Oral health care is not adequately considered. Oral Health Protocol for the Dependent Institutionalized Elderly

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1 Oral Health Protocol for the Dependent Institutionalized Elderly Jose Antonio Gil-Montoya, DDS, PhD, Ana Lucia Ferreira de Mello, DDS, Ciro Barreto Cardenas, DDS, and Inmaculada Guardia Lopez, DDS Establishing an oral hygiene protocol for the frail and functionally dependent elderly should be of special concern to health care providers. The previous assessment of a care center, including patients or residents and staff, allows an effective strategy to be designed. Oral health protocols are mainly based on the daily removal of bacterial plaque from teeth or prostheses (or both), cleaning of oral mucosa, and continual oral hydration. These practices are facilitated by the use of electric toothbrushes and products such as chlorhexidine, fluoride toothpastes, and rinses or gels for dry mouth. This type of protocol should include regular collaboration with dental professionals and provide a program of continuous training for nursing staff on oral health issues. (Geriatr Nurs 2006;27:95-101) Oral health care is not adequately considered in most protocols on personal hygiene and general health for the elderly in hospitals, long-term care units (units with nursing care but no complex medical facilities), or intensive care units, and it is poorly addressed by health policies aimed at the community-living elderly. 1,2 Oral health, although rarely life-threatening, plays an essential role in the quality of life, 3 management of medical problems, nutrition, and social interaction of the elderly. 4 However, there appears to have been no improvement over the past few years in the oral health status of the elderly, especially among those at high risk for oral disease. These high-risk groups include old people in institutions or who are functionally dependent for activities of daily living. Briefly, they are characterized by poor tooth and prosthesis hygiene; presence of few functional teeth; edentulous mouths; and dry mouth, which can severely impair well-being. 1,5,6 There is firm evidence of the oral etiology of some respiratory and cardiovascular diseases. 7,8 Despite this, health care providers for elderly patients at high risk of destabilization and deterioration of their medical condition for example, in intensive care units or acute care hospitals do not pay proper attention to daily oral hygiene. 2 There is consensus that any oral hygiene technique, procedure, or set of guidelines must focus on the removal of bacterial plaque, mainly composed of pathogenic anaerobic gram-negative germs. 9 However, dental researchers are still debating the ideal oral health care system and equipment and the optimal frequency of applications, as well as who should be responsible for oral health Interestingly, most articles on strategies and guidelines for good oral hygiene practices have appeared in the nursing and critical care literature, although little is known about the influence of these publications on the behavior of caregivers. 2,11,13 16 To date, authors have proposed standard action plans or protocols for maintaining oral hygiene in patients admitted to their centers. In our view, however, the design of action strategies and guidelines should follow an audit of the center, including the collection and analysis of relevant characteristics of residents or patients, such as their conscious or unconscious (comatose or vegetative) state, the presence of nasogastric tubes, or the need for mechanical ventilation. The audit would also include an assessment of the facilities at the center and of the training and degree of cooperation of the nursing staff. With this background, the objective of this work was to develop an oral care protocol for elderly patients admitted to an acute care hospital with a long-stay unit after analyzing the oral health status and level of cooperation of the patients and studying existing dental practices at the center. Geriatric Nursing, Volume 27, Number 2 95

2 Materials and Methods The study was performed at San Rafael Hospital, in Granada, Spain. This hospital, classified as both an acute care and long-stay facility, admits patients with acute or chronic disease that causes severe dependence, including patients requiring palliative care. Ninety percent of patients are over 65 years old, and more than 50% of these remain for long periods in the center. The hospital admits around 100 new patients per year, maintaining the same proportion ( 95%) of functionally dependent elderly (especially for general and oral hygiene). At the time of this study, 146 patients were institutionalized at the hospital, of whom 114 completed the examination, 7 refused the examination, and 25 were younger than 65 years. The following information was collected from patients: demographic data; main cause of admission; current medication, especially noting drugs with potential xerostomic effects; status of teeth and oral mucosa; presence and condition of prostheses; oral dryness; and oral hygiene conditions. The usual dental practices carried out by the nursing staff (registered and licensed practical nurses) were also recorded. Dental examinations were performed by a single examiner in the patient s hospital room, with the patient on a chair or in bed, using a gloved hand, disposable dental mirror, and portable lamp. The patient examination was classified as being very difficult to perform or not, with consideration of the patient s cooperation. The cooperation level depended on the patients cognitive impairment and level of consciousness and whether they were bed-bound or required mechanical ventilation or a nasogastric tube. A questionnaire was administered to nursing staff to assess existing routine oral health care practices and the difficulties they experienced in carrying them out. It included items related to age, gender, educational level, professional experience, daily oral and dental health care delivered to patients, and problems in implementing specific care strategies. After collecting this information, a first draft of oral health care guidelines was prepared and discussed with the hospital s medical and nursing staff to ensure that they were appropriate to the real working conditions at the hospital. In addition, a meeting was held with the hospital staff on oral and dental health and hygiene in the elderly to unify criteria and obtain the highest caregiver adherence and cooperation for effective implementation of the guidelines. Results In this study, 114 patients aged over 65 years were examined (78 women [68.4%] and 36 men [31.6%]), with a mean ( SD) age of years. The main causes of admission were stroke (23.7%), bone fracture (23.7%), and neurological disease (13.2%). These patients consumed a mean of drugs, and 97.4% of patients received some type of drug with xerostomic effects. Among the latter, 91.8% were administered medicines from 1 or more of the most xerostomic groups 17 : antihypertensives (85.1%), antipsychotics (59.6%), antidepressants (24.6%), and diuretics (52.6%). The examination of 23 of the patients was very difficult, largely because of restricted mouth opening. Oral Health Status of the Elderly Of the elderly patients studied, 41.2% were edentulous, but only 13.2% of the patients wore some kind of dental prosthesis; the mean number of healthy teeth was ; 56% of the patients showed signs of dry mouth, such as depapillated tongue, dry and fissured mucosa or lips, dry floor of the mouth, or sticky saliva. Oral and dental hygiene was assessed according to the amount of bacterial plaque accumulated on teeth or prostheses: 89% of patients with natural teeth and 70% of those with prostheses presented some bacterial plaque. More than half of the patients with natural teeth had inflamed gingiva, 10 had oral mucosal disorders (sores, blisters, or hyperplasia), 55 presented with tongue disorders, and 14 with palatal disorders. Survey of Nursing Staff The questionnaire was completed by 45 licensed practical nurses and 10 registered nurses, 9 men and 46 women, with a mean age of 25.4 years and mean professional experience of 32 months; 97.2% reported receiving information about oral and dental care, whereas only 34% received specific information on oral care of the elderly. According to their reports, 70.9% had examined the oral cavity of their patients at some point in time, 7.3% never had, and 21.8% only when the patient reported discomfort. Ta- 96 Geriatric Nursing, Volume 27, Number 2

3 Table 1. Oral Care Practices Reported by Nursing Staff Practice n (%) Tooth brushing 13 (23.6) Prosthesis brushing 11 (20.0) Prosthesis rinsing 29 (52.7) Administering oral mouthwash 34 (61.8) Cleaning mouth with gauze 34 (61.8) Encouraging/supervising 23 (41.8) toothbrushing None 5 (9.1) ble 1 lists the oral care practices most frequently carried out by nursing staff. The main difficulties reported by these caregivers were lack of time (81.8%), little or no patient cooperation (54.4%), and lack of knowledge and experience (7.2%). Only two caregivers reported no difficulties in carrying out these tasks. Description of Protocol The protocol was mainly aimed at systematizing the oral care that health caregivers provided to patients. It included regular oral examinations and daily cleaning of teeth or prostheses and mucosa. The protocol specified the staff, equipment, and products required to carry out these tasks; the frequency and timing of the activities; and their duration. It also included procedures for meeting immediate oral care needs. The protocol required the preparation of a short oral health history as a basis for planning an individualized oral health regimen for each patient (Figure 1). Medical staff or dentists produced this document as part of the overall geriatric assessment at patient admission. The history was to be reviewed every 6 months by nursing staff and once a year by a dentist. According to the protocol, oral hygiene practices were performed in the hospital room or bathroom in the case of functionally dependent patients, preferably with the patient sitting or, if necessary, in lateral decubitus position. The best time of the day was considered to be bedtime or after breakfast. An average of 2 minutes per patient was estimated, except for dentate patients with prostheses, who could require more than 3 minutes. The oral hygiene equipment required included an electric toothbrush with replaceable brush head, 0.12% chlorhexidine solution, fluoride toothpaste, a tongue depressor, sterile gauze, an electric suction unit, petroleum jelly or lip balm, and protective wear for the nursing staff. For patients who were functionally independent, oral hygiene routines needed only to be monitored, encouraging patients to use recommended practices. Because the ability of the patients to cooperate was critical, they were classified as conscious or unconscious (Figure 2). In unconscious patients and those requiring mechanical ventilation or nasogastric tubes, nonfixed dental prostheses should be removed. The self-cleaning of bacterial plaque produced by chewing and salivation is inadequate in unconscious patients, patients with severe cognitive impairment, those requiring pureed food, and those whose mouths are constantly open. In these cases, oral hygiene practices were more difficult, but the same general guidelines applied. Most of the patients presented with oral dryness at the examination. When drugs with potential xerostomic effects could not be discontinued or changed, a palliative and symptomatic treatment was applied to improve the quality of life of the patient and avoid complications such as sores, candidiasis, dental caries, or periodontal disease. The oral mucosa of unconscious or severely cognitively impaired patients should be hydrated using gauzes soaked in physiological saline, and their lips should be coated with petroleum jelly or lip balm. Conscious and cooperating patients should receive continual encouragement to drink, chew or consume sugar-free gum or sweets, and make use of products designed for dry mouth, including toothpastes, nonalcoholic mouthwashes, gels, and artificial saliva. When nursing staff identified a need for immediate dental care (e.g., denture ulcers, abscesses, pain, root remnants, severe dry mouth, poor condition of prosthesis, etc.), it was reported to the medical staff, who arranged for swift transfer of the patient to a public or private dental care service, either within or outside the center. Discussion Protocols for nursing tasks must be clear, systematic, and simple to follow if they are to Geriatric Nursing, Volume 27, Number 2 97

4 Oral Clinical History Date of examination: Name: Room No: 1. Does he/she have any natural teeth? ( ) No ( ) Yes, Upper ( ) Yes, Lower 2. Does he/she use removable dental prosthesis? ( ) No ( ) Yes, Upper ( ) Yes, Lower 3. Are his/her gums inflamed (reddened or bleeding)? ( ) No ( ) Yes 4. Does he/she have bacterial plaque or tartar on teeth or prosthesis? ( ) No ( ) Medium amount ( ) A lot 4. Does his/her mouth show signs of dryness? ( ) No ( ) Yes 5. He/she carries out hygiene ( ) on his/her own ( ) with some help ( ) someone has to do it for him/her Reason: 6. ( ) Immediate dental care by the dental service is required. Recommendations for care of teeth and prostheses Dates Encourage/supervise tooth and/or prosthesis brushing Remove prostheses at bedtime Clean teeth with electric toothbrush Clean prostheses with electric toothbrush Clean oral mucosa with gauze % CLX Rinse with 0.12% Chlorhexidine solution Moisten/coat lips with vaseline or lip balm Transfer for immediate dental care Incidences Figure 1. Oral Clinical History meet their objective. Numerous published studies have pointed out the inadequate attention paid to the oral and dental health of the elderly, but few authors have attempted to describe how this issue should be addressed. In this study, an oral care protocol was developed in an acute care hospital with a long-stay unit characterized by a high proportion of dependent elderly patients. This protocol cannot be directly extrapolated to any other geriatric center, although it can be adapted for centers with a similar proportion of dependent users. The preliminary assessment of oral health needs at the care center facilitated the development of appropriate protocols and provided some explanations for previous deficiencies in the systematic delivery of oral health care. The success of this approach depends on the cooperation of health care staff at the center and of the patients families 12 ; a lack of cooperation or a negative attitude toward oral health can lead to failure, which represents a limitation of this study. The most frequently observed obstacle to good oral health practice was that caregivers did not consider oral health to be a priority or part of their daily personal hygiene responsibilities for patients. This attitude may be ascribed to various factors, including inadequate training and information, shortage of time, communication difficulties, and the unpleasant nature of the task, with implications for educators, policy makers, practitioners, and researchers. 18,19 As in other studies, 20 the responses of nursing staff to our questionnaire on hygiene 98 Geriatric Nursing, Volume 27, Number 2

5 Unconscious Patients Conscious Patients Dentate Edentulous Oral Dryness Tooth Hygiene Oral Mucosa Hygiene Prosthesis Hygiene Oral Dryness Use electric toothbrush moistened in 0.12% chlorhexidine solution without toothpaste. Clean all mucosa (cheeks, palate, tongue, lips, and gums) with sterile gauze soaked with chlorhexidine. Coat lips with Vaseline or lip balm. Clean oral mucosa only with sterile gauze soaked in chlorhexidine, (cheeks, palate, tongue, lips, and gums). Coat lips with Vaseline or lip balm. Moisten oral mucosa with gauze soaked in physiological saline (2 3 times daily). Remove prostheses and brush all surfaces with electric toothbrush and fluoride toothpaste. Clean oral mucosa only with sterile gauze soaked in chlorhexidine, (cheeks, palate, tongue, lips, and gums). If the patient cooperates, rinse for 1 min with 0.12% chlorhexidine solution. Coat lips with Vaseline or lip balm. Remove and clean with electric toothbrush and water. All removable prostheses must be taken out at bedtime. Increase fluid intake, moisten mucosa with gauze and saline solution, and provide topical stimulation. Figure 2. Protocol Implementation practices were not consistent with the amount of accumulated bacterial plaque detected on the teeth and prostheses of their patients. This can again be attributed to the inadequate training in oral hygiene techniques and the large number of tasks to be carried out in a limited time, reducing oral hygiene to a simple mouth wash or ineffective brushing of prostheses. It must be emphasized to health care providers that the regular implementation of simple and inexpensive procedures can reduce high-cost outcomes associated with poor oral care (e.g., pneumonia) 21 resulting in cost savings and improved quality of care. 13 Health care professionals who work with the elderly should receive training on oral health issues and their importance, and centers should develop and implement guidelines involving nursing and dental health care professionals, as presented in this article. Considerable scientific evidence supports the use of chlorhexidine and fluoride as preventive and chemical control measures against bacterial plaque. 22 Notably, studies by DeRiso et al 23 and Houston et al 24 demonstrated that the use of 0.12% chlorhexidine washes by patients before their intubation for surgery reduced the incidence of nosocomial pneumonia. In the past few years, the commercialization of a spray form of chlorhexidine gluconate has facilitated its use in the dependent elderly, showing similar effectiveness to that of mouthwash and varnish treatments. 25 Fluoride toothpastes and varnishes or fluoride gels have also proved their effectiveness in reducing and remineralizing coronal and radicular caries in elderly patients. 26 Finally, sufficient scientific evidence exists to recommend that caregivers working with noncooperating patients use electric toothbrushes with rotation-oscillation action rather than manual toothbrushes for removing plaque. 27 Dry mouth impairs the quality of life of affected individuals, and its management is of great importance in this population. It is a common condition among the elderly because of the high proportion who receive drugs with potentially xerostomic effects. 28 There are no effective pharmacological treatments that definitively improve these symptoms, and the recommended measures can only be palliative, based on continuous moisturizing with fluids and sugar-free chewing gum or candy and on the use of nighttime humidifiers and mucin-based artificial saliva. Dry mouth syndrome, mostly induced by the use of certain drugs, warrants the application of local preventive measures by the topical application of fluoride and chlorhexidine and the use of products that replace natural saliva defense systems, such as the peroxidase system. 29 The role of nursing staff in the assessment of patients oral health is controversial. 30 From our point of view, caregivers should receive adequate training to perform the oral hygiene practices set out in our protocol. In this study, only 30% of staff members interviewed had received specific training in elderly oral care, hampering their correct implementation of the protocol. Because it is not always possible to provide a permanent dental service at centers, patients usual caregivers appear to be the ideal candidates for this task. 30 They should also be able to detect the most frequent oral and dental conditions, enabling rapid transfer of the patient to a dental service and improving treatment and quality of life outcomes. Thus, studies by Kayser- Geriatric Nursing, Volume 27, Number 2 99

6 Jones et al 31 and Arvidson-Bufano et al 32 reported that an adequate training of nursing staff minimizes the morbidity associated with poor oral hygiene. On the other hand, the effects of the continued use of this type of protocol and its impact on the health status of the institutionalized elderly have yet to be established. Conclusions Health policies and care protocols for the elderly with severe functional dependence should pay more attention to oral health. Despite reports associating poor oral hygiene with high morbidity rates, especially in elderly patients, oral hygiene practices are not a priority for caregivers. Protocols at centers for the elderly should not be prepared in isolation but should take account of the human and material resources available and the degree of patient cooperation to establish routine and ongoing practices. References 1. Peltola P, Vehkalahti MM, Wuolijoki-Saaristo K. Oral health and treatment needs of the long-term hospitalised elderly. Gerontology 2004;21: Jones H, Newton JT, Bower EJ. A survey of the oral care practices of intensive care nurses. Intensive Crit Nurs 2004;20: Locker D, Clarke M, Payne B. Self-perceived oral health status, psychological well-being, and life satisfaction in an older adult population. J Dent Res 2000;79: McGrath C, Bedi R. The importance of oral health to older people s quality of life. Gerodontology 1999;16: Wyatt CL. Elderly Canadians residing in long-term care hospitals: medical and Dental Status. J Can Dent Assoc 2002;68: Spanish Geriatric Oral Health Research Group. Oral health issues of Spanish adults aged 65 and over. Int Dent J 2001;51: Khader YS, Albashaireh ZSM, Alomari MA. Periodontal diseases and the risk of coronary heart and cerebrovascular diseases: a meta-analysis. J Periodontol 2004;75: Mattila KJ, Asikainen S, Wolf J, et al. Age, dental infections, and coronary heart disease. J Dent Res 2000;79: Hunt RJ, Drake CW, Beck JD. Streptococcus mutans, lactobacilli and caries experience in older adults. Spec Care Dent 1992;12: Sumi Y, Nakamura Y, Michiwaki Y. Development of a systematic oral care program for frail elderly persons. Spec Care Dent 2002;22: Johnson V, Chalmers J. Evidence based protocol oral hygiene care for functionally dependent and cognitively impaired older adults. J Gerontol Nurs 2004;30: British Society for Disability and Oral Health. Guidelines for oral health care for long stay patients and residents. Report of British Society for Disability and Oral Health Working Group. Available at Accessed November 15, Coleman P. Improving oral health care for the frail elderly: a review of widespread problems and best practices. Geriatr Nurs 2002;23: Munro CL, Grap MJ. Oral health and care in the intensive care unit: state of the science. Am J Crit Care 2004;13: Fitch JA, Munro CL, Glass CA, et al. Oral care in the adult intensive care unit. Am J Crit Care 1999;8: Stiefel KA, Damron S, Sowers NJ, et al. Improving oral hygiene for the seriously ill patient: implementing research-based practice. Med Surg Nurs 2000;9: Baker K, Levy SM, Chrischilles EA. Medications with dental significance: usage in a nursing home population. Spec Care Dent 1991;11: Fitzpatrick J. Oral health care needs of dependent older people: responsibilities of nurses and care staff. J Adv Nurs 2000;32: Eadie DR, Schou L. An exploratory study of barriers to promoting oral hygiene through careers of elderly people. Community Dent Health 1992;9: Samaranayake LP, Wilkieson CA, Lamey PJ, et al. Oral disease in the elderly in long-term hospital care. Oral Dis 1995;1: Terpenning M, Shay K. Oral health is cost-effective to maintain but costly to ignore. J Am Geriatr Soc 2002; 50: Davies RM. The rational use of oral care products in the elderly. Clin Oral Investig 2004;8: DeRiso AJ, Ladowski JS, Dillon TA, et al. Chlorhexidine gluconate 0.12% oral rinse reduces the incidence of total nosocomial respiratory infection and nonprophylactic systemic antibiotic use inpatients undergoing heart surgery. Chest 1996;109: Houston S, Hougland P, Anderson JJ, et al. Effectiveness of 0.12% chlorhexidine gluconate oral rinse in reducing prevalence of nosocomial pneumonia in patients undergoing heart surgery. Am J Crit Care 2002;11: Francetti L, Del Fabbro M, Basso M, et al. Chlorhexidine spray versus mouthwash in the control of dental plaque after implant surgery. J Clin Periodontol 2004;31: Ellwood R, Fejerskov O. Clinical use of fluoride. In: Fejerskov O, Kidd E, eds. Dental caries: the diseases and its clinical management. Denmark: Blackwell Munksgaard; 2003: Heanue M, Deacon SA, Deery C, et al. Manual versus powered toothbrushing for oral health. Cochrane Database Syst Rev. 2003;(1):CD [Review]. 28. Cassolato SF, Turnbull RS. Xerostomia: clinical aspects and treatment. Gerodontology 2003;20: Epstein JB, Emerton S, Le ND, et al. A double-blind crossover trial of Oral Balance gel and Biotene toothpaste versus placebo in patients with xerostomia following radiation therapy. Oral Oncol 1999;35: Geriatric Nursing, Volume 27, Number 2

7 30. Nordenram G, Ljunggren G. Oral status, cognitive and functional capacity versus oral treatment need in nursing home residents: a comparison between assessments by dental and ward staff. Oral Dis 2002;8: Kayser-Jones J, Bird W, Paul S, et al. An instrument to assess the oral health status of nursing home residents. Gerontologist 1995;35: Arvidson-Bufano U, Blank L, Yellowitz J. Nurses oral and health assessments of nursing home residents preand post-training: a pilot study. Spec Care Dent 1996; 16: JOSÉ ANTONIO GIL MONTOYA, DDS, PhD, is assistant professor at the School of Dentistry, Granada University, Department of Special Care in Dentistry and Gerodontology, and director of the Domiciliary Assistant Dental Program in Granada City. ANA LUCIA FERREIRA DE MELLO, DDS, is assistant professor, University of Santa Catarina, Florianopolis, Brasil. CIRO BARRETO CÁRDENAS, DDS, and INMACULADA GUARDIA LÓPEZ, DDS, are gerodontology dental residents at the School of Dentistry, Granada University, Granada City, Spain. ACKNOWLEDGMENTS The authors wish to thank the staff of San Rafael Hospital, especially Jacinto Escobar and Paloma Calero Martín de Villodres, for their enormous contribution to this study /06/$ - see front matter 2006 Elsevier Inc. All rights reserved. doi: /j.gerinurse Geriatric Nursing, Volume 27, Number 2 101