equipment in consultation with dental professionals to facilitate oral care (eg, mouth props, backward-bending toothbrush, spray/gel fluoride preparations).
Regular Oral Health Assessment
• Identify and document risk factors for poor oral hygiene (eg, cognitive/functional impairment, medication use, presence of active oral disease, xerostomia, dysphagia, movement disorder).
• Perform baseline and periodic oral health assessment and documentation using an appropriate tool. • Identify oral self-care ability (identify oral hygiene aids, products, and frequency of use for level of dependence). • Conduct periodic oral and dental examinations with feedback/recommendations on resident oral hygiene adequacy. Attention to Diet
• Minimize sugar intake (sweetened tea, coffee) and fermentable carbohydrates. • Limit between-meal cariogenic snacks. • Encourage consumption of noncariogenic or cariostatic foods (eg, milk, cheese) with cariogenic foods (eg, cookies). Niessen L, Douglass C. Preventive actions for enhancing oral health. Clin Geriatr Med 1992;8:201-14. Ettinger R. Oral care for the homebound and institutionalized. Clin Geriatr Med 1992;8:659-72. Steele J, Walls A. Strategies to improve the quality of oral health care for frail and dependent older people. Qual Health Care 1997;6:165-9.
plaque and its associated complications.29 Daily plaque removal is important. In acute care settings, the toothbrush often is not used by nurses for mouth care.30 In contrast, high levels of toothbrushing activity in nursing home settings are reported,31 with the average time spent brushing each resident’s teeth noted between 3-4 minutes.7 This level and intensity of oral care, however, are inconsistent with the documented oral health status of the institutionalized elderly. The service, while provided, may be performed ineffectively. It is not easy to brush someone else’s teeth, particularly when positioning or gaining his or her cooperation is required. Moreover, providing toothbrushing assistance or supervision to an elder with poor neuromuscular strength or coordination may not reduce plaque optimally. Recent studies comparing ultrasonic and conventional manual brushes in care-dependent32 and outpatient elderly33 populations have demonstrated improvement in oral health indices (eg, plaque levels, gingival bleeding) for the ultrasonic devices, in addition to easy use and caregiver acceptance. Specially designed manual brushes (eg, Collis-
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Curve)34 in nursing home populations provide superior plaque reduction, are easier to manipulate, and take less time relative to conventional models. The sonic brushes and Collis-Curve models may be effective and practical ways to provide improved oral care in institutionalized settings, although issues of cost and maintenance must be considered. Additionally, simple adaptation of toothbrush handles may help facilitate oral self-care in elders. Foam swabs. Foam swabs are used frequently by nurses to clean teeth35 and are the preferred tool for oral care by nurses.24 However, foam swabs are ineffective in cleaning tooth surfaces and controlling plaque,36 which is particularly disadvantageous for dentate institutionalized elders. Swabs may be useful to cleanse and moisten oral mucosa and prevent trauma to delicate tissues, but promoting a moist oral cavity and reducing bacterial plaque can be accomplished just as well with a moistened toothbrush. Lemon and glycerin swabs. Lemon and glycerin swabs for oral hygiene have been a part of nursing practice for more than 60 years but are ineffective oral care cleansers or moisturizers.37 Lemon reduces the oral pH to
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2-4, below the normal level (6-7). The acid conditions can irritate the mouth, cause pain, decalcify teeth, and increase the risk of dental caries. Glycerin dehydrates the oral tissues. Choice of oral care agents should be based on knowledge of their characteristics, an understanding of oral physiology, and oral assessment. Lemon and glycerin swabs are not only ineffective but in fact harmful and should not be used. Mouth rinses. A variety of cleansing, antimicrobial, and moisturizing agents are available for oral care, including normal saline, hydrogen peroxide, sodium bicarbonate, and chlorhexidine. Interventions using these agents are found primarily in the cancer nursing literature. In the nursing home, nurses’ aides report providing a high percentage of mouth rinsing as part of oral hygiene for residents, although the specific types usually are not identified. In one study, only 33% could recall if the mouthrinse contained fluoride.31 Nurses commonly use hydrogen peroxide and sodium bicarbonate, although the clinical base for the safe use of either preparation as oral care agents has not been established.37 Hydrogen peroxide has antimicrobial properties and permits mechanical cleansing of debris, but recent evidence suggests it harms the oral mucosa and elicits many negative subjective reactions by patients, so it is not recommended.38 Sodium bicarbonate is also controversial. It dissolves mucus and oral debris but has an unpleasant taste35 and can cause oral mucosal burns if not diluted properly. Moreover, altering the pH may disrupt the normal oral flora. It is important to note that bacterial plaque will continue to accumulate when mouthrinsing is the only form of oral hygiene performed. Chlorhexidine (eg, Peridex, PerioGard) preparations (mouthrinses/sprays/gels) are discussed in the nursing literature. Chlorhexidine has been used widely in dentistry to chemically inhibit plaque growth and treat gingival and periodontal disease and other oral infections.39 It has been used to improve oral hygiene in populations with special needs (eg, disabled and mentally retarded adults and children, adults with poor oral hygiene) for whom mechanical plaque removal is difficult.40 Chlorhexidine has been advocated as an intervention strategy for frail and dependent elders when oral self-care is too demanding.41 Recent studies in critical care populations have suggested that, in addition to its powerful effect on dental plaque growth, chlorhexidine also reduces plaque bacterial colonization by respiratory pathogens and may reduce the risk of nosocomial pneumonia.42 A chemotherapeutic approach using chlorhexidine for institutionalized elders with limited self-care skills may be a rational approach to oral disease prevention and reduction in pneumonia risk, given its potent antimicrobial and antiplaque activity, easy application (gel/spray), and reversible local effects. Saliva substitutes. Saliva substitutes can be effective in maintaining oral comfort for the relief of xerostomia,
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but because they do not provide the antibacterial and antiviral properties of natural saliva,1 frequent oral fluids and fluoride and antimicrobial rinses should be considered. Given elders’ frequent complaint of dry mouth, studies suggest that nursing interventions, such as the use of artificial saliva and fluoride rinses that could minimize the effect of xerostomia (and caries formation), are being underused.
FACILITATING BEST PRACTICES More than 40 years ago, Virginia Henderson43 suggested that the overall standard of nursing care could be judged by the state of the patient’s mouth. Significant institutional, professional, and personal barriers must be overcome to improve oral care standards and facilitate best practices for oral health care for elderly nursing home residents. Strategies need to include educational, research, and advocacy efforts and methods to improve practice. These strategies must begin with the development of a culture, both institutional and professional, that promotes, values, and communicates oral health caregiving as fundamental to geriatric nursing practice as are restraint reduction and skin care practices. Oral care is a resource-intensive task that is easy to delegate, perceived as burdensome and undesirable,44 frequently omitted under time constraints,45 performed in isolation, and currently offers little opportunity for professional recognition and status. But oral care is important, like feeding and bathing, and must be promoted as an activity central to caring for older adults.
Educational Approaches Educational interventions can improve nurses’ knowledge and accuracy of oral health assessment. Kayser-Jones and colleagues46 developed the Brief Oral Health Status Examination (BOHSE), an instrument to assess the oral health status of cognitively impaired and unimpaired nursing home residents. Shown in Figure 1, the BOHSE is useful for the nondental professional because it describes how to assess the various oral components (lips, gums, tongue), which are evaluated by observation or manipulation rather than self-report. Empirical research with the BOHSE has demonstrated that nursing personnel (RNs, LPNs, CNAs) can be taught to evaluate residents’ oral health with considerable accuracy if trained to use the assessment tool. These findings and others47 suggest that, with adequate training, nurses can identify oral health problems, initiate appropriate interventions (eg, referral to a dentist or hygienist), and prevent or minimize the significant morbidity associated with poor oral health. Interventions that include oral health education with direct hands-on training for LTC nursing assistants (NAs) have demonstrated improved oral health outcomes for residents. Pyle48 and Frenkel49 demonstrated that an oral health educational program, including both didactic and hands-on training, for NAs improved dentate residents’
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Oral care is important, like feeding and bathing, and must be promoted as an activity central to caring for older adults.
oral health status compared with NAs who had not completed such training. These results show that oral care for nursing home residents can be improved and support the feasibility of educational intervention studies to facilitate and achieve higher standards of geriatric oral health care. The difficulties and challenges of providing oral care to cognitively impaired and behaviorally difficult residents has been identified as a major factor discouraging oral care performance by NAs.31 Effective strategies to facilitate oral care for cognitively impaired nursing home residents have been reported recently. Kayser-Jones et al.50 discuss 11 strategies found successful during 625 oral health examinations in two research studies involving residents with severe functional and cognitive impairments. Chalmers51 presents communication techniques (eg, rescuing, taskbreakdown, distraction, bridging) successful in both conducting geriatric dental research and clinical practice with cognitively impaired older adults. Table 3 describes some of these strategies, which can be adapted to encourage oral hygiene care for residents. Research focusing on the development and implementation of these strategies in the clinical setting is needed. Other educational approaches that may be useful include the participation of dentists or hygienists in formal presentations of oral health curricular content in professional nursing programs, as well as strategies that emphasize the institutional value of oral health through educational programs that include all levels of the nursing home, from administration to NAs. Forming alliances with local universities or technical schools with dental hygiene or assisting programs to initiate student rotations may help elevate the status of oral health care and provide opportunities for continuing education.
Care Delivery Models Appropriate knowledge and skills are necessary to perform effective oral care, but just as important are positive attitudes and behavior toward performance of this care. The introduction of the “oral care aide”31,52—specially trained and supervised to promote, provide, and raise awareness of oral care and communicate resident oral health problems within the multidisciplinary team—has demonstrated some positive impact on resident oral health outcomes. Meaningful recognition of this work, through administrative support and encouragement, clear job descriptions, and financial rewards, are crucial to successful implementation of the oral care specialist concept. Directors of nursing in LTC settings can communicate the value of oral health care by legitimizing this role. This strategy deserves further investigation to determine its long-term impact on resident oral health, fiscal, and staff outcomes. Promoting active involvement of the dental team members is warranted. Models that emphasize interdisciplinary collaboration between nursing and dental hygienists may help facilitate decision making, information sharing, and open communication about oral care prob-
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Figure 1. Kayser-Jones Brief Oral Health Status Examination (BOHSE) Resident’s Name Examiner’s Name Category
Measurement
0
1
2
Lymph nodes
Observe and feel nodes
No enlargement
Enlarged, not tender
Enlarged and tender*
Lips
Observe, feel tissue, and ask resident, family, or staff (eg, primary caregiver)
Smooth, pink, moist
Dry, chapped, or red at corners*
White or red patch, bleeding or ulcer for 2 weeks*
Tongue
Observe, feel tissue, and ask resident, family, or staff (eg, primary caregiver)
Normal roughness, pink and moist
Coated, smooth, patchy, severely fissured, or some redness
Red, smooth, white or red patch; ulcer for 2 weeks*
Tissue inside cheek, floor and roof of mouth
Observe, feel tissue, and ask resident, family, or staff (eg, primary caregiver)
Pink and moist
Dry, shiny, rough red, or swollen*
White or red patch, bleeding, hardness; ulcer for 2 weeks*
Gums between teeth or under artificial teeth
Gently press gums with tip of tongue blade
Pink, small indentations; firm, smooth, and pink under artificial teeth
Redness at border around 1-6 teeth; one red area or sore spot under artificial teeth*
Swollen or bleeding gums, redness at border around 7 or more teeth, loose teeth; generalized redness or sores under artificial teeth*
Saliva (effect on tissue)
Touch tongue blade to center of tongue and floor of mouth
Tissue moist, saliva free-flowing and watery
Tissues dry and sticky
Tissues parched and red, no saliva*
Condition of natural teeth
Observe and count number of decayed or broken teeth
No decayed or broken teeth/roots
1-3 decayed or broken teeth/roots*
4 or more decayed or broken teeth/roots; fewer than 4 teeth in either jaw*
Condition of artificial teeth
Observe, and ask resident, family, or staff (eg, primary caregiver)
Unbroken teeth, worn most of the time
1 broken/missing tooth, or artificial teeth worn for eating or cosmetics only
More than 1 broken or missing tooth; denture either missing or never worn*
Pairs of teeth in chewing position (natural or artificial)
Observe and count pairs of teeth in chewing position
12 or more pairs of teeth in chewing position
8-11 pairs of teeth in chewing position
0-7 pairs of teeth in chewing position*
Oral cleanliness
Observe appearance of teeth or dentures
Clean, no food particles/tartar in the mouth or on artificial teeth
Food particles/tartar in one or two places in the mouth or on artificial teeth
Food particles/tartar in most places in the mouth or on artificial teeth
*Refer to dentist immediately Upper dentures labeled: Yes ______ No ______ None _______ Lower dentures labeled: Yes ______ No ______ None _______ Is your mouth comfortable? Yes _____ No ______ If no, explain: _____________________________________________________ Additional comments:
Reprinted with permission of Jeanie Kayser-Jones, RN, PhD
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Table 3. Communication Techniques to Facilitate Oral Hygiene Care for Cognitively Impaired and Behaviorally Difficult Residents Technique
Description
Example
Rescuing
A second caregiver enters a situation and tells the first caregiver to leave so that he or she can “help” the resident.
The dentist/caregiver is unable to remove the resident’s dentures, so a caregiver enters, takes over, and removes the dentures.
Task breakdown
The activity is broken down into short steps that are slowly repeated and demonstrated.
For toothbrushing: “Pick up the toothbrush,” “Squeeze out the toothpaste,” etc.
Distraction
Singing, playing music, holding items, touching gently, and talking are used to distract the resident from a distressing situation.
A rummage box or busy apron/cushion/ board (with a familiar theme) occupies the active hands of a resident during oral care/examination.
Bridging
Improve sensory connection and task focus by having the resident hold the same object as the caregiver while the caregiver carries out an activity.
The resident holds a toothbrush while the caregiver uses a backward-bent toothbrush to assist in breaking perioral muscle spasms to gain access to the oral cavity.
Hand-over-hand
The caregiver’s hand is placed over the resident’s hand to guide him or her through the activity.
The caregiver places the lower denture in the resident’s hand, then places his or her hand over the resident’s to guide the lower denture back into the mouth.
Chaining
The caregiver starts the activity, and the resident completes it.
The caregiver places the toothpaste on the toothbrush and places it in the resident’s hand, then the resident brushes his or her teeth.
Chalmers J. Behavior management and communication strategies for dental professionals when caring for patients with dementia. Special Care Dentistry 2000;20:147-54.
lems and can heighten awareness of the necessity and value of oral health considerations. Additional research is needed to determine how dentists, nurses, and other health care providers can work together to improve the oral health status of nursing home elders.
Oral Care Practice Protocols Recently, research-based oral care protocols have been developed for critical care settings,53,54 demonstrating significant improvements in patients’ oral health when implemented by bedside nurses. The development and implementation of oral care protocols for institutional settings by nurses in collaboration with dentistry and other disciplines (hygienists, physicians, NAs) would provide a sound and sophisticated basis for delivering care at the bedside. Certainly, the future of oral health for nursing home elders partly depends on how we practice. Oral hygiene practice in institutional settings should be guided by two principles. First, clinical decision making regarding product choice must have the goal of plaque reduction and control of bacterial growth to reduce gingivitis, periodontal disease, caries, and systemic infections. Oral fluoride (rinses, toothpaste, topical application), a conventional or electric toothbrush for mechanical plaque removal, and chlorhexidine gluconate rinses or gel are effective agents. Second, a moist, pink, and intact oral mucosa with a pH between 6 and 7 must be maintained.
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Products commonly available but contraindicated for routine oral hygiene include hydrogen peroxide, sodium bicarbonate, and lemon and glycerin. Toothbrushes with large heads or hard bristles should be avoided because of the trauma potential to delicate mucosal surfaces. Artificial saliva and nonalcoholic mouthwashes may be helpful to maintain moisture. Nurses can advocate for improved oral health policy and care practices through representation on institutional purchasing committees to support the purchase and use of appropriate oral care products based on the best available evidence. Low-cost interventions in oral hygiene have the potential to reduce the high-cost outcomes associated with poor oral care (eg, pneumonia),55 resulting in cost savings and improved quality of care. Gerontologic nurses are central to the achievement of these important goals.
CONCLUSION The evidence suggests that poor oral hygiene among institutionalized elders is a much greater problem than commonly realized. Oral hygiene for this population typically has been perceived as a burden, but good oral care has significant benefits for both the quality of life and overall general health of frail elders. Nurses can play a critical role in improving oral health care for these older adults, thus promoting better patient outcomes, and the nursing and related health care professions can support
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the efforts of caregivers by recognizing, recommending, and supporting best practices in this important area. REFERENCES 1. Shay K, Ship J. The importance of oral health in the older patient. J Am Geriatr Soc 1995;43:1414-22. 2. Andrews M, Farnum S. Brain abscess secondary to dental infection. General Dentistry 1990;38:224-5. 3. Feihn N, Gutshik E, Larsen T, Bangsborg J. Identity of streptococcal blood isolates and oral isolates from two patients with infective endocarditis. J Clin Microbiol 1995;33:1399-1401. 4. Bartzokas C, Johnson R, Jane M, Martin M, Pearce P, Saw Y. Relation between mouth and haematogenous infection in total joint replacements. Br Med J 1994;309:506-8. 5. Joshipura K, Rimm E, Douglass C, Trichopoulos D, Ascheriio A, Willett W. Poor oral health and coronary heart disease. J Dental Res 1996;75:1631-6. 6. Scannapieco F. Role of oral bacteria in respiratory infection. J Periodontol 1999;70:793-802. 7. Kambhu P, Levy S. Oral hygiene care levels in Iowa intermediate care facilities. Special Care Dentistry 1993;13:209-14. 8. Kiyak H, Grayston M, Crinean C. Oral health problems and needs of nursing home residents. Comm Dent Oral Epidemiol 1993;21:49-52. 9. Empey G, Kiyak H, Milgrom P. Oral health in nursing homes. Special Care Dentistry 1983;3:65-7. 10. Gift H, Cherry-Peppers G, Oldakowski R. Oral health status and related behaviours of U.S. nursing home residents, 1995. Gerodontology 1997;14:89-99. 11. MacEntee M, Weiss R, Waxler-Morrison N, Morrison B. Factors influencing oral health in long-term care facilities. Comm Dent Oral Epidemiol 1987;15:314-6. 12. Simons D, Kidd E, Beighton D. Oral health of elderly occupants in residential homes. Lancet 1999;353:1761. 13. Vigild M. Oral hygiene and periodontal conditions among 201 dentate institutionalized elderly. Gerodontics 1988;4:140-5. 14. Wardh I, Hallberg L, Berggren U, Andersson L, Sorensen S. Oral health care-low priority in nursing. Scand J Caring Sci 2000;14:137-42. 15. Ettinger R, Manderson R. Dental care of the elderly. Nursing Times 1975;10:1003-6. 16. Berkey D, Berg R, Ettinger R, Meskin L. Research review of oral health status and service use among institutionalized older adults in the United States and Canada. Special Care Dentistry 1991;11:131-6. 17. Karuza J, Miller W, Lieberman D, Ledenyi L, Thines T. Oral status and resident well-being in a skilled nursing facility population. Gerontologist 1995;35:104-2. 18. Schwartz M. The oral health of the long-term care patient. Ann Long-Term Care 2000;8:41-6. 19. Taylor G, Loesche W, Terpenning M. Impact of oral diseases on systemic health in the elderly: diabetes mellitus and aspiration pneumonia. J Public Health Dentistry 2000;60:313-20. 20. Niessen L, Douglass C. Preventive actions for enhancing oral health. Clin Geriatr Med 1992;8:201-14. 21. Matear D. How important is oral health care in geriatric institutions? Perspectives 1999;23:9-17. 22. Ettinger R. Oral care for the homebound and institutionalized. Clin Geriatr Med 1992;8:659-72. 23. Ship J, Pillemer S, Baum B. Xerostomia and the geriatric patient. J Am Geriatr Soc 2002;50:535-43. 24. Adams R. Qualified nurses lack adequate knowledge related to oral health, resulting in inadequate oral care of patients on medical wards. J Adv Nurs 1996;24:552-60. 25. Beck J, Garcia R, Heiss G, Vokonas P, Offenbacher S. Periodontal disease and cardiovascular disease. J Periodontol 1996;67:1123-37. 26. Scannepieco F, Stewart E, Mylotte J. Colonization of dental plaque by respiratory pathogens in medical intensive care patients. Crit Care Med 1992;20:740-5. 27. Russell S, Boylan R, Kaslick R, Scannapieco R, Katz R. Respiratory pathogen colonization of the dental plaque of institutionalized elders. Special Care Dentistry 1999;19:128-34. 28. Yoneyama T, Yoshida M. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc 2002;50:430-3. 29. Steele J, Walls A. Strategies to improve the quality of oral health care for frail and dependent older people. Qual Health Care 1997;6:165-9. 30. Kite K. Changing mouth care practice in intensive care: implications of the clinical setting context. Intens Crit Care Nurs 1995;11:203-9. 31. Chalmers J, Levy S, Buckwalter K, Ettinger R, Kambhu P. Factors influencing nurses’ aides’ provision of oral care for nursing facility residents. Special Care Dentistry 1996;16:71-9. 32. Day J, Martin M, Chin M. Efficacy of a sonic toothbrush for plaque removal by caregivers in a special needs population. Special Care Dentistry 1998;18:202-6. 33. Whitmyer C, Terezhalmy G, Miller D, Hujer M. Clinical evaluation of the efficacy and safety of an ultrasonic toothbrush system in an elderly patient population. Geriatr Nurs 1998;18:29-33.
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34. Kambhu P, Levy S. An evaluation of the effectiveness of four mechanical plaque-removal devices when used by a trained care-provider. Special Care Dentistry 1993;13:9-14. 35. Barnett J. A reassessment of oral healthcare. Prof Nurs 1991;6:703-8. 36. Pearson L. A comparison of the ability of foam swabs and toothbrushes to remove dental plaque: implications for nursing practice. J Adv Nurs 1996;23:62-69. 37. Trenter-Roth P, Creason N. Nurse-administered oral hygiene: is there a scientific basis? J Adv Nurs 1986;11:323-31. 38. Tombes M, Gallucci B. The effects of hydrogen peroxide rinses on the normal oral mucosa. Nurs Res 1993;42:332-7. 39. Brecx M. Strategies and agents in supragingival chemical plaque control. Periodontology 1997;15:100-8. 40. Steifel D, Truelove E, Chin M, Zhu X, Lerous B. Chlorhexidine swabbing applications under various conditions of use in preventive oral care for persons with disabilities. Special Care Dentistry 1995;15:159-65. 41. MacEntee M. Oral care for successful aging in long-term care. J Public Health Dentistry 2000;60:326-9. 42. Fourrier F, Cau-Pottier E, Boutigny H, Roussel-Delvallez M, Jourdain M, Chopin C. Effects of dental plaque antiseptic decontamination on bacterial colonization and nosocomial infections in critically ill patients. Intensive Care Med 2000;26:1239-47. 43. Henderson V. Basic principles of nursing care. Geneva: International Council for Nursing: 1960. 44. Wardh I, Anderson L, Sorenson S. Staff attitudes to oral health care. A comparative study of registered nurses, nursing assistants and home care aides. Gerodontology 1997;14:28-32. 45. Bowers B, Becker M. Nurses’ aides in nursing homes: the relationship between organization and quality. Gerontologist 1992;32:360-6. 46. Kayser-Jones J, Bird W, Paul S, Long L, Schell E. An instrument to assess the oral health status of nursing home residents. Gerontologist 1995;35:814-24. 47. Arvidson-Bufano U, Blank L, Yellowitz J. Nurses’ oral and health assessments of nursing home residents pre-and post-training: a pilot study. Special Care Dentistry 1996;16:58-64. 48. Pyle M, Massie M, Nelson S. A pilot study on improving oral care in longterm care settings. J Gerontol Nurs 1998;45:31-8. 49. Frenkel, H, Newcombe, R. Improving oral health in institutionalised elderly people by educating caregivers: a randomised controlled trial. Community Dent Oral Epidemiol 2001;29:289-97. 50. Kayser-Jones J, Bird W, Redford M. Strategies for conducting dental examinations among cognitively impaired nursing home residents. Special Care Dentistry 1996;16:46-52. 51. Chalmers J. Behavior management and communication strategies for dental professionals when caring for patients with dementia. Special Care Dentistry 2000;20:147-54. 52. Charteris P, Kinsella T. The oral care link nurse: a facilitator and educator for maintaining oral health for patients at the Royal Hospital for NeuroDisability. Special Care Dentistry 2001;21:68-71. 53. Fitch J, Munro C, Glass C, Pellegrini J. Oral care in the adult intensive care unit. Am J Crit Care 1999;8:314-8. 54. Stiefel K, Damron S, Sowers N. Improving oral hygiene for the seriously ill patient: implementing research-based practice. Medsurg Nurs 2000;9:403,46. 55. Terpenning M, Shay K. Oral health is cost-effective to maintain but costly to ignore. J Am Geriatr Soc 2002;50:584-5.
PATRICIA COLEMAN, PhD, RN, APRN, BC, is an assistant professor in the Syracuse University School of Nursing and a postdoctoral research fellow in the Center for Clinical Research on Aging, University of Rochester School of Nursing, in Rochester, N.Y. Acknowledgments The author is grateful to Jean Johnson, PhD, RN, FAAN, and Diana Biro, PhD, for their thoughtful comments on this manuscript. Copyright 2002 by Mosby, Inc. 0197-4572/2002/$35.00 + 0 34/1/126964 doi:10.1067/mgn.2002.126964
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CE
Contact hours: 1.0 Minimum passing score: 70% Test processing fee: $9 Test ID: G126964
1. Tooth loss can alter food selection that results in a diet high in: A. Protein B. Fiber C. Fats D. Carbohydrates
8. Concepts and principles for oral hygiene practice include the following EXCEPT: A. Plaque reduction B. Control of bacterial growth C. Aggressive brushing with hard bristles D. Intact oral mucosa
2. Periodontal disease involves: A. Dry mouth and inflamed tongue B. Tooth decay and root caries C. Bacterial inflammation of gingival and supporting tissue D. Inflamed mucous membranes from the presence of yeast
9. Which is NOT on the list of common drugs contributing to xerostomia? A. Antioxidants B. Antihistamines C. Antihypertensives D. Antidepressants
3. Denture stomatis involves: A. Dry mouth and inflamed tongue B. Tooth decay and root caries C. Bacterial inflammation of gingival and supporting tissue D. Inflamed mucous membranes from the presence of yeast 4. Xerostomia may be a result of the following EXCEPT: A. Sjogren’s syndrome B. Tooth loss C. Medication therapy D. Sarcoidosis 5. Rank the following in order of most effective to least effective: 1. Large manual toothbrush 2. Ultrasonic brush 3. Small soft toothbrush 4. Collis-Curve A. 4, 3, 2, 1 B. 1, 2, 3, 4 C. 2, 4, 3, 1 D. 3, 1, 4, 2 6. Which of the following has the author recommended NOT to use: A. Foam swabs B. Lemon and glycerin swabs C. Mouth rinse D. Saliva substitutes 7. Which of the following was NOT listed as a communication technique for cognitively impaired older adults? A. Establishing structure B. Task breakdown C. Bridging D. Distraction 198
For questions 10-13 match the technique with the description or example: 10. Rescuing A. Resident holds same object while caregiver performs activity B. Caregiver starts activity and resident completes it C. Caregiver takes over and performs task D. Resident’s hands are busy in a box or apron while examination proceeds 11. Distraction A. Resident holds same object while caregiver performs activity B. Caregiver starts activity and resident completes it C. Caregiver takes over and performs task D. Resident’s hands are busy in a box or apron while examination proceeds 12. Chaining A. Resident holds same object while caregiver performs activity B. Caregiver starts activity and resident completes it C. Caregiver takes over and performs task D. Resident’s hands are busy in a box or apron while examination proceeds 13. Bridging A. Resident holds same object while caregiver performs activity B. Caregiver starts activity and resident completes it C. Caregiver takes over and performs task D. Resident’s hands are busy in a box or apron while examination proceeds
Geriatric Nursing 2002 • Volume 23 • Number 4
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Improving Oral Health Care FOR THE FRAIL ELDERLY:
A Review of Widespread Problems AND Best Practices
Patricia Coleman, PhD, RN, APRN, BC Instructions to CE enrollees: The closed-book, multiple-choice examination that follows this article is designed to test your understanding of the educational objectives listed below. The answer form is on page198. On completion of this article, the reader should be able to: 1. Describe the prevalence of poor oral health care among institutionalized elders 2. Discuss oral disease prevention 3. Review and recommend interventions for oral hygiene
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Abstract Oral health is an important component of overall health, wellbeing, and quality of life for institutionalized elders. Despite reports by nurses of the importance of oral hygiene, empirical evidence shows that daily oral care interventions have not been effective in safeguarding the oral and general health of this vulnerable population. Effective practice must involve not only recognizing its importance but also ensuring that daily oral hygiene receives the same priority as other care practices. (Geriatr Nurs 2002;23:189-97) 189
M
aintaining oral health in elderly individuals is essential to ensure comfort, health, and well-being. Poor oral health in geriatric populations can lead to lifethreatening conditions, including malnutrition and dehydration,1 brain absesses,2 valvular heart disease,3 joint infections,4 cardiovascular disease,5 and pneumonia.6 Epidemiologic prevalence studies, however, reveal that the oral health status of the institutionalized elderly is poor. Studies in the United States,7-10 Canada,11 Great Britian,12 and Europe13 have demonstrated high prevalence rates of caries, poor oral hygiene and denture care, gingival inflammation, dry mouth, bleeding gums, and periodontal disease among nursing home elders. Indeed, a survey11 of 1063 residents in 31 nursing homes throughout Washington indicated that the greatest single need among the dentate elderly was routine oral hygiene. The seriousness of poor oral health in institutionalized elders is not generally recognized by nursing home staff, and thus attention to oral hygiene is afforded low priority by nurses.14 The purpose of this article is to describe the prevalence and consequences of poor oral health care for the institutionalized elderly, discuss the prevention of oral disease conditions, review the evidence base for selected care interventions used for oral hygiene, and recommend ways that health practitioners can facilitate best practices for oral health care in institutionalized elders.
THE IMPORTANCE OF ORAL HEALTH Oral care neglect occurs at significant levels in longterm care (LTC) settings. One of the earliest investigations, which analyzed 442 institutionalized elderly in Edinburgh, Scotland, revealed that 65% of the sample wearing dentures had visible soft debris, calculus, and stains that would not wash off; 53% had denture-induced pathology requiring treatment about which staff were unaware.15 In a stratified random sample of 41 LTC facilities in Vancouver, British Columbia, researchers explored the oral health needs of 653 residents and found similar problems.11 More than a third of the sample had denture stomatitis or other mucosal lesions associated with dentures that had been used for more than 15 years. Hygiene and structure of the dentures were very poor, with thick layers of plaque found in more than 50% of those with dentures, and 20% were using dentures with missing parts, fractures, and other structural defects. Fifty-five percent of the dentate subjects had evidence of tooth decay, and 11% had severe periodontal disease, resulting in extremely mobile teeth. Vigild13 examined the oral hygiene status of 201 dentate elderly subjects in eight randomly selected nursing homes in Denmark. More than two-thirds of the sample had abundant plaque on remaining teeth, and abundant calculus was observed on almost a third of the sample’s remaining teeth. Severe gingivitis, ulceration, and/or spontaneous bleeding was found in 25%. Interestingly, the el-
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ders who depended on nursing home staff members for oral hygiene care had significantly more abundant plaque and gingivitis than those who cleaned their own teeth. Similar findings emerged in studies conducted in England and the United States. Simons and colleagues12 assessed the oral health of 1041 residents in a random sample of 55 nursing homes in England. They found 51% of the sample had root caries, which were significantly related to high plaque accumulation and gingival conditions. Other clinically significant oral problems were angular cheilitis, oral ulcerations, glossitis, xerostomia, fissured/sore tongue, and denture stomatitis. Similar findings of poor oral hygiene in nursing home samples were found in U.S. studies as well. Poor oral hygiene, broken/loose dentures, dry mouth, bleeding gums, and periodontal disease are commonly reported.8,9,16
NEGATIVE IMPACTS OF POOR ORAL HEALTH Poor oral hygiene can have serious adverse effects on the psychosocial and systemic health of institutionalized elders. The mouth plays important roles in appearance, speech and communication, and intimacy. The impact of poor oral health (eg, pain, xerostomia, halitosis, unattractive dentition) on these oral functions can lead to poor self-esteem, social isolation, and depression.17 Moreover, adults who are depressed or disengaged may neglect oral hygiene and thus contribute to poor oral status. Thus, preserving oral health is an important yet underrecognized way to enhance the psychosocial well-being of institutionalized elders. Poor oral health affects systemic health in several ways. First, poor oral hygiene can result in malnutrition, pain, and serious dentally derived infections (eg, pneumonia, bacteremia).18 Second, poor oral hygiene can complicate the management of systemic illnesses. For example, periodontal disease adversely affects glycemic control in diabetics.19 Third, the presence of systemic illnesses (eg, Parkinson’s disease, Alzheimer disease, stroke, arthritis, psychiatric illness) and the drugs used to treat them can complicate oral health care.18 Multiple medications may produce adverse effects on oral health (dry mouth, movement disorders) that complicate effective oral hygiene care.
SPECIFIC CONDITIONS RESULTING FROM POOR ORAL HYGIENE Tooth loss. Most tooth loss is caused by two preventable diseases: dental caries (tooth decay) and periodontal disease.1 Missing teeth can have a profound effect on both oral and systemic health. Uncompensated tooth loss leads to food impaction, risk for periodontal disease, difficulty chewing, and further tooth loss.1 Tooth loss alters food selection, resulting in a carbohydrate-rich diet lacking fiber and protein, putting the elder at risk for malnutrition.18 Tactile and textural perceptions of food may become impaired, altering swallowing ability and increasing the risk of aspiration. Tooth loss, even when replacement
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prostheses are worn, can affect an individual’s quality of life, as dental prostheses are imperfect replacements for teeth and may affect an elder’s social interactions, facial aesthetics, chewing, swallowing, and speaking.1 Dental caries. The incidence and prevalence of dental caries are increasing in older adults.20 Untreated caries can result in pain, tooth loss, abscess formation, cellulitis, and bacteremia. Caries-causing bacteria residing in dental plaque destroy the tooth structure. Because elders form plaque more rapidly than younger individuals,1 lapses in daily oral hygiene can increase the risk of developing new and recurrent tooth decay. Periodontal disease. Periodontal disease is an inflammatory disease of the gingival and supporting tissues caused by bacteria residing in dental plaque.18 Periodontal conditions are associated with tooth loss and mobility, halitosis, bleeding gums, chewing difficulty, and choking—outcomes that influence self-esteem, social relationships, and nutritional intake. Furthermore, periodontal infections increase elders’ susceptibility to pneumonia,6 brain abscesses, uncontrolled blood glucose levels, and infective endocarditis.1 Medication use and chronic diseases associated with aging increase the morbidity associated with periodontal disease. Denture stomatitis. Denture-induced stomatitis is a chronic inflammation of the mucous membranes under the dentures, producing red, inflamed tissue from the presence of yeast and bacteria.21 Prevalent in surveys of institutionalized older adults, the condition is associated with continuous denture-wearing or poor or nonexistent oral and denture hygiene and may result in significant alterations in nutrition, mood, and behavior.22 Tingling, burning pain, and taste disturbances may be reported, although the condition is often asymptomatic.1 Some medical conditions also may contribute to tissue susceptibility to inflammation, such as broad-spectrum antibiotic use, impaired salivary flow, corticosteroid inhalers, and immunocompromised states.1 Xerostomia. Prevalence increases with age, and recent estimates suggest that at least 30% of adults 65 and older report xerostomia.23 Reduction in salivary flow is attributed to systemic conditions and medication use rather than the aging process itself.18 More than 500 drugs in 42 categories contribute to xerostomia; some of the major categories are listed in Table 1. Other major causes of dry mouth are Sjogren’s syndrome, diabetes mellitus, Alzheimer disease, sarcoidosis, chronic anxiety and depression, oxygen therapy, oral suctioning, and NPO status. 23 Salivary gland hyposecretion increases the adherence of dental plaque and thus the frequency and severity of dental caries and periodontal disease.1 Xerostomia may cause taste abnormalities, problems with denture retention, pain, diminished food enjoyment, reduced medication compliance, and difficulty swallowing, speaking, or sleeping. All these make the oral cavity more vulnerable to infection. Although xerostomia is one of the most common undesirable effects of drugs on an elder’s oral health,
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Table 1. Common Drugs Contributing to Xerostomia Anxiolytics Anticholinergics/antireflux Anticonvulsants Antidepressants Antihypertensives Antipsychotics Antihistamines/decongestants Cytotoxics Diuretics Opiates
nurses’ knowledge about the impact of drug therapy on oral health is limited.24
Oral Hygiene and Systemic Disease The oral cavity is a refuge for a large variety of microbes that have the potential to cause both oral and systemic disease. Oral bacteria have been implicated in bacteremias after dental manipulation, flossing, and toothbrushing. Recent reports have been made of associations among severe periodontal diseases, oral hygiene, and coronary heart disease.25 Bacteria commonly associated with pneumonia have been found to colonize the dental plaque of older hospitalized patients26 and residents in nursing homes,27 two groups who often demonstrate poor oral hygiene. Increased dental plaque load from poor hygiene promotes oral colonization by respiratory pathogens and increases the risk of pneumonia in susceptible individuals. Moreover, recent data demonstrate that providing regular oral hygiene care to elderly nursing home residents reduces the incidence of pneumonia in this population.28 These studies provide compelling support for attention to good oral hygiene in frail elders.
THE IMPORTANCE OF PREVENTION General preventive measures are essential to promoting good oral and general health in the elderly, including daily oral hygiene practices with specific attention to control of dental plaque and xerostomia,20 regular oral health assessment,22 and dietary awareness.29 Table 2 illustrates these principles.
ORAL CARE INTERVENTIONS Selected oral care interventions that have particular relevance to these oral hygiene goals will be reviewed, with specific attention to these practices in the nursing home setting. Toothbrushing. A small, soft toothbrush is considered the most effective mechanical method to control dental
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Table 2. General Oral Health Prevention Practices Daily Oral Hygiene to Reduce Plaque Accumulation on Teeth and Dentures
• Mechanically remove plaque from natural teeth with small, soft toothbrush (or electric toothbrush) and fluoride dentifrice twice a day; gently brush teeth, tongue, and gums daily. Facilitate flossing as appropriate. Consider oral or topical fluoride or antiplaque agents in consultation with dental professional.
• Clean dental prostheses with denture brush twice a day; remove and soak them at night whenever possible. Regularly inspect prostheses for cracks, sharp edges, missing teeth. Regularly clean denture storage container, and initiate denture identification program.
• Alleviate/prevent xerostomia: routinely ask elder if mouth feels dry or uncomfortable. Give fluids, such as water-based mouth rinses, frequently. Use artificial saliva or lip lubricants. Have elder chew sugar-free gum or suck on sugar-free candy as appropriate. Periodically review xerostomia-inducing medications for reduction of drug levels/alternate drugs.
• Seek assistance from dental team for communication/behavioral strategies for cognitively impaired and behaviorally difficult residents. Use modified physical or chemical equipment in consultation with dental professionals to facilitate oral care (eg, mouth props, backward-bending toothbrush, spray/gel fluoride preparations).
Regular Oral Health Assessment
• Identify and document risk factors for poor oral hygiene (eg, cognitive/functional impairment, medication use, presence of active oral disease, xerostomia, dysphagia, movement disorder).
• Perform baseline and periodic oral health assessment and documentation using an appropriate tool. • Identify oral self-care ability (identify oral hygiene aids, products, and frequency of use for level of dependence). • Conduct periodic oral and dental examinations with feedback/recommendations on resident oral hygiene adequacy. Attention to Diet
• Minimize sugar intake (sweetened tea, coffee) and fermentable carbohydrates. • Limit between-meal cariogenic snacks. • Encourage consumption of noncariogenic or cariostatic foods (eg, milk, cheese) with cariogenic foods (eg, cookies). Niessen L, Douglass C. Preventive actions for enhancing oral health. Clin Geriatr Med 1992;8:201-14. Ettinger R. Oral care for the homebound and institutionalized. Clin Geriatr Med 1992;8:659-72. Steele J, Walls A. Strategies to improve the quality of oral health care for frail and dependent older people. Qual Health Care 1997;6:165-9.
plaque and its associated complications.29 Daily plaque removal is important. In acute care settings, the toothbrush often is not used by nurses for mouth care.30 In contrast, high levels of toothbrushing activity in nursing home settings are reported,31 with the average time spent brushing each resident’s teeth noted between 3-4 minutes.7 This level and intensity of oral care, however, are inconsistent with the documented oral health status of the institutionalized elderly. The service, while provided, may be performed ineffectively. It is not easy to brush someone else’s teeth, particularly when positioning or gaining his or her cooperation is required. Moreover, providing toothbrushing assistance or supervision to an elder with poor neuromuscular strength or coordination may not reduce plaque optimally. Recent studies comparing ultrasonic and conventional manual brushes in care-dependent32 and outpatient elderly33 populations have demonstrated improvement in oral health indices (eg, plaque levels, gingival bleeding) for the ultrasonic devices, in addition to easy use and caregiver acceptance. Specially designed manual brushes (eg, Collis-
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Curve)34 in nursing home populations provide superior plaque reduction, are easier to manipulate, and take less time relative to conventional models. The sonic brushes and Collis-Curve models may be effective and practical ways to provide improved oral care in institutionalized settings, although issues of cost and maintenance must be considered. Additionally, simple adaptation of toothbrush handles may help facilitate oral self-care in elders. Foam swabs. Foam swabs are used frequently by nurses to clean teeth35 and are the preferred tool for oral care by nurses.24 However, foam swabs are ineffective in cleaning tooth surfaces and controlling plaque,36 which is particularly disadvantageous for dentate institutionalized elders. Swabs may be useful to cleanse and moisten oral mucosa and prevent trauma to delicate tissues, but promoting a moist oral cavity and reducing bacterial plaque can be accomplished just as well with a moistened toothbrush. Lemon and glycerin swabs. Lemon and glycerin swabs for oral hygiene have been a part of nursing practice for more than 60 years but are ineffective oral care cleansers or moisturizers.37 Lemon reduces the oral pH to
Geriatric Nursing 2002 • Volume 23 • Number 4
2-4, below the normal level (6-7). The acid conditions can irritate the mouth, cause pain, decalcify teeth, and increase the risk of dental caries. Glycerin dehydrates the oral tissues. Choice of oral care agents should be based on knowledge of their characteristics, an understanding of oral physiology, and oral assessment. Lemon and glycerin swabs are not only ineffective but in fact harmful and should not be used. Mouth rinses. A variety of cleansing, antimicrobial, and moisturizing agents are available for oral care, including normal saline, hydrogen peroxide, sodium bicarbonate, and chlorhexidine. Interventions using these agents are found primarily in the cancer nursing literature. In the nursing home, nurses’ aides report providing a high percentage of mouth rinsing as part of oral hygiene for residents, although the specific types usually are not identified. In one study, only 33% could recall if the mouthrinse contained fluoride.31 Nurses commonly use hydrogen peroxide and sodium bicarbonate, although the clinical base for the safe use of either preparation as oral care agents has not been established.37 Hydrogen peroxide has antimicrobial properties and permits mechanical cleansing of debris, but recent evidence suggests it harms the oral mucosa and elicits many negative subjective reactions by patients, so it is not recommended.38 Sodium bicarbonate is also controversial. It dissolves mucus and oral debris but has an unpleasant taste35 and can cause oral mucosal burns if not diluted properly. Moreover, altering the pH may disrupt the normal oral flora. It is important to note that bacterial plaque will continue to accumulate when mouthrinsing is the only form of oral hygiene performed. Chlorhexidine (eg, Peridex, PerioGard) preparations (mouthrinses/sprays/gels) are discussed in the nursing literature. Chlorhexidine has been used widely in dentistry to chemically inhibit plaque growth and treat gingival and periodontal disease and other oral infections.39 It has been used to improve oral hygiene in populations with special needs (eg, disabled and mentally retarded adults and children, adults with poor oral hygiene) for whom mechanical plaque removal is difficult.40 Chlorhexidine has been advocated as an intervention strategy for frail and dependent elders when oral self-care is too demanding.41 Recent studies in critical care populations have suggested that, in addition to its powerful effect on dental plaque growth, chlorhexidine also reduces plaque bacterial colonization by respiratory pathogens and may reduce the risk of nosocomial pneumonia.42 A chemotherapeutic approach using chlorhexidine for institutionalized elders with limited self-care skills may be a rational approach to oral disease prevention and reduction in pneumonia risk, given its potent antimicrobial and antiplaque activity, easy application (gel/spray), and reversible local effects. Saliva substitutes. Saliva substitutes can be effective in maintaining oral comfort for the relief of xerostomia,
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but because they do not provide the antibacterial and antiviral properties of natural saliva,1 frequent oral fluids and fluoride and antimicrobial rinses should be considered. Given elders’ frequent complaint of dry mouth, studies suggest that nursing interventions, such as the use of artificial saliva and fluoride rinses that could minimize the effect of xerostomia (and caries formation), are being underused.
FACILITATING BEST PRACTICES More than 40 years ago, Virginia Henderson43 suggested that the overall standard of nursing care could be judged by the state of the patient’s mouth. Significant institutional, professional, and personal barriers must be overcome to improve oral care standards and facilitate best practices for oral health care for elderly nursing home residents. Strategies need to include educational, research, and advocacy efforts and methods to improve practice. These strategies must begin with the development of a culture, both institutional and professional, that promotes, values, and communicates oral health caregiving as fundamental to geriatric nursing practice as are restraint reduction and skin care practices. Oral care is a resource-intensive task that is easy to delegate, perceived as burdensome and undesirable,44 frequently omitted under time constraints,45 performed in isolation, and currently offers little opportunity for professional recognition and status. But oral care is important, like feeding and bathing, and must be promoted as an activity central to caring for older adults.
Educational Approaches Educational interventions can improve nurses’ knowledge and accuracy of oral health assessment. Kayser-Jones and colleagues46 developed the Brief Oral Health Status Examination (BOHSE), an instrument to assess the oral health status of cognitively impaired and unimpaired nursing home residents. Shown in Figure 1, the BOHSE is useful for the nondental professional because it describes how to assess the various oral components (lips, gums, tongue), which are evaluated by observation or manipulation rather than self-report. Empirical research with the BOHSE has demonstrated that nursing personnel (RNs, LPNs, CNAs) can be taught to evaluate residents’ oral health with considerable accuracy if trained to use the assessment tool. These findings and others47 suggest that, with adequate training, nurses can identify oral health problems, initiate appropriate interventions (eg, referral to a dentist or hygienist), and prevent or minimize the significant morbidity associated with poor oral health. Interventions that include oral health education with direct hands-on training for LTC nursing assistants (NAs) have demonstrated improved oral health outcomes for residents. Pyle48 and Frenkel49 demonstrated that an oral health educational program, including both didactic and hands-on training, for NAs improved dentate residents’
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Oral care is important, like feeding and bathing, and must be promoted as an activity central to caring for older adults.
oral health status compared with NAs who had not completed such training. These results show that oral care for nursing home residents can be improved and support the feasibility of educational intervention studies to facilitate and achieve higher standards of geriatric oral health care. The difficulties and challenges of providing oral care to cognitively impaired and behaviorally difficult residents has been identified as a major factor discouraging oral care performance by NAs.31 Effective strategies to facilitate oral care for cognitively impaired nursing home residents have been reported recently. Kayser-Jones et al.50 discuss 11 strategies found successful during 625 oral health examinations in two research studies involving residents with severe functional and cognitive impairments. Chalmers51 presents communication techniques (eg, rescuing, taskbreakdown, distraction, bridging) successful in both conducting geriatric dental research and clinical practice with cognitively impaired older adults. Table 3 describes some of these strategies, which can be adapted to encourage oral hygiene care for residents. Research focusing on the development and implementation of these strategies in the clinical setting is needed. Other educational approaches that may be useful include the participation of dentists or hygienists in formal presentations of oral health curricular content in professional nursing programs, as well as strategies that emphasize the institutional value of oral health through educational programs that include all levels of the nursing home, from administration to NAs. Forming alliances with local universities or technical schools with dental hygiene or assisting programs to initiate student rotations may help elevate the status of oral health care and provide opportunities for continuing education.
Care Delivery Models Appropriate knowledge and skills are necessary to perform effective oral care, but just as important are positive attitudes and behavior toward performance of this care. The introduction of the “oral care aide”31,52—specially trained and supervised to promote, provide, and raise awareness of oral care and communicate resident oral health problems within the multidisciplinary team—has demonstrated some positive impact on resident oral health outcomes. Meaningful recognition of this work, through administrative support and encouragement, clear job descriptions, and financial rewards, are crucial to successful implementation of the oral care specialist concept. Directors of nursing in LTC settings can communicate the value of oral health care by legitimizing this role. This strategy deserves further investigation to determine its long-term impact on resident oral health, fiscal, and staff outcomes. Promoting active involvement of the dental team members is warranted. Models that emphasize interdisciplinary collaboration between nursing and dental hygienists may help facilitate decision making, information sharing, and open communication about oral care prob-
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Figure 1. Kayser-Jones Brief Oral Health Status Examination (BOHSE) Resident’s Name Examiner’s Name Category
Measurement
0
1
2
Lymph nodes
Observe and feel nodes
No enlargement
Enlarged, not tender
Enlarged and tender*
Lips
Observe, feel tissue, and ask resident, family, or staff (eg, primary caregiver)
Smooth, pink, moist
Dry, chapped, or red at corners*
White or red patch, bleeding or ulcer for 2 weeks*
Tongue
Observe, feel tissue, and ask resident, family, or staff (eg, primary caregiver)
Normal roughness, pink and moist
Coated, smooth, patchy, severely fissured, or some redness
Red, smooth, white or red patch; ulcer for 2 weeks*
Tissue inside cheek, floor and roof of mouth
Observe, feel tissue, and ask resident, family, or staff (eg, primary caregiver)
Pink and moist
Dry, shiny, rough red, or swollen*
White or red patch, bleeding, hardness; ulcer for 2 weeks*
Gums between teeth or under artificial teeth
Gently press gums with tip of tongue blade
Pink, small indentations; firm, smooth, and pink under artificial teeth
Redness at border around 1-6 teeth; one red area or sore spot under artificial teeth*
Swollen or bleeding gums, redness at border around 7 or more teeth, loose teeth; generalized redness or sores under artificial teeth*
Saliva (effect on tissue)
Touch tongue blade to center of tongue and floor of mouth
Tissue moist, saliva free-flowing and watery
Tissues dry and sticky
Tissues parched and red, no saliva*
Condition of natural teeth
Observe and count number of decayed or broken teeth
No decayed or broken teeth/roots
1-3 decayed or broken teeth/roots*
4 or more decayed or broken teeth/roots; fewer than 4 teeth in either jaw*
Condition of artificial teeth
Observe, and ask resident, family, or staff (eg, primary caregiver)
Unbroken teeth, worn most of the time
1 broken/missing tooth, or artificial teeth worn for eating or cosmetics only
More than 1 broken or missing tooth; denture either missing or never worn*
Pairs of teeth in chewing position (natural or artificial)
Observe and count pairs of teeth in chewing position
12 or more pairs of teeth in chewing position
8-11 pairs of teeth in chewing position
0-7 pairs of teeth in chewing position*
Oral cleanliness
Observe appearance of teeth or dentures
Clean, no food particles/tartar in the mouth or on artificial teeth
Food particles/tartar in one or two places in the mouth or on artificial teeth
Food particles/tartar in most places in the mouth or on artificial teeth
*Refer to dentist immediately Upper dentures labeled: Yes ______ No ______ None _______ Lower dentures labeled: Yes ______ No ______ None _______ Is your mouth comfortable? Yes _____ No ______ If no, explain: _____________________________________________________ Additional comments:
Reprinted with permission of Jeanie Kayser-Jones, RN, PhD
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Table 3. Communication Techniques to Facilitate Oral Hygiene Care for Cognitively Impaired and Behaviorally Difficult Residents Technique
Description
Example
Rescuing
A second caregiver enters a situation and tells the first caregiver to leave so that he or she can “help” the resident.
The dentist/caregiver is unable to remove the resident’s dentures, so a caregiver enters, takes over, and removes the dentures.
Task breakdown
The activity is broken down into short steps that are slowly repeated and demonstrated.
For toothbrushing: “Pick up the toothbrush,” “Squeeze out the toothpaste,” etc.
Distraction
Singing, playing music, holding items, touching gently, and talking are used to distract the resident from a distressing situation.
A rummage box or busy apron/cushion/ board (with a familiar theme) occupies the active hands of a resident during oral care/examination.
Bridging
Improve sensory connection and task focus by having the resident hold the same object as the caregiver while the caregiver carries out an activity.
The resident holds a toothbrush while the caregiver uses a backward-bent toothbrush to assist in breaking perioral muscle spasms to gain access to the oral cavity.
Hand-over-hand
The caregiver’s hand is placed over the resident’s hand to guide him or her through the activity.
The caregiver places the lower denture in the resident’s hand, then places his or her hand over the resident’s to guide the lower denture back into the mouth.
Chaining
The caregiver starts the activity, and the resident completes it.
The caregiver places the toothpaste on the toothbrush and places it in the resident’s hand, then the resident brushes his or her teeth.
Chalmers J. Behavior management and communication strategies for dental professionals when caring for patients with dementia. Special Care Dentistry 2000;20:147-54.
lems and can heighten awareness of the necessity and value of oral health considerations. Additional research is needed to determine how dentists, nurses, and other health care providers can work together to improve the oral health status of nursing home elders.
Oral Care Practice Protocols Recently, research-based oral care protocols have been developed for critical care settings,53,54 demonstrating significant improvements in patients’ oral health when implemented by bedside nurses. The development and implementation of oral care protocols for institutional settings by nurses in collaboration with dentistry and other disciplines (hygienists, physicians, NAs) would provide a sound and sophisticated basis for delivering care at the bedside. Certainly, the future of oral health for nursing home elders partly depends on how we practice. Oral hygiene practice in institutional settings should be guided by two principles. First, clinical decision making regarding product choice must have the goal of plaque reduction and control of bacterial growth to reduce gingivitis, periodontal disease, caries, and systemic infections. Oral fluoride (rinses, toothpaste, topical application), a conventional or electric toothbrush for mechanical plaque removal, and chlorhexidine gluconate rinses or gel are effective agents. Second, a moist, pink, and intact oral mucosa with a pH between 6 and 7 must be maintained.
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Products commonly available but contraindicated for routine oral hygiene include hydrogen peroxide, sodium bicarbonate, and lemon and glycerin. Toothbrushes with large heads or hard bristles should be avoided because of the trauma potential to delicate mucosal surfaces. Artificial saliva and nonalcoholic mouthwashes may be helpful to maintain moisture. Nurses can advocate for improved oral health policy and care practices through representation on institutional purchasing committees to support the purchase and use of appropriate oral care products based on the best available evidence. Low-cost interventions in oral hygiene have the potential to reduce the high-cost outcomes associated with poor oral care (eg, pneumonia),55 resulting in cost savings and improved quality of care. Gerontologic nurses are central to the achievement of these important goals.
CONCLUSION The evidence suggests that poor oral hygiene among institutionalized elders is a much greater problem than commonly realized. Oral hygiene for this population typically has been perceived as a burden, but good oral care has significant benefits for both the quality of life and overall general health of frail elders. Nurses can play a critical role in improving oral health care for these older adults, thus promoting better patient outcomes, and the nursing and related health care professions can support
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the efforts of caregivers by recognizing, recommending, and supporting best practices in this important area. REFERENCES 1. Shay K, Ship J. The importance of oral health in the older patient. J Am Geriatr Soc 1995;43:1414-22. 2. Andrews M, Farnum S. Brain abscess secondary to dental infection. General Dentistry 1990;38:224-5. 3. Feihn N, Gutshik E, Larsen T, Bangsborg J. Identity of streptococcal blood isolates and oral isolates from two patients with infective endocarditis. J Clin Microbiol 1995;33:1399-1401. 4. Bartzokas C, Johnson R, Jane M, Martin M, Pearce P, Saw Y. Relation between mouth and haematogenous infection in total joint replacements. Br Med J 1994;309:506-8. 5. Joshipura K, Rimm E, Douglass C, Trichopoulos D, Ascheriio A, Willett W. Poor oral health and coronary heart disease. J Dental Res 1996;75:1631-6. 6. Scannapieco F. Role of oral bacteria in respiratory infection. J Periodontol 1999;70:793-802. 7. Kambhu P, Levy S. Oral hygiene care levels in Iowa intermediate care facilities. Special Care Dentistry 1993;13:209-14. 8. Kiyak H, Grayston M, Crinean C. Oral health problems and needs of nursing home residents. Comm Dent Oral Epidemiol 1993;21:49-52. 9. Empey G, Kiyak H, Milgrom P. Oral health in nursing homes. Special Care Dentistry 1983;3:65-7. 10. Gift H, Cherry-Peppers G, Oldakowski R. Oral health status and related behaviours of U.S. nursing home residents, 1995. Gerodontology 1997;14:89-99. 11. MacEntee M, Weiss R, Waxler-Morrison N, Morrison B. Factors influencing oral health in long-term care facilities. Comm Dent Oral Epidemiol 1987;15:314-6. 12. Simons D, Kidd E, Beighton D. Oral health of elderly occupants in residential homes. Lancet 1999;353:1761. 13. Vigild M. Oral hygiene and periodontal conditions among 201 dentate institutionalized elderly. Gerodontics 1988;4:140-5. 14. Wardh I, Hallberg L, Berggren U, Andersson L, Sorensen S. Oral health care-low priority in nursing. Scand J Caring Sci 2000;14:137-42. 15. Ettinger R, Manderson R. Dental care of the elderly. Nursing Times 1975;10:1003-6. 16. Berkey D, Berg R, Ettinger R, Meskin L. Research review of oral health status and service use among institutionalized older adults in the United States and Canada. Special Care Dentistry 1991;11:131-6. 17. Karuza J, Miller W, Lieberman D, Ledenyi L, Thines T. Oral status and resident well-being in a skilled nursing facility population. Gerontologist 1995;35:104-2. 18. Schwartz M. The oral health of the long-term care patient. Ann Long-Term Care 2000;8:41-6. 19. Taylor G, Loesche W, Terpenning M. Impact of oral diseases on systemic health in the elderly: diabetes mellitus and aspiration pneumonia. J Public Health Dentistry 2000;60:313-20. 20. Niessen L, Douglass C. Preventive actions for enhancing oral health. Clin Geriatr Med 1992;8:201-14. 21. Matear D. How important is oral health care in geriatric institutions? Perspectives 1999;23:9-17. 22. Ettinger R. Oral care for the homebound and institutionalized. Clin Geriatr Med 1992;8:659-72. 23. Ship J, Pillemer S, Baum B. Xerostomia and the geriatric patient. J Am Geriatr Soc 2002;50:535-43. 24. Adams R. Qualified nurses lack adequate knowledge related to oral health, resulting in inadequate oral care of patients on medical wards. J Adv Nurs 1996;24:552-60. 25. Beck J, Garcia R, Heiss G, Vokonas P, Offenbacher S. Periodontal disease and cardiovascular disease. J Periodontol 1996;67:1123-37. 26. Scannepieco F, Stewart E, Mylotte J. Colonization of dental plaque by respiratory pathogens in medical intensive care patients. Crit Care Med 1992;20:740-5. 27. Russell S, Boylan R, Kaslick R, Scannapieco R, Katz R. Respiratory pathogen colonization of the dental plaque of institutionalized elders. Special Care Dentistry 1999;19:128-34. 28. Yoneyama T, Yoshida M. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc 2002;50:430-3. 29. Steele J, Walls A. Strategies to improve the quality of oral health care for frail and dependent older people. Qual Health Care 1997;6:165-9. 30. Kite K. Changing mouth care practice in intensive care: implications of the clinical setting context. Intens Crit Care Nurs 1995;11:203-9. 31. Chalmers J, Levy S, Buckwalter K, Ettinger R, Kambhu P. Factors influencing nurses’ aides’ provision of oral care for nursing facility residents. Special Care Dentistry 1996;16:71-9. 32. Day J, Martin M, Chin M. Efficacy of a sonic toothbrush for plaque removal by caregivers in a special needs population. Special Care Dentistry 1998;18:202-6. 33. Whitmyer C, Terezhalmy G, Miller D, Hujer M. Clinical evaluation of the efficacy and safety of an ultrasonic toothbrush system in an elderly patient population. Geriatr Nurs 1998;18:29-33.
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34. Kambhu P, Levy S. An evaluation of the effectiveness of four mechanical plaque-removal devices when used by a trained care-provider. Special Care Dentistry 1993;13:9-14. 35. Barnett J. A reassessment of oral healthcare. Prof Nurs 1991;6:703-8. 36. Pearson L. A comparison of the ability of foam swabs and toothbrushes to remove dental plaque: implications for nursing practice. J Adv Nurs 1996;23:62-69. 37. Trenter-Roth P, Creason N. Nurse-administered oral hygiene: is there a scientific basis? J Adv Nurs 1986;11:323-31. 38. Tombes M, Gallucci B. The effects of hydrogen peroxide rinses on the normal oral mucosa. Nurs Res 1993;42:332-7. 39. Brecx M. Strategies and agents in supragingival chemical plaque control. Periodontology 1997;15:100-8. 40. Steifel D, Truelove E, Chin M, Zhu X, Lerous B. Chlorhexidine swabbing applications under various conditions of use in preventive oral care for persons with disabilities. Special Care Dentistry 1995;15:159-65. 41. MacEntee M. Oral care for successful aging in long-term care. J Public Health Dentistry 2000;60:326-9. 42. Fourrier F, Cau-Pottier E, Boutigny H, Roussel-Delvallez M, Jourdain M, Chopin C. Effects of dental plaque antiseptic decontamination on bacterial colonization and nosocomial infections in critically ill patients. Intensive Care Med 2000;26:1239-47. 43. Henderson V. Basic principles of nursing care. Geneva: International Council for Nursing: 1960. 44. Wardh I, Anderson L, Sorenson S. Staff attitudes to oral health care. A comparative study of registered nurses, nursing assistants and home care aides. Gerodontology 1997;14:28-32. 45. Bowers B, Becker M. Nurses’ aides in nursing homes: the relationship between organization and quality. Gerontologist 1992;32:360-6. 46. Kayser-Jones J, Bird W, Paul S, Long L, Schell E. An instrument to assess the oral health status of nursing home residents. Gerontologist 1995;35:814-24. 47. Arvidson-Bufano U, Blank L, Yellowitz J. Nurses’ oral and health assessments of nursing home residents pre-and post-training: a pilot study. Special Care Dentistry 1996;16:58-64. 48. Pyle M, Massie M, Nelson S. A pilot study on improving oral care in longterm care settings. J Gerontol Nurs 1998;45:31-8. 49. Frenkel, H, Newcombe, R. Improving oral health in institutionalised elderly people by educating caregivers: a randomised controlled trial. Community Dent Oral Epidemiol 2001;29:289-97. 50. Kayser-Jones J, Bird W, Redford M. Strategies for conducting dental examinations among cognitively impaired nursing home residents. Special Care Dentistry 1996;16:46-52. 51. Chalmers J. Behavior management and communication strategies for dental professionals when caring for patients with dementia. Special Care Dentistry 2000;20:147-54. 52. Charteris P, Kinsella T. The oral care link nurse: a facilitator and educator for maintaining oral health for patients at the Royal Hospital for NeuroDisability. Special Care Dentistry 2001;21:68-71. 53. Fitch J, Munro C, Glass C, Pellegrini J. Oral care in the adult intensive care unit. Am J Crit Care 1999;8:314-8. 54. Stiefel K, Damron S, Sowers N. Improving oral hygiene for the seriously ill patient: implementing research-based practice. Medsurg Nurs 2000;9:403,46. 55. Terpenning M, Shay K. Oral health is cost-effective to maintain but costly to ignore. J Am Geriatr Soc 2002;50:584-5.
PATRICIA COLEMAN, PhD, RN, APRN, BC, is an assistant professor in the Syracuse University School of Nursing and a postdoctoral research fellow in the Center for Clinical Research on Aging, University of Rochester School of Nursing, in Rochester, N.Y. Acknowledgments The author is grateful to Jean Johnson, PhD, RN, FAAN, and Diana Biro, PhD, for their thoughtful comments on this manuscript. Copyright 2002 by Mosby, Inc. 0197-4572/2002/$35.00 + 0 34/1/126964 doi:10.1067/mgn.2002.126964
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CE
Contact hours: 1.0 Minimum passing score: 70% Test processing fee: $9 Test ID: G126964
1. Tooth loss can alter food selection that results in a diet high in: A. Protein B. Fiber C. Fats D. Carbohydrates
8. Concepts and principles for oral hygiene practice include the following EXCEPT: A. Plaque reduction B. Control of bacterial growth C. Aggressive brushing with hard bristles D. Intact oral mucosa
2. Periodontal disease involves: A. Dry mouth and inflamed tongue B. Tooth decay and root caries C. Bacterial inflammation of gingival and supporting tissue D. Inflamed mucous membranes from the presence of yeast
9. Which is NOT on the list of common drugs contributing to xerostomia? A. Antioxidants B. Antihistamines C. Antihypertensives D. Antidepressants
3. Denture stomatis involves: A. Dry mouth and inflamed tongue B. Tooth decay and root caries C. Bacterial inflammation of gingival and supporting tissue D. Inflamed mucous membranes from the presence of yeast 4. Xerostomia may be a result of the following EXCEPT: A. Sjogren’s syndrome B. Tooth loss C. Medication therapy D. Sarcoidosis 5. Rank the following in order of most effective to least effective: 1. Large manual toothbrush 2. Ultrasonic brush 3. Small soft toothbrush 4. Collis-Curve A. 4, 3, 2, 1 B. 1, 2, 3, 4 C. 2, 4, 3, 1 D. 3, 1, 4, 2 6. Which of the following has the author recommended NOT to use: A. Foam swabs B. Lemon and glycerin swabs C. Mouth rinse D. Saliva substitutes 7. Which of the following was NOT listed as a communication technique for cognitively impaired older adults? A. Establishing structure B. Task breakdown C. Bridging D. Distraction 198
For questions 10-13 match the technique with the description or example: 10. Rescuing A. Resident holds same object while caregiver performs activity B. Caregiver starts activity and resident completes it C. Caregiver takes over and performs task D. Resident’s hands are busy in a box or apron while examination proceeds 11. Distraction A. Resident holds same object while caregiver performs activity B. Caregiver starts activity and resident completes it C. Caregiver takes over and performs task D. Resident’s hands are busy in a box or apron while examination proceeds 12. Chaining A. Resident holds same object while caregiver performs activity B. Caregiver starts activity and resident completes it C. Caregiver takes over and performs task D. Resident’s hands are busy in a box or apron while examination proceeds 13. Bridging A. Resident holds same object while caregiver performs activity B. Caregiver starts activity and resident completes it C. Caregiver takes over and performs task D. Resident’s hands are busy in a box or apron while examination proceeds
Geriatric Nursing 2002 • Volume 23 • Number 4
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Name
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18. ❑ A 19. ❑ A ❑B ❑B ❑C ❑C ❑D ❑D
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