12
Figure. Objectives of oral hygiene care. Modified from Rawlins and Trueman (2001) by V. Blanco Johnson ©2011.
cludes the gingiva, periodontal liga- (Chalmers et al., 2003; Chalmers Jablonski, Munro, et al., 2009).
ment (fibers supporting the tooth & Pearson, 2005b; Ghezzi & Ship, The use of “elderspeak” should be
root within the bone), cementum 2000; IOM, 2011; Mancini, Grap- avoided to minimize resistive be-
(surface layer of the tooth root), and pasonni, Scuri, & Amenta, 2010). havior. This refers to the content,
alveolar bone (Harris et al., 2009). When identifying older patients pitch, and tone of voice that con-
Plaque-related oral diseases: Re- at greatest risk for plaque-related veys a patronizing and infantilizing
fers to dental caries and periodon- dental diseases, level of cogni- form of communication (Jablonski,
tal disease caused by the presence tive impairment must be assessed. 2010; Williams, Herman, Gajewski,
of pathogenic dental plaque on Examples of commonly used & Wilson, 2009). Other specific
tooth surfaces and on gum tissues. research-based tools include the communication techniques for use
These diseases are not caused by a Mini-Mental Status Examination during oral hygiene care can be
single pathogenic microorganism. (Folstein, Folstein, & McHugh, used and are included in the full
It is an accumulation of numerous 1975), the Global Deterioration guideline.
bacterial species that comprise den- Scale (Reisberg, Ferris, de Leon, & Functional Impairment. Func-
tal plaque (Harris et al., 2009). Crook, 1982), and a clock-drawing tionally impaired dependent
Xerostomia: Patient’s subjective test (Sunderland et al., 1989). These adults are at an increased risk for
complaint indicates dry mouth and tests should be administered by a oral problems due to their limited
difficulty eating or swallowing. Xe- trained interviewer and placed in physical dexterity and impaired
rostomia is often a side effect of cer- the patient’s health record. sensory perceptions, which then
tain medications. Disruptive Behavior/Resistance leads to reliance on others for their
to Care. Caregivers have often care. Older patients can be assessed
INDIVIDUALS AT RISK FOR cited cognitive impairment and re- for level of dependency on others
ORAL PROBLEMS sistive behavior in older adults as a through assessment of activities
Patient-Related Factors to Consider major barrier to oral hygiene care. of daily living (ADLs) and instru-
Cognitive/Neurological Impair- This is especially true when care- mental ADLs (Chalmers & Pear-
ment. Oral health generally de- givers feel inadequately trained, son, 2005a; Coleman et al., 2006;
clines when cognitive impairment are fearful of being injured, do not IOM, 2011; Katz, Ford, Moskow-
progresses. Overall, older adults have the proper supplies and equip- itz, Jackson, & Jaffe, 1963). Assis-
who are cognitively impaired are ment to provide oral care, or lack tive oral hygiene aids can be cus-
found to have poor oral health, un- an oral care protocol (Chalmers & tomized to maintain independence
treated dental decay, and accumu- Pearson, 2005a; Coleman, Hein, & (e.g., modified toothbrush handles,
lated plaque on teeth and dentures Gurenlian, 2006; Jablonski, 2010; electric toothbrushes).
14
feine consumption are also related lack of daily oral hygiene will ex- Of greatest concern for older
to decreased salivary flow. Medical acerbate the condition. Once the adults is the development of root
conditions such as Sjogren’s syn- disease has begun, it is difficult to caries. Root caries develop quickly
drome and other autoimmune dis- manage without regular profes- because the root surface is less re-
eases can directly cause dry mouth. sional dental care, to which most sistant to decay due to being less
In addition, older adults who have dependent older adults do not have mineralized than the crown of the
had radiation to the head and neck access. Another periodontal fac- tooth. Gingival recession exposes
area may have reduced flow of sa- tor to consider is that dental treat- the root surface and precedes the
liva. ment has increasingly included the development of root caries. In the
Hypersalivation (Sialorrhea). placement of periodontal implants, presence of xerostomia, poor oral
Some older adults experience an in- which may be particularly chal- care, and a diet high in refined sug-
crease in their salivary flow, which lenging in older adults. Accumula- ar and fermentable carbohydrates,
can be difficult to manage. Swal- tion of plaque and debris around this disease process can encircle
lowing problems and problems implants leads to peri-implantitis, the tooth and is difficult to restore
with innervation of oral muscula- affecting the periodontium in a (Featherstone et al., 2011; Harris et
ture can result in the accumulation manner similar to periodontal dis- al., 2009; IOM, 2011).
and collection of saliva at the cor- ease. The treatment is therefore Fluoride is the most effective
ners of the lips. Thus, older adults similar to treatment for periodon- method for dental caries prevention
with neurological conditions such tal disease and underscores the (IOM, 2011), through fluoridated
as Parkinson’s disease or amyo- importance of daily oral hygiene drinking water and daily use of oral
trophic lateral sclerosis can experi- for those with implants (Chalm- care products. There is strong evi-
ence saliva pooling and dribbling ers & Ettinger, 2008; Harris et al., dence that long-term exposure to
or drooling. Likewise, cholinergic 2009). As previously discussed, the an optimal level of fluoride results
agents may have a similar effect. connection between periodontal in reducing the amount of caries in
Medications can be prescribed in disease and systemic health is rel- the adult population (IOM, 2011;
consultation with a prescribing evant, particularly for older adults. Petersen, 2003).
practitioner to try to reduce saliva There is sufficient evidence to de-
flow; however, this is not routinely velop comprehensive care planning ASSESSMENT CRITERIA
recommended because of the many that includes oral assessment and Older adults who will benefit
other side effects of such medica- hygiene when seeking the best pos- most from use of this guideline are
tions. sible patient outcomes (Iacopino, those who meet the following as-
Swallowing Problems. Older 2006; IOM, 2011). sessment criteria:
adults with dysphagia may often Dental Caries. Tooth loss has l Have cognitive impairments
appear to have excess saliva, but decreased through the years, which or neurological conditions.
this is often the result of their in- means older adults need continued l Are functionally dependent
ability to retain contents in the oral routine, regular dental care (IOM, and/or require assistance with per-
cavity and to swallow adequately. 2011). On the other hand, if older forming daily oral hygiene.
Because of the inability to effec- adults have had previous oral dis- l Report having xerostomia
tively clear the mouth of saliva or ease, they are more susceptible to (dry mouth).
food, debris may accumulate with- oral problems when self-care is l Are undergoing treatment
in the oral cavity. This “pocketing” compromised. In addition, the in- that causes oral side effects (e.g.,
or “pouching” of food and debris tegrity of previously restored teeth medication, cancer treatment).
in the vestibule of the mouth en- can become threatened when not l Have chronic medical condi-
courages bacterial growth. When kept clean, and recurrent caries tions that affect the mouth or teeth
left undisturbed or when oral hy- can develop (Chalmers & Ettinger, (e.g. diabetes, immunosuppressive
giene care is inadequate, the patient 2008; Featherstone, Singh, & Cur- conditions, Sjogren’s syndrome).
risks aspiration of debris and bac- tis, 2011; IOM, 2011). l Have swallowing difficulties
terial growth that is detrimental to Dental caries can develop on dif- and nutritional intake challenges.
oral and systemic health. ferent parts of the tooth. Chewing
Periodontal Disease. Older in- surfaces have deep pits and fissures DESCRIPTION OF THE
dividuals are at increased risk for that are high risk areas for car- PRACTICE
periodontal disease because of ies. Areas around former restora- The proposed intervention for
lifetime disease accumulation. If tions are also at risk because of the assisting with and providing oral
periodontal disease has already be- “unnatural” junction between the hygiene care includes the previous-
gun, even in its mildest form, the tooth surface and filling or crown. ly described identification of risk
16
sistance of another caregiver, evalu- EVALUATION OF OUTCOME older adults with cognitive impair-
ating communication techniques for INDICATORS ment who are unable to verbally
effectiveness (e.g., avoiding elder- Documentation can help deter- communicate discomfort and may
speak, approaching at eye level). A mine the success of the program with instead become agitated. Identify-
video and booklet with visual ex- each resident. The following tools ing and treating oral and local in-
amples and demonstrations of the are intended to continuously audit fections can prevent other systemic
other described strategies are avail- the individual’s oral health status and problems that, in turn, lead to more
able to accompany the guideline oral hygiene care serious outcomes.
(Chalmers, Colgate-Palmolive Pty. A thoroughly outlined oral care
Ltd., Australian Dental Association, OHAT and Assessment of Current protocol provides consistency of
& Alzheimer’s Association, 2002). Oral Hygiene care and encourages individualized
These previously discussed tools oral hygiene and behavioral man-
EVALUATION OF PROCESS provide information about the resi- agement recommendations. From
INDICATORS dent’s current oral health condition the recognition of individuals at
Process indicators are those in- and oral hygiene regimen. Changes increased risk for oral problems to
terpersonal and environmental fac- recorded in these areas can monitor the provision of palliative oral care,
tors that can facilitate use of the positive or negative outcomes, and the Oral Hygiene Care for Func-
guideline. Caregiving staff should they can highlight areas of success or tionally Dependent and Cognitive-
complete the Oral Health Knowl- need for modification. ly Impaired Older Adults guideline
edge Assessment and the Process is not a “one-size-fits-all” endeav-
Evaluation Monitor. Oral Hygiene Outcomes Monitor or. For example, specific, unique
Each resident receiving care de- oral and dental conditions war-
Oral Health Knowledge Assessment tailed in this guideline should have a rant individualized oral product
The Oral Health Knowledge As- copy of the Oral Hygiene Outcomes use and cleansing techniques (i.e.,
sessment is a brief, multiple-choice Monitor in his or her health record. some oral products are contraindi-
item set of questions specifically The monitor should be completed cated in patients with xerostomia).
targeted to highlight important weekly, and it contains yes/no ques- Likewise, the guideline describes
care aspects of the program. Nurs- tions in the following six areas: oral palliative mouth care, an often
es and staff caregivers involved problems, oral hygiene status, signs overlooked aspect of care, provid-
with the implementation of the of oral discomfort/pain, record of ing critical recommendations to
oral care program should be given oral hygiene recommendations, re- promote quality of life and high-
the opportunity to complete this cord of appropriateness of patient quality end-of-life care for older
assessment, followed by reviewing management strategies, and record adults.
answers with the person adminis- of improvement or decline in oral Oral care programs are optimal-
tering the test. hygiene care. ly implemented when a dedicated
team of care providers is educated,
Process Evaluation Monitor CONCLUSION AND supported, and trained (didactic
This nine-item set of questions RECOMMENDATIONS FOR and clinical) with the ongoing as-
is completed by caregivers involved GERONTOLOGICAL NURSING sistance of a dentist and/or dental
with the implementation of the oral PRACTICE hygienist. Pharmacists and prima-
care program. Nurses and staff care- Maintaining oral health can best ry care practitioners play a crucial
givers with higher scores on this be achieved through periodic oral role in identifying long-term use of
monitor are indicating they are well assessments, regular and thorough medications that may exacerbate
equipped to implement the guide- daily oral hygiene care, and pro- oral problems such as xerosto-
line and understand its use and pur- fessional dental treatment on an mia, candidal infections, gingival
pose. On the other hand, nurses and ongoing basis. Through oral as- overgrowth, and tardive dyskine-
staff caregivers who have relatively sessment and daily oral hygiene, sia. Additionally, family caregiv-
low scores are in need of more train- the early detection and prevention ers should be educated about the
ing, education, and support regard- of oral problems can be addressed risks of poor oral hygiene and the
ing use of the guideline. Feedback to and minimized (Chalmers & Et- overall health benefits gained when
each individual who completes this tinger, 2008). The early detection of oral health is maintained. The con-
evaluation form should be provided oral problems can also prevent the tinuous collaboration of efforts
by the person overseeing the imple- development of oral pain, which and expertise of interdisciplinary
mentation process. can lead to behavioral problems in health care teams benefits everyone
18
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& Loesche, W.J. (1998). Predictors of iors: Some practical suggestions for cop- Schols, J.M.G.A., & de Baat, C. (2011).
aspiration pneumonia: How important ing with Alzheimer’s disease and related Risk factors for aspiration pneumonia in
is dysphagia? Dysphagia, 13, 69-81. illnesses. Ypsilanti: Eastern Michigan frail older people: A systematic literature
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Ames, IA: Wiley-Blackwell. on quality of life in the US and Austra- Williams, K.N., Herman, R., Gajewski, B.,
Mancini, M., Grappasonni, I., Scuri, S., & lian populations. Community Dentistry & Wilson, K. (2009). Elderspeak com-
Amenta, F. (2010). Oral health in Al- and Oral Epidemiology, 37, 171-181. munication: Impact on dementia care.
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zheimer Research, 7, 368-373. Scannapieco, F.A., Bush, R.B., & Paju, S. ease & Other Dementias, 24, 11-20.
Mattila, K.J., Pussinen, P.J., & Paju, S. (2003). Associations between periodon- doi:10.1177/1533317508318472
(2005). Dental infections and cardiovas- tal disease and risk for nosocomial bacte-
cular diseases: A review. Journal of Peri- rial pneumonia and chronic obstructive ABOUT THE AUTHOR
odontology, 76(11 Suppl.), 2085-2088. pulmonary disease. A systematic review. Ms. Johnson is a continuing educa-
doi:10.1902/jop.2005.76.11-S.2085 Annals of Periodontology, 8(1), 54-69. tion provider for nursing, dental, and
Mustapha, I.Z., Debrey, S., Oladubu, M., & doi:10.1902/annals.2003.8.1.54 other agencies. At the time this article
Ugarte, R. (2007). Markers of systemic Seymour, G.J., Ford, P.J., Cullinan, M.P., was written, Ms. Johnson was Associate
bacterial exposure in periodontal disease Leishman, S., & Yamazaki, K. (2007). Professor, University of Missouri-Kan-
and cardiovascular disease risk: A sys- Relationship between periodon- sas City, School of Dentistry, Kansas
tematic review and meta-analysis. Jour- tal infections and systemic disease. City, Missouri. Dr. Schoenfelder is
nal of Periodontology, 78, 2289-2302. Clinical Microbiology and Infection, Associate Clinical Professor and Editor,
doi:10.1902/jop.2007.070140 13(Suppl. 4), 3-10. doi:10.1111/j.1469- John A. Hartford Center for Geriatric
Niedzielska, I., Janic, T., Cierpka, S., & 0691.2007.01798.x Excellence, The University of Iowa,
Swietochowska, E. (2008). The effect Shay, K., Scannapieco, F.A., Terpenning, Iowa City, Iowa.
of chronic periodontitis on the devel- M.S., Smith, B.J., & Taylor, G.W. (2005). The author has disclosed no po-
opment of atherosclerosis: Review of Nosocomial pneumonia and oral health. tential conflicts of interest, financial
the literature. Medical Science Moni- Special Care in Dentistry, 25, 179-187. or otherwise. Guidelines in this series
tor, 14(7), RA103-106. Retrieved from doi:10.1111/j.1754-4505.2005.tb01647.x were originally produced with support
http://www.medscimonit.com/fulltxt_ Sjögren, P., Nilsson, E., Forsell, M., Johans- provided by grant P30-NR03971 (PI:
free.php?ICID=863657 son, O., & Hoogstraate, J. (2008). A Toni Tripp-Reimer, The University
Pace, C.C., & McCullough, G.H. (2010). systematic review of the preventive ef- of Iowa College of Nursing), Na-
The association between oral microor- fect of oral hygiene on pneumonia and tional Institute of Nursing Research,
ganisms and aspiration pneumonia in respiratory tract infection in elderly National Institutes of Health, and
the institutionalized elderly: Review and people in hospitals and nursing homes: revised with support of The Univer-
recommendations. Dysphagia, 25, 307- Effect estimates and methodological sity of Iowa John A Hartford Foun-
322. doi:10.1007/s00455-010-9298-9 quality of randomized controlled trials. dation Center of Geriatric Nursing
Petersen, P.E. (2003). The World Oral Journal of the American Geriatrics Soci- Excellence. Copyright ©2010 The
Health Report 2003. Continuous im- ety, 56, 2124-2130. doi:10.1111/j.1532- University of Iowa John A. Hartford
provement of oral health in the 21st cen- 5415.2008.01926.x Foundation Center of Geriatric Nurs-
tury—The approach of the WHO Global Sunderland, T., Hill, J.L., Mellow, A.M., ing Excellence.
Oral Health Programme. Retrieved from Lawlor, B.A., Gundersheimer, J., Ne- E-mail correspondence to Valerie
the World Health Organization website: whouse, P.A., & Grafman, J.H. (1989). Blanco Johnson, RDH, MS, at
http://www.who.int/oral_health/media/ Clock drawing in Alzheimer’s disease. johnson_jb@hotmail.com.
en/orh_report03_en.pdf A novel measure of dementia severity. doi:10.3928/00989134-20121003-02