Health Issues Related to Oral Health in Old Age

Oral Health and Nursing Care in Old Age

Oral Health and other health issues related to oral hygiene.Tools for oral Assessment Nursing Strategies and Interventions. 

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.