Good oral health is important to overall health; poor oral health is linked not only to oral diseases but also to systemic disease. The most prevalent oral diseases secondary to poor oral health in Americans are dental caries and gingival and periodontal diseases. Periodontal disease may be related to the pathogenesis of cardiovascular diseases, stroke, and diabetes, all of which are major causes of mortality in the United States (Miniño, Heron, Murphy, & Kochanek, 2007). Oral and pharyngeal cancers (OPC) account for only 2% of all cancers; however, according to the Surveillance, Epidemiology and End Results program data, the 5-year survival rate is surprisingly low at 60.8% overall and only 37.3% for African-American men (National Cancer Institute, 2011). It is estimated that 7,900 Americans will die each year from OPC (National Cancer Institute, 2011). Mortality has shown no significant change over the past 30 years and is largely explained by the fact that approximately 66% of these cancers are diagnosed at a late stage (III and IV). This is in stark contrast to cancers involving other sites. The steepest drop in cancer deaths in the United States was reported in January 2007 (Jemal, Ward, & Thun, 2010). The greatest decline in mortality was in all four major cancer sites in men (lung, colon, rectum, and prostate) and in women (breast and colorectal), except for lung cancer among women. For most of these cancer sites, the decline reflects improvements in early detection and health promotion (Jemal et al., 2010).
Most oral diseases are preventable, with 75% of oral cancers being linked to tobacco and alcohol use (Glick & Greenberg, 2005), and effective options are available through early detection. Yet, less than two thirds of the people in the United States visit the dentist annually (Wall & Brown, 2003). The Surgeon General’s national call to action to promote good oral health in 2000 (U.S. Department of Health and Human Services, 2000) emphasized the need for all health care providers to be more proactive with oral disease prevention. Nurses are ideally situated to provide information regarding oral health to the people they care for, particularly those who are elderly and those with chronic illness (Clemmens & Kerr, 2008). Although the majority of nursing programs now include health assessment, health promotion, and issues related to geriatric needs in their curricula (Berman et al., 2005), the topic of oral health is not well integrated into nursing curricula (Hein, Schönwetter, & Iacopino, 2011). In fact, little is known about the depth and breadth of teaching related to oral health.
Nurses are in the position to integrate and conduct oral health assessments across many practice settings. Oral health assessment should include an examination of the oral cavity and soft tissue, being able to identify the two most significant types of lesions (red and white patches), retracting the tongue, and palpating the neck. Nurses should be able to recognize the most common sites for oral cancer—the lateral borders of the tongue, floor of the mouth, and lips—recognized as early detection assessment (Silverman, 2007). In addition, nurses should understand the risks of tobacco and alcohol contributing to OPC and be knowledgeable about cessation programs.
However, a series of surveys of intensive care nurses (Ganz et al., 2009), staff nurses (Adams, 1996), and nurse practitioners (Sirphant, Drury, Horowitz, & Harris, 2001) showed that the majority of the nurses surveyed had limited knowledge about the risk factors and signs and symptoms of OPC. They felt inadequately trained or uncomfortable examining the oral cavity and did not consider oral health screening to be their responsibility. Costello and Coyne’s (2008) study of oral care practices and use of assessment tools revealed that there was inadequate knowledge about oral care and lack of evidence-based care provided to their patients. In a study of patients receiving radiation oncology, who were at high risk for developing oral health complications, 76% of nurses conducted an assessment of oral health only after the onset of complications (Southern, 2007). Where do these attitudes and practices originate?
Nursing education programs require the integration of the natural and human sciences and humanities. The Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing, 2008) provides a framework for preparing nurses across health care settings. The emphasis has been on identifying the knowledge, skills, and attitudes that nurses need to practice effectively. Elements essential to nursing practice include preventative health promotion strategies, including oral health screening, especially for vulnerable and older adult populations. The purpose of our study was to identify the knowledge, attitudes, and practices of baccalaureate nursing students about oral health assessment.
A convenience sample of 163 students in two undergraduate courses within a baccalaureate nursing education program comprised the study sample. Twenty-five percent of the sample was traditional 4-year students, and 75% already had a college degree. The survey was voluntary and intentionally distributed to students in both a sophomore nursing nonclinical course (Health Assessment) and a junior nursing clinical course (Fundamentals) to describe the knowledge, attitudes, or practice of nursing students over two semesters. Although no demographic data were collected from the 163 participants, the school’s nursing population draws from a heterogeneous cross-section of culturally and ethnically mixed individuals. Overall, classes were composed of 10% men and 90% women students, with an average age of 27 years.
The research question “What are the knowledge, attitudes, and practices related to oral health assessment in baccalaureate nursing students in a large, private, urban university?” guided the study. A 13-item, self-report survey, using a 4-point Likert-type scale (1 = very important to 4 = not at all important) was adapted for this study from a dental practice questionnaire targeting dentists’ and dental hygienists’ knowledge, attitudes, and practices related to oral health and cancer screening (Silverman, Kerr, & Epstein, 2010). Any questions pertaining specifically to dental or hygienic practice were not included. Alcohol screening questions were not included in this survey because the focus was on overall oral health assessments and students’ knowledge of how tobacco use affects oral health. Survey questions asked students to estimate the percentage of their practice time in which they performed an oral health assessment, what they included in that assessment (visual examination of the soft tissue and of the lateral borders), and whether they asked patients about their tobacco use and discussed cessation. Reliability and validity measures were not available for this instrument from the original sample.
No identifying information was elicited from the respondents. Prior to survey distribution, the investigators received Human Subjects Review Board approval. One of the study investigators (D.C.), who did not teach either of the courses, distributed the surveys, obtained acknowledged consent, and collected the completed surveys.
Three core concepts were targeted in the study: (a) knowledge, (b) attitudes, and (c) practice regarding oral health assessment and tobacco cessation teaching. No significant differences were found between the sophomore and junior nursing student responses.
Three of the knowledge questions focused on an association of gum disease with a specific health issue (i.e., “Which of the following demonstrates an association with gum disease [periodontal disease]?”). Ninety-seven percent of respondents (n = 158) stated that they believed they had a good understanding of what composes an oral health assessment. However, only 25% (n = 40) of students were able to correctly identify the components of an oral health assessment. Respondents answered correctly 100% of the time about the positive correlation between gum disease and use of tobacco products, diabetes, poor oral hygiene, and advancing age.
The majority of respondents reported that oral health and knowledge of smoking cessation was essential to their nursing practice. Sixty-nine percent (n = 112) reported never having tried tobacco or having experimented with it a few times. Twenty percent (n = 32) reported using tobacco in the past, and 6% (n = 10) currently used it. The remainder of students (n = 9) chose not to answer this question.
Four questions targeted nursing practice in conducting an oral health assessment. Forty-nine percent (n = 80) of respondents stated that they performed oral health assessments on some of their patients. Less than 2% reported performing oral health assessments on all of their patients. For this latter group, they palpated the neck and retracted the tongue for half of their assessments and rarely performed a visual inspection of the soft tissue. The majority of respondents agreed that knowledge of smoking cessation was important in nursing practice, and 74% (n = 120) did encourage their patients who smoked to quit. However, the students were not able to correctly identify the core components that make up effective smoking cessation.
Based on the findings, it is clear that although this sample of baccalaureate nursing students viewed knowledge about oral health as important to their nursing practice, they did not have a full understanding of the key components of an oral health examination nor of teaching strategies to use in helping patients to quit smoking. In reviewing the syllabi for the two courses, it was noted that both courses included oral health assessment in their topical outline, but only the clinical course incorporated the pathophysiology and disease states associated with oral health. In addition, students were exposed to variations in oral health assessment techniques used by nurses across a range of clinical institutions. It is noteworthy from the literature that RNs generally do not incorporate oral health screening into their practice (Adams, 1996; Ganz et al., 2009).
The extent to which students can integrate all of their teaching in health assessment and accumulated knowledge during their training into practice each semester has always been a challenge for nursing faculty. Curricula tend to be more and more laden with content (Benner, Sutphen, Leonard, & Day, 2010), further testing the teaching skills of faculty, especially in translating the content to the clinical setting. How do we help tease out the most salient topics and applications to practice that are most relevant? Can nursing students’ perceptions be changed to understand the significant role that oral health screening plays in uncovering not only oral diseases but also systemic diseases?
The reliability and validity of the survey questions have not been established on a cohort of nurses, with some questions possibly causing confusion and misinterpretation on the part of the nursing student respondents. One question was removed from analysis because of poor wording. Revising the survey and adding a senior class to the study, comparing any changes in knowledge, attitudes, and practice, would have provided a broader picture across the nursing curriculum.
Implications for Practice
Several opportunities to improve the teaching of oral health exist across the nursing program curriculum. An analysis of oral health content and skills taught across all nursing clinical and laboratory courses would provide a baseline of how this topic is covered. Assessment of faculty knowledge, attitudes, and practice regarding oral health, as well as practices across clinical settings, could provide a basis for an educational forum on the topic. This includes ambulatory settings, primary and specialty clinics, and community health settings. Identifying oral health assessments as indicators of quality assurance could highlight the topic as significant to nursing practice, facilitating the integration of this into practice. Integrating theoretical content and simulated applications into the clinical settings is integral to nursing students’ learning (Benner et al., 2010), with more oral health case studies and problem-based learning approaches possibly being developed. Curricula need to include participation in clinical training programs and simulations as an important component of student practical education. For example, attending training programs, such as smoking cessation programs, and time spent with a nurse practitioner specializing in ears, nose, and throat could be extremely valuable in bridging theory into practice. Training programs have been effective in changing nurses’ accuracy with oral health assessment (Arvidson-Bufano, Blank, & Yellowitz, 1996).
The evidence regarding oral health as integral to overall health is growing. Nurses are in an ideal position to integrate oral health assessment into their practice with large numbers of patients across a variety of health care and community settings. The inclusion of oral health as a significant topic within nursing curricula, with integration into clinical teaching, can strengthen the emerging practice of nurses with a greater potential effect on positive health outcomes of their patients.
- Adams, R. (1996). Qualified nurses lack adequate knowledge related to oral health, resulting in inadequate oral care of patients on medical wards. Journal of Advanced Nursing, 24, 552–560. doi:10.1046/j.1365-2648.1996.22416.x [CrossRef]
- American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from http://www.aacn.nche.edu/Education/essentials.htm
- Arvidson-Bufano, U.B., Blank, L. & Yellowitz, J.A. (1996). Nurses’ oral health assessments of nursing home residents pre- and post-training: A pilot study. Specialty Care Dentist, 16, 58–64. doi:10.1111/j.1754-4505.1996.tb00835.x [CrossRef]
- Benner, P., Sutphen, M., Leonard, V. & Day, L. (2010). Educating nurses: A call for radical transformation. Stanford, CA: Jossey-Bass.
- Berman, A., Mezey, M., Kobayashi, M., Fulmer, T., Stanley, J., Thornlow, D. & Rosenfeld, P. (2005). Gerontological nursing content in baccalaureate nursing programs: Comparison of findings from 1997 and 2003. Journal of Professional Nursing, 21, 268–275. doi:10.1016/j.profnurs.2005.07.005 [CrossRef]
- Clemmens, D.A. & Kerr, R. (2008). Improving oral health in women: Nurses’ call to action. Maternal and Child Care Nursing, 33, 10. doi:10.1097/01.NMC.0000305650.56000.e8 [CrossRef]
- Costello, T. & Coyne, I. (2008). Nurses’ knowledge of mouth care practices. British Journal of Nursing, 17, 264–268.
- Ganz, F.D., Fink, N.F., Raanan, O., Asher, M., Bruttin, M., Nun, M.B. & Benbenishty, J. (2009). ICU nurses’ oral care practices and the current best evidence. Journal of Nursing Scholarship, 41, 132–138. doi:10.1111/j.1547-5069.2009.01264.x [CrossRef]
- Glick, M. & Greenberg, B.L. (2005). Primary cardiovascular risk screening by dentists. Journal of the American Dental Association, 136, 1541–1546.
- Hein, C., Schönwetter, D.J. & Iacopino, A.M. (2011). Inclusion of oral-systemic health in predoctoral/undergraduate curricula of pharmacy, nursing, and medical schools around the world: A preliminary study. Journal of Dental Education, 79, 1187–1199.
- Jemal, A., Ward, E. & Thun, M. (2010). Declining death rates reflect progress against cancer. PLoS ONE, 5(3), e9584. doi:10.1371/journal.pone.0009584 [CrossRef]
- Miniño, A.M., Heron, M.P., Murphy, S.L. & Kochanek, K.D. (2007). Deaths: Final data for 2004. National Vital Statistics Report, 54(19), 1–49.
- National Cancer Institute, Surveillance Epidemiology and End Results. (2011). SEER cancer statistics review, 1975–2008. Retrieved from http://seer.cancer.gov/csr/1975_2008/index.html
- Silverman, S. (2007). Mucosal lesions in older adults. Journal of the American Dental Association, 13(Suppl.), 41S–46S.
- Silverman, S., Kerr, R. & Epstein, J.B. (2010). Oral and pharyngeal cancer control and early detection. Journal of Cancer Education, 25, 279–281. doi:10.1007/s13187-010-0045-6 [CrossRef]
- Sirphant, P., Drury, T., Horowitz, A. & Harris, R. (2001). Oral cancer knowledge and opinions among Maryland nurse practitioners. Journal of Public Health Dentistry, 61, 138–144. doi:10.1111/j.1752-7325.2001.tb03380.x [CrossRef]
- Southern, H. (2007). Oral care in cancer nursing: Nurses’ knowledge and education. Journal of Advanced Nursing, 57, 631–638. doi:10.1111/j.1365-2648.2006.04159.x [CrossRef]
- U.S. Department of Health and Human Services. (2000). Oral health in America: A report of the Surgeon General. Rockville, MD: National Institute of Dental and Craniofacial Research, National Institutes of Health.
- Wall, T.P. & Brown, J. (2003). Dental visits among Hispanics in the United States. Journal of the American Dental Association, 135, 1011–1017.