Journal of Gerontological Nursing

Evidence-Based Protocol: Oral Hygiene Care for Functionally Dependent and Cognitively Impaired Older Adults

Jane Chalmers, BDSc, MS, PhD; Valerie Johnson, RDH, MS

Abstract

Oral health problems experienced by older adults are generally preventable and are usually age-related rather than the direct result of aging. Oral diseases, although generally not life threatening or seriously impairing for most elderly individuals, can have an adverse effect on quality of life and the management of medical conditions, general health, nutrition, and behavior. However, recent research has evidenced a relationship between periodontal diseases and cardiovascular conditions, as well as a link between the accumulation of dental plaque on natural teeth and dentures over time and the development of aspiration pneumonia (Limeback, 1998; Loesche & Lopatin, 1998; Russell, Boylan, Kaslick, Scannapieco, & Katz, 1999).

Regular assessment of the oral cavity is critical for the prevention of other systemic problems that can lead to more serious outcomes (Navazesh & Mulligan, 1995). For example, assessing the ability to chew and swallow adequately can assist with identifying ways to improve nutritional intake (Horn, Hodge, & Treuer, 1994). The early detection of orai problems also can prevent the development of oral pain, which can lead to behavioral problems in cognitively impaired elderly individuals who are unable to verbally communicate discomfort and may "act out" instead.

Dentures and denture-related oral lesion problems. This category includes problems of naming of dentures, not wearing of dentures, storage of dentures, and denture relatedulcers. Strategies may include assessment of denture-related lesions and physical cleaning of dentures. Actions include practical tips for naming and cleaning of dentures, and treatment of denture-related oral lesions (Chalmers et al., 2001; Chalmers, Australian Dental Association, Alzheimer's Association, and Colgate Oral Care, 2002). For instance, whenever possible, dentures should be removed until ulcers are healed. Warm salt and water mouth rinses, spray bottle, or saturated gauze can be applied several times daily to ulcers.

Natural teeth problems. These problems include broken teeth, retained tooth roots, pain, bad breath, plaque and food accumulation, and bleeding gums. Strategies include use of adjunctive chemical and physical oral hygiene care strategies, assessment of oral disease risk, and assessment of oral hygiene care abilities and needs. Actions include the use of practical dental products (e.g., fluorides, antimicrobials), treatment of dry mouth, use of modified dental equipment, and organization of dental treatment (Chalmers et al., 2001, 2002).

Dry mouth, hypersalivation, and swallowing problems. These problems include choking, difficulty eating and swallowing, burning mouth, dry mouth, and painful oral tissues. Few strategies may be taken. These include the assessment of medications, swallowing problems, and xerostomia and salivary gland dysfunction. Actions include the frequent use of water and water-based mouth rinses that are rinsed or sprayed onto the tongue and oral tissues; the avoidance of alcohol-containing mouth rinses and toothpastes, which may burn and irritate the dry oral tissues; and the use of oral saliva substitute sprays, gels, or tablets (e.g., Oral Balance Gel [Laclede], Optimoist or Xerolube [Colgate Oral Pharm], Moi-Stir [Kingswood Labs]) (Chalmers et al., 2001, 2002).

Palliative oral hygiene care problems. When patients are in the final stages of an illness or are undergoing complex medical treatment, their mouths can become dry and painful from the medical treatments and associated medications being used (e.g., chemotherapy, radiation, immunosuppression, behavior, pain control). If the oral tissues of the tongue, cheeks, gums, and lips are swollen, inflamed, red, painful, or ulcerated, they can easily tear; a combination of mouth rinses can be comforting and can be rinsed or sprayed into the mouth with a small atomizer or spray bottle (Chalmers et al., 2001, 2002). Any excessive nasal and oral secretions can be removed using a tongue depressor wrapped with gauze that has been soaked in Chlorhexidine gluconate. If patients have bacterial and…

Oral health problems experienced by older adults are generally preventable and are usually age-related rather than the direct result of aging. Oral diseases, although generally not life threatening or seriously impairing for most elderly individuals, can have an adverse effect on quality of life and the management of medical conditions, general health, nutrition, and behavior. However, recent research has evidenced a relationship between periodontal diseases and cardiovascular conditions, as well as a link between the accumulation of dental plaque on natural teeth and dentures over time and the development of aspiration pneumonia (Limeback, 1998; Loesche & Lopatin, 1998; Russell, Boylan, Kaslick, Scannapieco, & Katz, 1999).

Regular assessment of the oral cavity is critical for the prevention of other systemic problems that can lead to more serious outcomes (Navazesh & Mulligan, 1995). For example, assessing the ability to chew and swallow adequately can assist with identifying ways to improve nutritional intake (Horn, Hodge, & Treuer, 1994). The early detection of orai problems also can prevent the development of oral pain, which can lead to behavioral problems in cognitively impaired elderly individuals who are unable to verbally communicate discomfort and may "act out" instead.

To maintain quality of life, older adults should be able to (Chalmers, Jolly, Briggs, Fuss, & Reeves, 2001; Nordenram, Ronnberg, & Winblad, 1994):

* Stay pain free.

* Eat and talk comfortably.

* Feel happy with their appearance.

* Maintain social interaction.

* Stay as healthy as possible.

* Maintain self-esteem and health care habits and standards they have had throughout their life.

Although at any one point in time, not all older adults will have severe oral diseases, the probability is high that at some point in the future, the majority of older adults will be at high risk for developing oral diseases (Chalmers, 2002). Many community-living functionally dependent and cognitively impaired older adults move into long-term care as their general health deteriorates and functional dependence increases; as this occurs, their oral disease and conditions also will deteriorate.

However, it is important to note recent research has validated clinical observations that deteriorating oral health starts before older adults enter long-term care institutions and continues to decline, sometimes rapidly, during the time spent in the long-term care setting. Frail and dependent elderly individuals face various inevitable declines in their health. However, their decline in oral health can be prevented with good regular oral hygiene care and dental treatment. Indeed, it is the professional caregivers of older adults who are crucial in the execution of oral hygiene care plans and the organization of dental treatment (Johnson & Lange, 1999; MacEntee, Thorne, & Kazanjian, 1999; U.S. Department of Health and Human Services, 2000). This article provides an overview of an evidence-based protocol (EBP) on oral hygiene care for functionally dependent and cognitively impaired older adults (Johnson & Chalmers, 2002). The full text of the EBP is available from the Research Dissemination Core Office.

PURPOSE

The purpose of this EBP is to provide practical information to assist nursing-directed best practice, longterm care staff, and caregivers with the provision and documentation of oral hygiene care for functionally dependent and cognitively impaired older adults to prevent plaque-related oral diseases. The protocol has three main components:

* Tools for the assessment of the oral cavity and oral problems.

* Maintenance of long-term oral health through the use of an oral care plan.

* Practical preventive techniques, and behavior and communication strategies to use when providing oral hygiene care.

Although this protocol focuses on long-term care, the components are all applicable and useful for hospitalbased and hospice nursing directed best practice and caregivers, as well as community-based caregivers of functionally dependent and cognitively impaired older adults.

INDIVIDUALS AT RISK FOR ORAL DISEASES

Groups of older individuals who have been evidenced to be at increased risk for developing plaquerelated oral diseases include those who (Chalmers, 2002; Chalmers, Ettinger, Thomson, & Spencer, 1 999; Horn et al., 1994; Ship & Puckett, 1994; Wyatt & MacEntee, 1997):

* Are cognitively impaired or have other neurological conditions.

* Are functionally dependent.

* Have dry mouth.

* Have a high experience of tooth decay.

* Have behavioral problems during oral hygiene care.

* Have swallowing problems.

* Are immunocompromised.

* Have diabetes.

Cognitively impaired elderly individuals are at high risk for dental diseases because they often forget or may be unable to continue oral hygiene. They also may have difficulty perceiving and reporting pain or discomfort and resist assistance from caregivers, which often indicates a dental problem may exist.

DESCRIPTION OF THE PRACTICE

Oral hygiene care for functionally dependent and cognitively impaired older adults includes the following components:

* Identification of factors that increase risk for oral problems.

* Baseline oral health assessment.

* Assessment of current oral hygiene care.

* Development of oral hygiene care plan.

* Description of oral hygiene practices for preventing oral diseases.

Identification of Factors That Increase Risk for Oral Problems

It is important to identify those older adults at greatest risk for plaque-related dental diseases who thus can benefit from oral hygiene care. Oral diseases are evident in older adults when there is also a decline in their general health and cognitive abilities, and an increase in their disabilities, functional dependence, and use of multiple medications (polypharmacy). The assessment of such non-dental risk factors is essential.

Various cognitive assessment tools commonly used include the Mini-Mental Status Examination (MMSE) (Folstein, Folstein, & McHugh, 1975), the Global Deterioration Scale (GDS) (Reisberg, Ferris, deLeon, & Crook, 1982), and a clock-drawing examination (Sunderland et al., 1989). Level of functional dependency on others can be assessed using tools such as the Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs) (Katz, Ford, Moskowitz, Jackson, OC Jaffee, 1963).

Older adults' location of residence also can influence their level of risk for oral diseases. For example, because institutionalized elderly individuals generally have more severe impairments and are dependent on others for their care, they are at very high risk for oral diseases.

Some medications can cause adverse oral effects, such as salivary gland hypofunction, xerostomia, gingival overgrowth, lichenoid reactions, tardive dyskinesia (oral musculature movements), and problems with speech, swallowing, and taste (Handelman, Baric, Saunders, & Espekand, 1989). Medications such as antipsychotics, antidepressants, tranquilizers, sedatives, diuretics, antihypertensives, anti-Parkinsonian agents, narcotic analgesics, anticonvulsants, antihistamines, and antiemetics have some of the most severe dry mouth and salivary gland hypofunction side effects.

Medical conditions such as Sjogren's syndrome and other autoimmune diseases also can directly cause dry mouth and salivary gland hypofunction. Older adults with Alzheimer's disease may have a reduced flow of saliva, as do those who have undergone irradiation to the head and neck area (Ship & Puckett, 1994).

Older adults who are taking medications that cause xerostomia are at an increased risk for plaquerelated oral diseases such as dental caries and periodontal diseases. In the presence of xerostomia, the oral bacteria can thrive and are not adequately buffered by the saliva. As a result, bacterial dental plaque is more virulent and the rate of tooth decay increases as the oral environment becomes more acidic (U.S. Department of Health and Human Services, 2000).

Other risk indicators include behaviors and attitudes that can predispose older adults to oral problems. Older adults who have had previous oral disease experience are more susceptible to oral problems when self-care is compromised. Older adults who have been irregular dental attenders and who have not visited the dentist for long periods of time are also at higher risk (Chalmers, 2002).

Baseline Oral Health Assessment

Periodontal diseases and dental caries account for most of the loss of teeth experienced by Americans. However, the major cause of tooth loss is dental caries and not periodontal diseases (Chalmers et al., 1999).

The prevalence of tooth loss has decreased during the past 50 years and can be attributed to improved early detection and treatment of oral disease and more effective preventive measures (such as water fluoridation and increased use of fluoride toothpastes). The use of fluoride-containing dentifrices and other oral care products is necessary for dental caries prevention, as is limiting the amount and frequency of fermentable carbohydrates in the diet. The prevention and control of gingivitis (inflammation of gingival tissues) and periodontal disease can be achieved through the mechanical removal and disruption of dental plaque (U.S. Department of Health and Human Services, 2000).

Regular oral care is important, but often an overlooked health care service in elderly individuals. Any dental treatment provided will fail in the long-term if adequate regular (ideally at least daily) preventive oral home care is not provided (Chalmers et al., 2001).

Numerous tools exist that can assess various aspects of oral conditions and health. Less plentiful are those that are user-friendly for non-dental personnel and are research-based. Most instruments require information be collected or accompanied by self-report of older adults. However, with cognitively impaired elderly individuals, these types of tools are not appropriate and would be difficult to modify without compromising validity of the instrument.

In the United States, federal regulations mandate comprehensive assessments of older adults' needs and the development of a care plan to ensure a minimal level of care in long-term care facilities receiving reimbursement through Medicare and Medicaid (Thai, Shuman, & Davidson, 1997). The tools used to execute this process include the Minimum Data Set (MDS) and Resident Assessment Protocol (RAP). Each enables the staff to systematically assess each condition (including oral conditions) and determine the need for consultation and referral.

The sections of the MDS pertaining to the oral and dental status are minimal and may tend to overlook the health of oral tissues and the presence of xerostomia. Although this tool is used nationwide, the law and regulations do not provide consistent directions or training on how to conduct the oral assessments using the MDS. Thus, individual state variation may occur with these regulations.

The Brief Oral Health Status Examination (BOHSE) has been tested on cognitively impaired and unimpaired elderly individuals (Kayser-Jones, Bird, Paul, Long, & Schell, 1995). Further, it has been modified and used on a population of cognitively impaired elderly individuals and found to be useful when administered by certified nursing assistants and nurses for oral assessments (Lin, Jones, Godwin, Godwin, & Knebl, 1999). Unlike the MDS, the BOHSE contains a "measurement" column that provides examiners with a description of how to assess the item directly on the form rather than requiring them to obtain direction from a separate section in a book.

The BOHSE is an instrument used for screening purposes only. It is not a diagnostic tool and does not replace the need for periodic examination by a professional dentist. Prior to using the BOHSE, staff should receive in-service education from professional dentists or dental hygienists, school of dentistry faculty, dentists in private practice, or dentists contracted to provide services to a nursing home.

The Oral Health Assessment tool (Table 1) is a modification of the BOHSE. Further validation and reliability testing of the Oral Health Assessment tool with cognitively impaired and functionally dependent older adults is ongoing. This assessment can be completed prior to implementing an individualized oral hygiene care plan to reduce older adults' risk for plaque-related oral diseases. Completing this assessment will help health care professionals assess older adults' current oral status and factors that can contribute to their risk for oral disease, thus making it possible to implement the most appropriate care plan.

TABLE 1ORAL HEALTH ASSESSMENT

TABLE 1

ORAL HEALTH ASSESSMENT

Assessment of Current Oral Hygiene Care

An assessment of older adults' current oral hygiene care is necessary to identify their routine for daily oral care. By identifying older adults' self-care ability, providers can determine what level of care is necessary - whether it is just reminding, assisting, providing, or palliative in nature. Information about oral hygiene care aids (types of brushes and oral care products) and frequency of use is helpful when attempting to appropriately develop an oral care plan. This Assessment of Current Oral Hygiene Care tool (Table 2) can be used periodically throughout the implementation of the protocol to assist with monitoring older adults' oral hygiene regimen.

Development of Oral Hygiene Care Plan

An individualized Oral Hygiene Care Plan (Table 3) will enable providers to focus on appropriate care for older adults. A plan should be developed and routinely updated as older individuals' cognitive or functional impairments, oral status, or self-care abilities change. The Oral Hygiene Care Plan includes pertinent information about older adults' oral status and level of assistance needed with oral hygiene care as well as the type of care necessary. Problems encountered with the older individual also are noted to assist providers with identifying strategies to use when providing care.

Table

TABLE 2ASSESSMENT OF CURRENT ORAL HYGIENE CARE

TABLE 2

ASSESSMENT OF CURRENT ORAL HYGIENE CARE

Description of Oral Hygiene Practices for Preventing Oral Diseases: General Oral Hygiene Care Strategies

Several practical preventive techniques and behavior and communication strategies to use for common oral hygiene care problems are described. These oral hygiene care problems include:

* Behavior, communication, and dementia problems.

* Dentures and denture-related oral lesion problems.

* Natural teeth problems.

* Dry mouth, hypersalivation, and swallowing problems.

* Palliative oral hygiene care problems.

Further description of these techniques and strategies is available in the full protocol.

Behavior, communication, and dementia problems. These problems include when individuals will not open their mouth, dentures cannot be taken out or put in individuals' mouth, individuals refuse oral hygiene care, individuals do not understand caregivers' directions about oral hygiene care, and when individuals cannot rinse and spit and swallow all liquids and toothpastes. Some strategies to be undertaken are breaking of perioral muscle spasms to gain access to the mouth, keeping the mouth open during oral hygiene care, and assessing the feasibility of completing oral hygiene care at that time. Actions required when providing oral hygiene include practical tips using dental equipment as well as dementia-focused communication and behavior management techniques such as task-breakdown, bridging, and chaining (Chalmers et al., 2001; Kayser-Jones, Bird, Redford, Schell, & Einhorn, 1996; Kovach, Weissman, Griffie, Matson, & Muchka, 1999).

Table

TABLE 3ORAL HYGIENE CARE PLAN

TABLE 3

ORAL HYGIENE CARE PLAN

Dentures and denture-related oral lesion problems. This category includes problems of naming of dentures, not wearing of dentures, storage of dentures, and denture relatedulcers. Strategies may include assessment of denture-related lesions and physical cleaning of dentures. Actions include practical tips for naming and cleaning of dentures, and treatment of denture-related oral lesions (Chalmers et al., 2001; Chalmers, Australian Dental Association, Alzheimer's Association, and Colgate Oral Care, 2002). For instance, whenever possible, dentures should be removed until ulcers are healed. Warm salt and water mouth rinses, spray bottle, or saturated gauze can be applied several times daily to ulcers.

Natural teeth problems. These problems include broken teeth, retained tooth roots, pain, bad breath, plaque and food accumulation, and bleeding gums. Strategies include use of adjunctive chemical and physical oral hygiene care strategies, assessment of oral disease risk, and assessment of oral hygiene care abilities and needs. Actions include the use of practical dental products (e.g., fluorides, antimicrobials), treatment of dry mouth, use of modified dental equipment, and organization of dental treatment (Chalmers et al., 2001, 2002).

Dry mouth, hypersalivation, and swallowing problems. These problems include choking, difficulty eating and swallowing, burning mouth, dry mouth, and painful oral tissues. Few strategies may be taken. These include the assessment of medications, swallowing problems, and xerostomia and salivary gland dysfunction. Actions include the frequent use of water and water-based mouth rinses that are rinsed or sprayed onto the tongue and oral tissues; the avoidance of alcohol-containing mouth rinses and toothpastes, which may burn and irritate the dry oral tissues; and the use of oral saliva substitute sprays, gels, or tablets (e.g., Oral Balance Gel [Laclede], Optimoist or Xerolube [Colgate Oral Pharm], Moi-Stir [Kingswood Labs]) (Chalmers et al., 2001, 2002).

Palliative oral hygiene care problems. When patients are in the final stages of an illness or are undergoing complex medical treatment, their mouths can become dry and painful from the medical treatments and associated medications being used (e.g., chemotherapy, radiation, immunosuppression, behavior, pain control). If the oral tissues of the tongue, cheeks, gums, and lips are swollen, inflamed, red, painful, or ulcerated, they can easily tear; a combination of mouth rinses can be comforting and can be rinsed or sprayed into the mouth with a small atomizer or spray bottle (Chalmers et al., 2001, 2002). Any excessive nasal and oral secretions can be removed using a tongue depressor wrapped with gauze that has been soaked in Chlorhexidine gluconate. If patients have bacterial and viral infections, they need appropriate medications prescribed by a doctor or dentist.

EVALUATION OF PROCESS AND OUTCOMES

To monitor the use and effectiveness of this protocol for older adults at risk for oral problems, both process and outcome factors should be evaluated. Process indicators are those factors related to the preparedness of health care providers to use the protocol. One process factor is the knowledge of staff about oral hygiene care. Following proper education on oral hygiene care, staff nurses or caregivers should be given a test, such as the Oral Hygiene Knowledge Assessment Test, contained in the full protocol.

Outcome indicators are those factors expected to change or improve from consistent implementation of the protocol. The following major outcome indicators should be monitored over time:

* Assessments reveal individuals' oral problems have diminished significantly.

* Oral health status and current oral hygiene care are documented in individuals' records.

* Observation of cognitively impaired individuals indicates absence of oral discomfort and pain.

* Recommendations for oral hygiene care are included in individuals' records.

* Appropriate management strategies for oral hygiene care are included in individuals' records.

* Improvements or declines in oral hygiene care are documented in individuals' record.

These outcomes should be assessed and recorded on a weekly basis.

CONCLUSION

To maintain long-term oral health for functionally dependent and cognitively impaired older adults, the existing evidence base advocates the use of an assessment tool by caregivers and long-term care staff for screening of the oral cavity and oral problems and an individualized oral care plan. These can be supplemented with the use of practical preventive techniques and effective behavior management and communication strategies during oral hygiene care.

REFERENCES

  • Key: R = Research, (L) = Literature, (N) = National Guidelines
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TABLE 2

ASSESSMENT OF CURRENT ORAL HYGIENE CARE

TABLE 3

ORAL HYGIENE CARE PLAN

10.3928/0098-9134-20041101-06

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