Older adults tend to face difficulty in oral nutrient intake due to dysphagia or other issues. In the case of severe dysphagia, non-oral feeding methods, such as parenteral nutrition, nasogastric tube feeding, and percutaneous endoscopic gastrostomy (PEG), are generally used. Nasogastric tube feeding, PEG, and other enteral nutrition options are important for appropriately maintaining a patient's nutritional status, as well as digestive and absorptive functions. The guideline for the provision and assessment of nutrition support therapy by the American Society for Parenteral and Enteral Nutrition recommends that enteral nutrition support therapies be selected as much as possible (McClave et al., 2016). However, the oral, pharyngeal, and esophageal functions are not used for such therapies because food does not enter the oral cavity. These functions are also not used for parenteral nutrition therapy. Clinicians empirically know that the oral conditions of such non-oral feeding patients are usually poor. Among oral feeding patients, dental plaque and food residue are observed. However, in non-oral feeding patients, dental plaque and food residue are rarely observed because food does not enter the oral cavity. However, in non-oral feeding patients, the formation of membranous substances and phlegm, as well as dry mouth, are sometimes observed instead of dental plaque and food residue (Kawase et al., 2014). Furthermore, as non-oral feeding patients have severe underlying diseases (e.g., cerebrovascular disease), they have other complications, such as upper-limb dysfunction and cognitive impairment, in addition to dysphagia. To maintain oral hygiene, non-oral feeding patients require assistance with oral care, as it is difficult for them to perform independently.
Although many studies have reported the relationship between oral status and nutrition, the focus has been on the masticatory function in most cases, such as the number of remaining teeth and dentures (Kikutani et al., 2013; Marshall, Warren, Hand, Xie, & Stumbo, 2002; Poisson, Laffond, Campos, Dupuis, & Bourdel-Marchasson, 2014; Sahyoun, Lin, & Krall, 2003; Yoshida et al., 2011). It is important to concentrate on the masticatory function and nutrition. However, it also is necessary to focus on the patient's oral hygiene status and nutrition. In addition, it is important to provide evidence that maintaining a favorable oral hygiene status is necessary in non-oral feeding patients. Therefore, it is essential to compare the oral conditions of non-oral feeding and oral feeding patients. However, no report exists on the oral hygiene status of non-oral feeding patients. In the current study, the oral status between non-oral and oral feeding patients was evaluated and compared to confirm the necessity of oral care for non-oral feeding patients.
This prospective, single-center investigation was conducted at one hospital from April to October 2015. The study protocol was approved by the institutional review board of the Japanese National Center for Geriatrics and Gerontology.
All participants were hospitalized patients. Patients referred to the Department of Dentistry for oral care evaluation by their attending physician were also included. In Japan, dentists provide support during the acute stage of oral care. Consultations were determined by the attending physician. Patients whose oral status could be evaluated on the day following their admission were analyzed as participants.
From the medical records, data related to age, sex, medical conditions that led to hospitalization, and feeding method were collected. Based on the feeding method at the time of evaluation, participants were divided into two groups: (a) non-oral (i.e., parenteral nutrition, nasogastric tube feeding, or PEG) and (b) oral feeding. Non-oral feeding was required mainly due to dysphagia caused by several diseases. Participants' oral conditions were evaluated using the Oral Assessment Guide (OAG; Eilers, Berger, & Petersen, 1988). The OAG was developed to assess the oral status of patients with cancer and has been used worldwide in at least nine countries. This tool can be used in any medical specialty and is based on a 3-point observer rating scale (3 points is the worst score and 1 point is the best score for each item) with eight items: voice, ability to swallow, lips, saliva, tongue, mucous membrane, gingiva, and teeth (Table 1). The worst total score is 24 points and the best total score is 8. Before providing oral care, participants' oral status was assessed using the OAG. The evaluation was conducted by two dentists (Y.H., M.K.) who were previously provided sufficient training on how to use the OAG. Characteristics and OAG scores were compared between the non-oral and oral feeding groups.
Oral Assessment Guide Rating Scale
Statistical analysis was performed using unpaired t (age), chi-square (sex and medical conditions), and Mann–Whitney U (OAG score) tests, and data were analyzed using PSAW Statistics version 18.0.0. The significance level was set at 0.05.
Among 206 patients who were consulted at the Department of Dentistry, 132 were evaluated for their oral status on the day following admission. There were 66 participants in the non-oral feeding group and 66 in the oral feeding group. The non-oral feeding group comprised 40 patients receiving parenteral nutrition, 20 receiving nasogastric tube feeding, and six receiving PEG. Table 2 shows participants' characteristics. Participants' mean age was 79.4 years (range = 68 to 105 years). There were no significant differences in age, sex, and medical conditions between the two groups.
Patient Characteristics (N =132)
Oral Assessment Guide Score
Table 3 shows the results of the OAG. The non-oral feeding group had higher mean scores than the oral feeding group for all items except gingiva. The non-oral feeding group had a significantly lower total average score than the oral feeding group (14.4 versus 16.8). The non-oral feeding group also had significantly lower average scores for the voice, swallowing, saliva, and tongue items. Although there were no significant differences between the two groups for the gingiva and teeth items, both groups had relatively poor scores for these items.
Average Oral Assessment Guide Score
The most important finding of the current study was clarifying the poor oral status of non-oral feeding patients. Although clinicians have recognized such a tendency, no data have confirmed it. The results of the current study provide ample evidence.
The oral cavity tends to become contaminated with dental plaque and food residue in oral feeding patients. Plaque and residue are rarely observed in non-oral feeding patients. However, it is inappropriate to consider that non-oral feeding patients do not require oral care in the absence of dental plaque or food residue. Most clinicians engaged in the oral care of older adults are aware of this, and the results of the current study are consistent with their recognition. Oral care is regarded as important to prevent aspiration pneumonia among older adults receiving oral feeding (Kaneoka et al., 2015; Yoneyama, Yoshida, Matsui, & Sasaki, 1999). As non-oral feeding patients' oral status was reportedly poorer than that of oral-feeding patients', it is more important for non-oral feeding patients to receive oral care (Maeda & Akagi, 2014). In the current study, all patients received consultations from the attending physicians because of poor oral hygiene; therefore, they had a poor oral status regardless of whether they received oral feeding. Under such conditions, the significantly poorer assessment results of the non-oral feeding patients may also be remarkable findings.
The second important finding was the differences between the two groups in scores for voice, tongue, and saliva items on the OAG. A tongue-related score of 3 corresponds to conditions described as blistered or cracked and indicates an association with xerostomia. A saliva-related score of 3 indicates the absence of saliva. Similarly, poor voice-related scores are observed when xerostomia is present, as it tends to affect pronunciation. In short, these scores are associated with xerostomia due to a reduced amount of saliva. However, oral feeding stimulates the oral cavity and promotes salivary secretion, facilitating self-clearance of the oral cavity. Under a non-oral feeding condition, oral stimulation decreases, resulting in a reduced amount of saliva. In such cases, reduced salivary clearance may be a problem. Saliva has various functions and contributes to the maintenance of a favorable oral condition. Therefore, approaches to resolve xerostomia are essential (Edgar, Dawes, & O'Mullane, 2004; Sreebny, 2000).
The current study involved older adult patients with a mean age of 79.4 years. It has been reported that the amount of resting saliva decreases but stimulating saliva is maintained in older adults (Nagler & Hershkovich, 2005a,b; Vissink, Spijkervet, & Van Nieuw Amerongen, 1996). Therefore, it is critical to provide oral care for patients receiving and not receiving oral feedings because it improves their oral status by increasing the secretion of the stimulating saliva through oral stimulation. In non-oral feeding patients, membranous substances and phlegm (Figure) are frequently attached to the oral mucosa (Kawase et al., 2014). However, contrary to the current authors' expectations, no significant differences were observed in mucosa-related OAG scores. This result was possibly due to the fact that the mucosa-related OAG score mainly reflects the statuses of ulcers and bleeding, rather than the formation of membranous substances. The OAG was used in the current study because it has been evaluated for its reliability and validity, and has been widely used. Another scale, the Oral Health Assessment Tool (OHAT; Chalmers, King, Spencer, Wright, & Carter, 2005) is available; however, it also assesses mucosal conditions by focusing on ulcers and bleeding. When performing oral care for non-oral feeding patients, it takes time to remove membranous substances and phlegm attached to the oral mucosa. Thus, it is important to evaluate mucosal conditions to estimate the burden of oral care. However, no appropriate tools exist for evaluating mucosal conditions by these substances. Although there are saliva-related items (representing the viscosity of saliva) in both the OAG and OHAT, substances attached to the oral mucosa of non-oral feeding patients are different from the saliva (Kawase et al., 2014). Therefore, it may be necessary to develop an appropriate scale to evaluate the mucosal conditions by membranous substances and phlegm from the viewpoint of oral care for older adults.
Membranous substances and phlegm in a non-oral feeding patient's oral mucosa.
One limitation of the current study was that nutritional status was not evaluated. Many studies have reported on oral status and nutrition (Kikutani et al., 2013; Marshall et al., 2002; Poisson et al., 2014; Sahyoun et al., 2003; Yoshida et al., 2011); however, they mainly focused on the relationship between the presence or absence of teeth, dentures, or occlusion and nutrition. In most studies, the effects of oral function on nutritional status have been examined, rather than discussing the effects of nutritional status on oral function. Although the current study did not directly examine the effects of nutritional status on oral status, the findings suggest the usefulness of feeding methods, which is helpful when making a comprehensive decision on the necessity of oral care. In the future, it may be necessary to examine nutritional status in more detail to compare the oral status among different nutritional conditions. In addition, it may be necessary to evaluate how long artificial feeding has been in place.
A second limitation was that the number of patients receiving nasogastric tube feeding and PEG was limited, so it may be important to conduct further studies to compare feeding methods in more detail. Third, as this study was performed at a Japanese geriatric hospital, the generalizability of the results to other types of hospitals and other countries with different health care systems and patient backgrounds may be limited. However, the current authors believe these findings can be applied to many types of hospitals and countries because multiple surveys have indicated that oral complications are one of the most common symptoms in independent older adults (Kikutani et al., 2013; Yoshida et al., 2011; Zuluaga, Ferreira, Montoya, & Willumsen, 2012).
Implications for Nurses
Oral care is part of nursing care. It is necessary to provide oral care to oral feeding and non-oral feeding patients. Non-oral feeding patients, especially, need more careful oral assessment because of their tendency to have a poor oral condition. The current authors were unable to determine the appropriate oral care method and frequency based only on their results. However, assessing patients' oral status is important for those receiving oral feeding and non-oral feeding to determine the appropriate oral care method and frequency, such as whether oral moisturizer is needed. According to the current results, OAG items relating to xerostomia are significantly poor in non-oral feeding patients. Therefore, when nurses provide oral care to non-oral feeding patients, it may be important to moisturize patients' oral cavity.
The current results support the clinical recognition that the oral status of non-oral feeding patients is poor, and underscores the importance of oral care for these patients.
- Chalmers, J.M., King, P.L., Spencer, A.J., Wright, F.A.C. & Carter, K.D. (2005). The oral health assessment tool—Validity and reliability. Australian Dental Journal, 50, 191–199. doi:10.1111/j.1834-7819.2005.tb00360.x [CrossRef]
- Edgar, M., Dawes, C. & O'Mullane, D. (2004). Saliva and oral health (3rd ed.). London, UK: British Dental Journal.
- Eilers, J., Berger, A.M. & Petersen, M.C. (1988). Development, testing, and application of the oral assessment guide. Oncology Nursing Forum, 15, 325–330.
- Kaneoka, A., Pisegna, J.M., Miloro, K.V., Lo, M., Saito, H., Riquelme, L.F. & Langmore, S.E. (2015). Prevention of healthcare-associated pneumonia with oral care in individuals without mechanical ventilation: A systematic review and meta-analysis of randomized controlled trials. Infection Control & Hospital Epidemiology, 36, 899–906. doi:10.1017/ice.2015.77 [CrossRef]
- Kawase, Y., Ogasawara, T., Kawase, S., Wakimoto, N., Matsuo, K., Shen, F.C. & Kakinoki, Y. (2014). Factors affecting the formation of membranous substances in the palates of elderly persons requiring nursing care. Gerodontology, 31, 184–193. doi:10.1111/ger.12020 [CrossRef]
- Kikutani, T., Yoshida, M., Enoki, H., Yamashita, Y., Akifusa, S., Shimazaki, Y. & Tamura, F. (2013). Relationship between nutrition status and dental occlusion in community-dwelling frail elderly people. Geriatrics and Gerontology International, 13, 50–54. doi:10.1111/j.1447-0594.2012.00855.x [CrossRef]
- Maeda, K. & Akagi, J. (2014). Oral care may reduce pneumonia in the tube-fed elderly: A preliminary study. Dysphagia, 29, 616–621. doi:10.1007/s00455-014-9553-6 [CrossRef]
- Marshall, T.A., Warren, J.J., Hand, J.S., Xie, X.J. & Stumbo, P.J. (2002). Oral health, nutrient intake and dietary quality in the very old. Journal of the American Dental Association, 133, 1369–1379. doi:10.14219/jada.archive.2002.0052 [CrossRef]
- McClave, S.A., Taylor, B.E., Martindale, R.G., Warren, M.M., Johnson, D.R., Braunschweig, C. & Compher, C. (2016). Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Journal of Parenteral and Enteral Nutrition, 40, 159–211. doi:10.1177/0148607115621863 [CrossRef]
- Nagler, R.M. & Hershkovich, O. (2005a). Age-related changes in unstimulated salivary function and composition and its relations to medications and oral sensorial complaints. Aging Clinical and Experimental Research, 17, 358–366. doi:10.1007/BF03324623 [CrossRef]
- Nagler, R.M. & Hershkovich, O. (2005b). Relationships between age, drugs, oral sensorial complaints and salivary profile. Archives of Oral Biology, 50, 7–16. doi:10.1016/j.archoralbio.2004.07.012 [CrossRef]
- Poisson, P., Laffond, T., Campos, S., Dupuis, V. & Bourdel-Marchasson, I. (2014). Relationships between oral health, dys-phagia and undernutrition in hospitalised elderly patients. Gerodontology, 33, 161–168. doi:10.1111/ger.12123 [CrossRef]
- Sahyoun, N.R., Lin, C.L. & Krall, E. (2003). Nutritional status of the older adult is associated with dentition status. Journal of the American Dietetic Association, 103, 61–66. doi:10.1053/jada.2003.50003 [CrossRef]
- Sreebny, L.M. (2000). Saliva in health and disease: An appraisal and update. International Dental Journal, 50, 140–161. doi:10.1111/j.1875-595X.2000.tb00554.x [CrossRef]
- Vissink, A., Spijkervet, F.K. & Van Nieuw Amerongen, A. (1996). Aging and saliva: A review of the literature. Special Care in Dentistry, 16, 95–103. doi:10.1111/j.1754-4505.1996.tb00842.x [CrossRef]
- Yoneyama, T., Yoshida, M., Matsui, T. & Sasaki, H. (1999). Oral care and pneumonia. Lancet, 354, 515. doi:10.1016/S0140-6736(05)75550-1 [CrossRef]
- Yoshida, M., Kikutani, T., Yoshikawa, M., Tsuga, K., Kimura, M. & Akagawa, Y. (2011). Correlation between dental and nutritional status in community-dwelling elderly Japanese. Geriatrics and Gerontology International, 11, 315–319. doi:10.1111/j.1447-0594.2010.00688.x [CrossRef]
- Zuluaga, D.J., Ferreira, J., Montoya, J.A. & Willumsen, T. (2012). Oral health in institutionalised elderly people in Oslo, Norway and its relationship with dependence and cognitive impairment. Gerodontology, 29, 420–426. doi:10.1111/j.1741-2358.2011.00490.x [CrossRef]
Oral Assessment Guide Rating Scale
|Category||Method of Observation||Rating 1||Rating 2||Rating 3|
|Voice||Converse with patient, listen to crying||Normal||Deeper or raspy||Difficulty talking or crying, or painful|
|Ability to swallow||Ask patient to swallow||Normal swallow||Some pain on swallowing||Unable to swallow|
|Lips||Observe and feel tissue||Smooth, pink, and moist||Dry or cracked||Ulcerated or bleeding|
|Saliva||Insert depressor into mouth, touching center of tongue and the floor of the mouth||Watery||Thick or ropy; excess salivation due to teething||Absent|
|Tongue||Observe appearance of tissue||Pink, moist, and papillae present||Coated or loss of papillae with a shiny appearance with or without redness; fungal infection||Blistered or cracked|
|Mucous membrane||Observe appearance of tissue||Pink and moist||Reddened or coated without ulceration; fungal infection||Ulceration with or without bleeding|
|Gingiva||Gently press tissue||Pink and firm||Edematous with or without redness, smooth; edema due to teething||Spontaneous bleeding or bleeding with pressure|
|Teeth||Observe appearance of teeth||Clean and no debris||Plaque or debris in localized areas (between teeth)||Plaque or debris generalized along gum line|
Patient Characteristics (N =132)
|Variable||Total||Oral Feeding Patients (n = 66)||Non-Oral Feeding Patients (n = 66)|
|Age (mean, SD)||79.4 (12.3)||80.8 (12.8)||78.1 (11.7)|
| Male||76 (58)||35 (53)||41 (62)|
| Female||56 (42)||31 (47)||25 (38)|
| Pneumonia||44 (33)||21 (32)||23 (35)|
| Cerebrovascular||21 (16)||14 (21)||7 (11)|
| Neurodegenerative||16 (12)||9 (14)||7 (11)|
| Dementia||14 (11)||5 (8)||9 (14)|
| Other||37 (28)||17 (26)||20 (30)|
Average Oral Assessment Guide Score
|Oral Feeding||Non-Oral Feeding|
|Voice||1.6 (0.6)||2.4 (0.7)*|
|Ability to swallow||1.8 (0.6)||2.6 (0.6)*|
|Lips||1.8 (0.5)||2.0 (0.4)|
|Saliva||1.7 (0.5)||2.0 (0.7)*|
|Tongue||1.8 (0.5)||2.0 (0.3)*|
|Mucosal membrane||1.8 (0.5)||1.9 (0.4)|
|Gingiva||1.9 (0.5)||1.9 (0.3)|
|Teeth||2.0 (0.6)||2.1 (0.5)|
|Total score||14.4 (2.9)||16.8 (2)*|