Linda J. O’Connor
EDUCATIONAL OBJECTIVES
On completion of this chapter, the reader should be able to:
1. Discuss the consequences of poor oral health
2. Describe a thorough oral assessment in the older adult
3. Describe the oral hygiene plan of care for nonintubated older adults
4. Discuss nursing interventions for oral care
OVERVIEW
Poor oral health is associated with malnutrition, dehydration, cardiovascular disease, pneumonia, aspiration pneumonia, poor glycemic control in type 1 and 2 diabetes, and chronic obstructive pulmonary disease (COPD) exacerbations (Bascones-Martinez, Gonzalez-Febles, & Sanz-Esporin, 2014; Belstrom, Damgaard, Nielsen, & Holmstrup, 2012; Bingham, Ashley, De Jong, & Swift, 2010; Cotti, Dessi, Piras, & Mercuro, 2011; Desvarieux et al., 2010; El-Solh, 2011; Holmlund & Lind, 2012; Jung et al., 2014; Ledic et al., 2013; Liu et al., 2012; Lockhart et al., 2009; Negrato, Tarzia, Jovanovic, & Chinellato, 2013; Nicolosi, Lewin, González, Jara, & Rubio Mdel, 2011; Oliveira et al., 2010; Ozcaka, Becerik, Bicakci, & Kiyak, 2014; Pace & McCullough, 2010; Si et al., 2012; Tada & Miura, 2010; Uyar et al., 2013). Oral health also affects nutritional status, ability to speak, self-esteem, mental wellness, and overall well-being (Haumschild & Haumschild, 2009; Montero, López, Galindo, Vicente, & Bravo, 2009; Naito et al., 2010; Quandt et al., 2010). Many oral diseases are not part of the natural aging process but side effects of medical treatment and medications.
BACKGROUND AND STATEMENT OF PROBLEM
Plaque retention is a problem in older adults who have difficulty in mechanically removing plaque caused by diminished manual dexterity, impaired vision, or chronic illness (Brown, Goryakin, & Finlayson, 2009; Hakuta, Mori, Ueno, Shinada, & Kawaguchi, 2009). An older adult’s functional ability and cognitive status affect his or her ability to perform oral care and denture care. Dental plaque harbors microorganisms, including Streptococcus, Staphylococcus, gram-positive rods, gram-negative rods, and yeasts (Coulthwaite & Verran, 2007). Dentures also have the potential to harbor Streptococcus pneumoniae, Haemophilus influenza, Escherichia coli, Klebsiella, and Pseudomonas secondary to spending time in nonhygienic environments (Coulthwaite & Verran, 2007). Dentures have been seen thrown in with patients’ clothing, thrown in a washbasin or other containers with bathing items, and so forth, instead of being properly cleaned and stored in a denture cup. Lack of good oral hygiene increases the risk of development of secondary infections, extended hospital stays, and significant negative health outcomes.
Multiple medications produce side effects that affect the oral cavity. Cardiac medications can cause salivary dysfunction, gingival enlargement, and lichenoid mucosal reactions. Steroid treatment can predispose a patient to oral candidiasis, and cancer treatments can cause a plethora of oral conditions such as stomatitis, salivary hypofunction, microbial infections, and xerostomia.
The mouth reflects the culmination of multiple stressors over the years and, as the mouth ages, it is less able to tolerate these stressors. With an increase in chronic disease and medication usage as a person ages, the prevalence of root caries, tooth loss, oral cancers, soft-tissue lesions, and periodontal problems increases significantly (Christensen, 2007; Saunders & Friedman, 2007). Many of the oral health problems seen in older adults could be avoided with routine preventive care. Many older adults believe in the myth that a decline in oral health is a normal part of aging.
ASSESSMENT OF THE PROBLEM
Physical Assessment
The promotion of oral health through assessment and good oral hygiene is an essential part of nursing care. Oral assessment is part of the nurse’s head-to-toe assessment of the older adult and is done on admission and at the beginning of each shift. The nurse assesses the condition of the oral cavity, which should be pink, moist, and intact; the presence of or absence of natural teeth and/or dentures; ability to function with or without natural teeth and/or dentures; and the patient’s ability to speak, chew, or swallow. Natural teeth should be intact, and dentures (partial or full) should fit comfortably and not be moving when the older adult is speaking. 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 informed.
Poorly fitting dentures can cause ulcerations and candidiasis (oral fungal infection, masses, and denture stomatitis). Denture stomatitis presents as red, inflamed tissue beneath dentures, caused by fungal infections and insufficient oral hygiene. Some oral mucosal diseases that nursing may see are angular cheilitis (red and white cracked lesions in the corners of the mouth, caused by inflammation and a fungal infection), cicatricial pemphigoid (produces red, inflamed lesions on the gingival, palate, tongue, and cheek tissues), lichen planus (most common form presents as a lacy white appearance on the tongue and/or cheeks), and pemphigus vulgaris (red bleeding tissues resulting from trauma but heal without scarring). Untreated lesions can develop into large, infected regions, which require immediate medical attention. Dental professionals diagnose oral mucosal diseases, but the nurse needs to be aware of any abnormal findings and report them immediately.
The nurse also needs to assess the patient for functional ability and manual dexterity to provide oral hygiene. The nurse needs to observe the older adult providing oral hygiene to make sure that it is effective. The primary focus for nurses is to maintain the older adult’s function so that older adults may participate in their daily care. Once the older adult performs his or her oral hygiene, the nurse must follow up as appropriate to complete the oral hygiene.
Assessment Tools
The Oral Health Assessment Tool (OHAT) is an eight-category screening tool that can be used with cognitively intact or impaired older adults. The OHAT provides an organized, efficient method for nurses to document their oral assessment. The eight categories (lips, tongue, gums and tissues, saliva, natural teeth, dentures, oral cleanliness, and dental pain) are scored from 0 (healthy) to 2 (unhealthy). Total scores range from 0 to 16; the higher the score, the poorer the older adult’s oral health (Chalmers, King, Spencer, Wright, & Carter, 2005). The OHAT may be implemented in any health care setting. See the Resources section for access to this tool.
INTERVENTION AND CARE STRATEGIES
The gold standard for providing oral hygiene is the toothbrush. It is the mechanical action of the toothbrush that is important for plaque removal. If the older adult has any decrease in function or manual dexterity, the nursing staff needs to assess the older adult’s ability to provide effective oral hygiene and provide assistance as needed. Foam swabs are available in numerous facilities to provide oral hygiene. Research has shown that foam swabs cannot remove plaque as well as toothbrushes can (Pace & McCullough, 2010). Foam swabs may be used for cleaning the oral mucus of an edentulous older adult.
Lemon–glycerin swabs or swab sticks cause drying of the oral mucosa and erosion of the tooth enamel. Lemon–glycerin swabs or swab sticks are detrimental to the older adult and are never to be used.
Alcohol-free commercial mouth rinses may be used. Toothpaste with fluoride is currently recommended by the American Dental Association to reduce cavities and to help reduce periodontal disease.
The use of chlorhexidine in the geriatric patient is determined by the dentist. There are some side effects of chlorhexidine (bitter taste; change in the taste of food; mouth irritation; and staining of teeth, mouth, fillings, and dentures) that may have negative outcomes for the older adult (Quagliarello et al., 2009). A good oral assessment by the nurse during each shift is essential for the geriatric patient on chlorhexidine and so is monitoring of the patient’s nutritional intake.
Education of the nursing staff is imperative. Two of the major barriers cited by nursing staff are inadequate knowledge of how to assess and provide care and lack of appropriate supplies. Implementation of evidence-based protocols combined with ongoing educational training sessions have been demonstrated to have a positive impact on oral care being provided and on the oral health status of older adults (Gluhak, Arnetzl, Kirmeier, Jakse, & Arnetzl, 2010; Ribeiro et al., 2009; Young, Murray, & Thompson, 2008). Staff needs to be instructed on oral hygiene and the proper care of different appliances. Dentures should be brushed before placing them into a denture cup. Dentures should be removed at night, but some older adults prefer to keep their dentures in continuously. It therefore becomes even more important for the nurse to do an assessment of the oral mucosa. In the acute care and long-term care setting, the older adult may not have dental adhesive and, therefore, there is a high risk for food particles to get caught underneath of their dentures. It is important that staff remember to take the dentures out after each meal, rinse them and the patient’s mouth, and place the dentures back in. Complete denture care should be given morning, night, and as needed.
Education of nursing staff, older adults, and families is imperative. Nurses need to be educated in oral assessment and nursing assistants need to be educated in observation of the oral cavity and what to report to the nurse. Both nurses and nursing assistants need to be educated about the proper techniques for providing oral hygiene and caring for oral appliances. Patients and families need to be educated on the importance of good oral health and hygiene and to dispel the oral-health myths that exist about oral health and aging in general.
Education focused on the importance of good oral health and hygiene in the older adult, the myths about oral health and aging, evidence-based practice protocols, implementing these protocols, and the appropriate products for providing oral hygiene to their patients and residents must be provided to administrators. Without the proper supplies, it is impossible for the nursing staff to provide the oral-hygiene care the older adult needs and to properly implement evidence-based protocols for oral health and hygiene in the older adult.
CASE STUDY
Mrs. Smith, an 84-year-old female with a history of Alzheimer’s-type dementia, was admitted for recent decreased oral intake and percutaneous endoscopic gastrostomy (PEG) placement. Mrs. Smith was alert, oriented to herself, pleasant, cooperative with care, and able to follow simple directions. She lived at home with her family and received care from a home health aide. The initial oral assessment was done on day 2 of admission and it was found that upper dentures and lower natural teeth were both covered with food particles. Her oral mucosa was noted to be dry. The upper dentures were difficult to remove and caused her pain. The upper denture was being “kept in place” by a collection of old food, which was found on removal. The oral mucosa under the upper denture was covered with sores and ulcers and was bleeding, infected, and very painful. The health team was notified, a dental consultant was called, and an oral hygiene plan of care was implemented. Mrs. Smith’s diet was changed to puree while her oral mucosa was healing and the PEG placement was put on hold. On inquiry, it was learned from the family that their long-time aide had just moved, and the new aide had been with them for only a few months. It was during this time that they noticed the decline in Mrs. Smith’s nutritional intake. The family chose to hire a new aide, and both the family and the new aide were educated on proper oral hygiene for Mrs. Smith. Once Mrs. Smith’s oral mucosa had healed, the upper denture was replaced, and she was returned to her regular diet. Her oral intake returned to baseline, and a PEG was no longer required.
Discussion
This case study illustrates how poor oral care often goes undetected, the importance of good oral care, the need for physical assessment by the nurse, and the need for staff and family education. This patient was being admitted for an invasive procedure secondary to poor oral health caused by poor oral care. Although the family was involved in Mrs. Smith’s care (she had no contractures or skin breakdown), her lack of oral care had gone unnoticed by them. The admitting nurse documented that the patient had dentures on the admission form but did not do a physical oral assessment. The nurse caring for the patient on day 2 had attended an oral health seminar and included the physical oral assessment in her morning rounds. She also followed up with the nursing assistants to ensure that oral care had been provided to the patient after each meal. The implementation of an oral hygiene plan of care and education of nursing staff, family, and home care staff ensured that Mrs. Smith received the oral care required for her oral mucosa to heal, her nutritional status to return to baseline, and prevented the unnecessary placement of a PEG.
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