Cherin Pace, RDH, MS, CCC-SLP Gary McCullough, PhD, CCC-SLP

Transcription

1 Cherin Pace, RDH, MS, CCC-SLP Gary McCullough, PhD, CCC-SLP

2 The presenters of this session, Cherin Pace & Gary McCullough, have no financial or nonfinancial agreements or interests relevant to the topic of this presentation.

3 Learning Objectives 1. Flashy Introduction with Little Substance. 2. Review anatomy & functions of the oral cavity to include microorganisms. 3. Define biofilm and its relationship to oral disease. 4. Discuss the relationship between: Pathological oral microorganisms Biofilm Oral disease Aspiration pneumonia. 5. Describe various methods of biofilm control for residents of long term care facilities to reduce the potential for oral disease and aspiration pneumonia.

4 Medical Concerns Aspiration pneumonia 7.6 x more likely in aspirators than nonaspirators 5.6x more likely in aspirators of thick liquid/solid Death 9.2x more likely in aspirators of thick liquid/solids than thin liquid Schmidt et al., 1994

5 Culprits in the Development of Aspiration Pneumonia Dependency for oral care Number of decayed teeth Number of medications Necessity of tube feeding Dependency for feeding Smoking Multiple medical diagnoses Requires suctioning COPD, CHF or other high risk medical diagnosis Weight loss Urinary tract infection Bedbound Decreased alertness Langmore 1998

6 Oh.and yes Dysphagia

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8 Daily cleaning of teeth/dentures 93.9

9 SLP Boy Meets DH Girl

10 1. Nursing home residents, particularly those with a history of neurologic disease, are at risk for dysphagia and, ultimately, aspiration pneumonia 2. These individuals are prone to poor oral health due to lack of oral hygiene care as well as conditions of periodontal and/or dental disease

11 In first 90 days, 416 downloads. People are now recognizing the strong association between oral hygiene and dysphagia-related illnesses. Pathways to treatment need to be defined and a service-delivery model needs to be constructed. Our goal is to provide a firmer base to move us in that direction.

12 Anatomy / Functions of the Oral Cavity Complex environment Teeth Functions Nutrition intake Saliva Gingival crevicular fluid Oral flora Air intake/outflow As alternative route to nasal cavity Speech

13 Speedy Micro Review Stained w/ crystal violet dye Gram positive Thick single-cell wall Retain violet color Gram negative Double-cell walls Do not retain color of dye Motile vs nonmotile Aerobic Require oxygen to live Anaerobic Cannot live in the presence of oxygen Facultative Can live with or without oxygen

14 thousands of species of bacteria most are not harmful to humans innocuous Species that are harmful to humans pathogenic or virulent capable of causing disease. Both innocuous and pathogenic bacteria live in symbiotic relationship within the oral cavity

15 In addition to bacteria Oral microbiota includes: Gram + & Gram facultative & anaerobic Cocci Rods Spriochetes

16 Supported by stratified squamous epithelium Mucosa Protects Mechanical, chemical, and thermal insult Cheek bite Toxins/enzymes from microbes Carcinogens Fluid loss

17 In utero, the oral cavity is sterile but shortly after birth within a few hours to one day a simple oral flora develops Microorganisms are transmitted > infant from mother, other family members and caretakers As the infant grows, introduction of microorganisms is ongoing and complex Oral microorganisms aid in the digestive process

18 The Bad Gram negative, anaerobic, nonmotile bacteria Associated w/ periodontal disease >500 species of bacteria isolated from one periodontal pocket 100, ,000,000 bacteria found in a specific site Mostly Gram negative

19 The Ugly: BIOFILM Microorganisms that adhere to surfaces and to one another forming a wellorganized community single bacterial species but usually many species of bacteria as well as other organisms and debris become embedded in an extracellular slime layer

20 The Ugly: BIOFILM Forms rapidly on most wet surfaces: plaque on teeth slime in fish tanks slime deposits that clog the sink drain indwelling IV and urinary catheters prosthetic devices heart valves, biliary stents, pacemakers, artificial joints Biofilm within a hotel air conditioning system > 1976 outbreak of Legionnaires disease > killed 29 people

21 Saliva necessary for oral health liters / day ml / minute Composition - dynamic 99% water w/ electrolytes, proteins, enzymes, immunoglobulins Provides protective covering between the oral microbes and the oral mucosa

22 Lubricates oral mucosa Moistens dry food; cools hot food Dissolves and neutralizes food Stimulates taste; initiates digestion Washes microbes from teeth Mineralizes, repairs enamel Provides protection for teeth w/ antibacterial compounds

23 Minor salivary gland dysfunction labial glands No documented reduction from parotid or submandibular glands Xerostomia is secondary to disease/medications caries, dry lips, painful mucosa, dysphagia, change in taste acuity Xerostomia is NOT a part of normal aging

24 Medication-Induced Xerostomia Anticholinergics Antihistamines Antidepressants Antineoplastics Antipsychotics Diuretics Antihypertensives Bronchodilators Amphetamines Cancer patients: Radiation tx to head/neck >severe xerostomia

25 Treatment for Xerostomia OTC Biotene Oasis Oramoist Xylimelts RX Fluoride Stannous Rinses Gum Toothpastes Lozenges Sprays

26 Oral Disease Dental Decay Tooth decay Caries Cavities Periodontal Disease Periodontitis Gum disease Pyorrhea Oral Cancer Head & neck cancer Laryngeal cancer

27 Elderly at increased risk Not a normal part of aging Risk factors pts w/: Osteoporosis Decreased tissue vascularity Increased risk for infection Xerostomia (secondary to meds) Chronic disease and physical dexterity altered immune response medication side effects plaque removal skills

28 Gram negative bacterial infection Destroys attachment fibers supporting bone that holds the teeth in the mouth When attachment is destroyed gum tissue separates from the tooth pockets form fill with plaque harbor bacteria

29 Healthy Gingival Tissue Characterized by healthy coral pink color Firm attachment of tissue against the teeth

30 Acute (gingivitis) Short-term response Few days to 3 weeks Reversible Subacute (periodontitis) Mid-term response 4-8 weeks Chronic Long-term response months or years

31 Minimal Data Set (MDS) nursing Section L 6 questions re: oral/dental status Resident Assessment Protocol (RAP) Very limited for oral status Brief Oral Health Status Examination 10 category screening tool for LTC settings Oral Health Assessment Tool (OHAT)

32 Oral Care Who? RN CNA DDS/RDH SLP All of the above! How? Chemical Mechanical Professional When? Daily 2X/day Every few hours

33 Lack of Knowledge / skill / training CNA s have low priority for their own OH Time CNA s resp for bathing, dressing, etc Limited (if any) accountability for completion of oral care Patient cooperation (or lack thereof) Fear of biting negative reactions/resistant behaviors

34 Who? Professional Services Dentistry / Dental hygiene Provide inservice education to SLP s, RN s, CNA s Issues of supervision restrictions for RDH Good news! Recent legislation in some states will change this

35 When? Oral Care Protocols No US standard Literature reports varying frequency: More often for high risk pts Every 2-4 hours dep on condition Every 8 hours for neuro pts Every 12 hours w/ oral moistening Every 2 hours while intubated

36 How? 1) Mechanical Toothbrushes, swabs, etc. 2) Chemical mouthrinses 3) Dentures, partials, and edentulous patients

37 Toothette High frequency of use by RN s Esp in ICU Studies show not effective for removal of dental plaque Lemon Glycerine Swabs No abrasive qualities not a substitute for brushing Ok for freshening mouth or removing dried secretions May> xerostomia at first, but saliva will rebound after a few days?acidic effect on enamel

38 Manual toothbrush Always use soft bristle type Collis Curve Toothbrush Suggest child size

39 Battery/electric toothbrushes

40 Floss Interdental brush

41 Waterpik Costly Can damage tissues if used incorrectly Will remove gross food debris But not plaque

42 Plak-Vac Suction Toothbrush combination yankauer suction tube and evacuator brush removes oral debris, plaque, bacteria, & fluid For patients with dysphagia &/or problems expectorating soft bristles - gentle to gums, teeth, oral mucosa Suction level controlled by finger control port located in handle

43 2) Chemical RX Chlorhexidine Gluconate (CHX) broad spectrum antiseptic rinse reduces both Gram positive & Gram negative bacteria Substantivity ability to remain chemically active on tissue for up to 6 hours Periodontal & dental implant surgery &: pre-surgical & general antiseptic hand scrub umbilical cord cleanser treating burns, cuts, acne

44 CHX U.S. 0.12% Europe 2.0% Disadvantages: Expense Shelf life Most contain alcohol Drying to tissues Not rec d for pts w/ xerostomia

45 Chemical OTC Rinses Listerine Disadvantage alcohol However, Listerine Zero Alcohol free Crest Pro-Health Alcohol free

46 Misc. Considerations Toothpaste Fluoride Small amount Water soluble moisturizer on lips/oral mucosa for comfort Sodium bicarbonate baking soda Mix w/ water /mouthrinse to make a paste Hydrogen peroxide Dilute 50/50 w/ water May cause superficial burns Esp cancer pts

47 For patients w/ dementia, use Tell-Show-Do approach: 1) TELL: Mrs. Jones, I m Cherin your speech therapist. I m going to brush your teeth and clean your mouth 2) SHOW: (use mouth model and toothbrush to show pt what/how you will do what you just told them) 3) DO: (do exactly what you told/showed them. If you alter, start back at TELL )

48 Resistant/semi-conscious won t/can t open mouth: Use mouth prop Disposable Home-made w/ tongue depressors and gauze

49 Often overlooked can be source of biofilm to include fungus Clean same as natural teeth Brush 2X day Remove at bedtime, clean, and soak in denture cleaning solution

50 Use warm not hot water Brush w/ denture brush Use denture cleanser, hand soap or baking soda NOT ajax or comet will scratch Clean over bowl of water or w/ towel in sink Rinse w/ cool water Nasty smell?! Soak in 1 tsp bleach/1cup water for 30 minutes Rinse well

51 Clean anyway! Swab gums and mucosa with Toothette or gauze soaked in CHX antimicrobial mouthrinse Listerine

52 Reimbursement Who pays for all this? Professional cleanings Mouthrinses Toothbrushes and adjunctive aids If treating pt for dysphagia, code as oral stim

53 Do we allow organic, rotting debris to elicit an inflammatory reaction on the heel or buttock? Should we maintain the same standard for the mouth, which in the presence of dysphagia, drains directly into the lungs? Drinka, 2010

54 Questions anyone? References and Cherin s contact information are in your handout! Thanks!!