Oral Health and Nursing Care in Old Age
Oral Health Related Health Issues
Poor oral health is associated with malnutrition, dehydration,
brain abscesses, valvular heart disease, joint infections, cardiovascular
disease, pneumonia, aspiration pneumonia, and poor glycemic control in type I
and II diabetes:
(Abe et al., 2006; Adachi, Ishihara, Abe, & Okuda, 2007:
Azarpazhooh &Leake , 2006; Bingham, Ashley, De Jong, & Swift, 2010;
Coulthwaite &Verran , 2007: Ferozali , Johnson, &Cavagnaro , 2007;
Kelsey & Lamster, 2008; Lockhart and al., 2009; Sato, Yoshihara, &
Miyazaki, 2006; Sjögren , Nilsson, Forsell , Johansson, &Hoogstraate ,
2008; Tran &Mannen , 2009; Touger -Decker & Mobley, 2007).
Oral health
also affects nutritional status, ability to speak, self-esteem, mental
wellness, and overall well-being ( Coulthwaite &Verran , 2007; Touger
-Decker & Mobley, 2007:
Gil-Montoya, Subirá , Ramón, & González-Moles ,
2008; Kanchisa , Yoshida, Taji , Akagawa , & Nakamura, 2009; Quandt et al.,
2010: Soini et al., 2006; Haumschild &Haumschild , 2009; Montero, López,
Galindo, Vicente, & Bravo, 2009; Naito et al., 2010). Many oral diseases
are not part of the natural aging process but side effects of medical treatment
and medications.
Oral Health Issues
Plaque retention is a problem in older adults who have difficulty
in mechanically removing plaque caused by diminished manual dexterity, impaired
vision, or chronic.
For description of Evidence Levels cited in this chapter, see
Chapter 1. Developing and Evaluating Clinical Practice Guidelines: A Systematic
Approach, page 7.illness ( Coulthwaite &Verran , 2007; Brown, Goryakin ,
& Finlayson, 2009; Hakuta , Mori, Ueno , Shinada , & Kawaguchi, 2009;
Ibayashi , Fujino , Pham, & Matsuda, 2008).
An older adult’s functional
ability and cognitive status affect their 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 wash-basin or other container 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 for 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 (Touger – Decker & Mobley,
2007; Christensen, 2007; Saunders & Friedmann, 2007).
Many of the oral
health problems in the older adults could be avoided with routine preventive
care. Many older adults believe in the myth that a decline in their oral health
is a normal part of aging
Assessment of Oral Health Issues
The promotion of oral health through assessment and good oral
hygiene is an essential of nursing care. The 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 with-out 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
tissue).
Lichen planus (most common form presents as a lacy white appearance on
the tongue and/or cheeks), and Pemphigus vulgaris (red bleeding tissues result
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 their functional
ability and manual dexterity to provide oral hygiene. The nurse needs to
observe the older adult providing their 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 provides their 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 Resource section for access to this tool.
Nursing Interventions And Strategies
The gold standard for providing oral hygiene is the toothbrush.
Toothbrushes should have soft nylon bristles (Pearson & Chalmers, 2004). It
is the mechanical action of the toothbrush that is important for plaque
removal.
If the older adult has any decrease in their 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 (Pearson &
Hutton, 2002). Foam swabs may be used for cleaning the oral mucous of an
edentulous older adult
Lemon-glycerin swabs or swab sticks are drying to the oral mucosa
and cause erosion of the tooth enamel.
This, combined with decreased salivary
flow and an increased rate of xerostomia in the older adult, potentiates the
corrosive effect of lemon-glycerin swabs (Pearson & Chalmers, 2004).
Lemon-glycerin swabs or swab sticks are detrimental to the older adult and are
never to be used.
Commercial mouth rinses, which contain alcohol are very trying to
the oral mucosa. If an older adult is using a commercial mouth rinse with
alcohol, a half-and-half mixture (commercial mouthwash and water) is
recommended.
Toothpaste with fluoride is currently recommended by the American
Dental Association to reduce cavities and can also help to 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, 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 each shift is essential for
the geriatric patient on chlorhexidine and monitoring of their 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 ( Touger -Decker et al., 2007; Akar &Ergül ,
2008 ; Dharamsi , Jivani, Dean, & Wyatt, 2009; Gluhak , Arnetzl , Kirmeier
, Jakse , &Arnetzl , 2010; Peltola , Vehkalahti , &Simoila , 2007;
Preston, Kearns, Barber, &Gosney , 2006; Reed, Broder, Jenkins, Spivack ,
&Janal , 2006; Ribeiro et al., 2009; Young, Murray, & Thomson, 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 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 in
the proper techniques for providing oral hygiene and caring for oral
appliances.
Patients and families need to be educated in 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.