Maintaining oral hygiene in elderly dentate adults in nursing

The Department of Health (2010) regards oral hygiene as a priority in maintaining high standards of patient care. Oral hygiene is vital for general health and wellbeing, notably to perform functions such as eating, speaking and non verbal communication (The Health and Social Care Information Centre 2011). Findings by the Adult Dental Health (2009) survey revealed that standards of oral health deteriorate with age. This is significant as the number of patients aged 75 and over admitted to hospital has risen by two thirds within the past ten years and this trend continues to grow (The Health and Social Care Information Centre 2011). This suggests that many elderly dentate patients may be admitted to hospital with pre existing dental problems or poor standards of oral hygiene.

Poor oral hygiene can prove detrimental to health leading to serious oral conditions including tooth decay, periodontal (gum) disease and xerostomia (dry mouth) (DH 2007). Swelling and pain associated with oral conditions can directly impact upon ones quality of life (DH 2007). For instance behaviours and choices adopted in response to oral discomfort can potentially lead to poor nutritional intake and place one at risk of malnutrition (Malkin 2009), notably having an impact on a key benchmark of patient care ‘Food and drink’ (DH 2010).

The effects of poor oral hygiene such as missing teeth or an unpleasant smell can also leave one feeling self conscious (DH 2007) and affect their ability to exchange information through verbal and non verbal ‘communication’, another key benchmark for patient care (DH 2010). Nurses are in a key position to facilitate and promote high standards of oral hygiene (Wood 2008, Xavier 2000), through providing assistance, equipment, a suitable environment and possessing specialist knowledge and skills to provide mouth care (DH 2010).

Elderly patients may require more assistance with mouth care due to the prevalence of physical and mental conditions that can affect this age group, notably vision and motor control impairments and states of confusion such as dementia (Fitzpatrick 2000). Nurses should provide mouth care for those patients who are unable to maintain their own oral hygiene needs (Wilson 2011). The level of assistance required or even desired by the patient can be deciphered by consulting patient care plans and communicating directly with the patient (Endacott et al 2009) An understanding of the patient’s background, current condition and how they are feeling today can inform the way in which mouth care is provided (Endacott et al 2009) and promote a patient centred approach (DH 2010).

Equipment must be supplied to facilitate mouth care (DH 2010). Numerous products are available, including toothbrushes, foam swabs and mouthwashes for brushing and rinsing (Endacott et al 2009). The quality of each of these products in providing mouth care has been researched extensively. For instance a study by Pearson and Hutton (2002) concluded that toothbrushes are more effective at removing dental plaque than foam swabs.

Plaque is known to cause tooth decay and periodontal (gum) disease, both factors that contribute to poor oral hygiene (The Health and Social Care Information Centre 2011). Although these findings are conclusive in identifying toothbrushes as an effective tool, it must be noted that the participants of this survey were healthy volunteers who brushed their teeth independently (Pearson & Hutton 2002). In a hospital setting mouth care may be given by a nurse (Pearson & Hutton 2002) and therefore the results are not entirely representative of hospitalised patients as the technique employed may vary.

Solutions for mouth rinsing are widely available yet Mooney (2007) suggests that mouth rinsing is not essential as toothpaste left in the mouth acts to protect teeth. Although the British Dental Health Foundation (2011) confirms that fluoride in toothpaste actively strengthens and protects teeth, findings by Berry & Davidson (2006) identify that residual toothpaste can encourage drying of the mucosa lining of the mouth. It can therefore be assumed that retaining toothpaste in the mouth may be detrimental to oral health and rinsing must be encouraged.

Endacott et al (2009) recommends the use of water as a rinsing agent as it is widely available and refreshes the mouth. However it does not have the advantage of antiseptic mouth washes, such as Corsodyl (Chlorhexidine gluconate) which can be included in a general mouth care routine (Cooley 2008) and is especially recommended when providing oral care for patients on mechanical ventilation systems (NICE 2008). However prolonged use can result in teeth discolouration and it can be difficult for patients to tolerate due to its unpleasant taste (Wood 2008). Products including a towel, bowl to spit into and a beaker of water should also be provided to ensure all steps of oral hygiene such brushing and rinsing are met (Endacott et al 2009) and dignity is maintained (NMC 2010).

The environment must be considered to maintain privacy and dignity (DH 2010, NMC 2010). It is best practice to assist a patient to the bathroom to use a sink (Mooney 2007), however this opportunity is often missed for patients who experience mobility problems (Endacott et al 2009). From practice it was observed that this could be overcome through using mobility aids in the hospital setting such as a zimmerframe or commode (with the lid on) to transport a patient to the bathroom. This facilitates a patient’s right to self care (DH 2010) and respects their autonomy (Xavier 2000). If this is not feasible, as in the case of bed bound patients Mooney (2008) recommends that a container should be placed under the patients chin and curtains must be drawn.

Knowledge and skills are crucial when delivering oral hygiene (DH 2010) demonstrated through the technique employed (NMC 2008). Endacott et al (2009) details a systematic approach to cleaning a patient’s teeth, involving brushing the top and bottom teeth, from the back to front in a circular motion holding the brush at 45 degrees to the teeth’s surface. This is continued by cleaning of the biting surfaces at 90 degrees and brushing of the gums, tongue and roof of the mouth (Endacott et al 2009) to ensure plaque is removed (BDHF 2010).

A holistic approach must be adopted to inform patient care (NMC 2010). This is especially true for health promotion of oral care as the Department of Health (2007) have identified that people living in socially deprived areas display significant levels of tooth decay. Furthermore vulnerable groups such as, adults with learning difficulties and those in long term care have also been identified as at risk of developing poor oral hygiene (DH 2007). Behaviours such as smoking, consuming sugar containing products and lack of tooth brushing are known to induce tooth decay and accelerate poor oral hygiene (The Health and Social Care Information Centre 2011). It is important to identify these risk factors and advice patients accordingly.

The British Dental Health Foundation (2011) recommends that teeth should be brushed twice a day however the frequency of oral hygiene regimes for patients is unclear. Xavier (2000) suggests that oral hygiene routines should be devised in response to an initial oral assessment; however Cooley (2008) reveals that often an initial oral assessment is omitted. Furthermore Cooley (2008) suggests the frequency of oral hygiene must be determined by assessing the possible risk to that patient. Malkin (2009) identifies many risk factors to poor oral health including age, mental health, poor diet, existing medical conditions and medications.

Wood (2008) further suggests that nurses pose a risk to patient’s oral health due to busy working environments, a ritualistic attitude and a culture where choices are based upon a adopted practices instead of evidence. Cooley (2008) affirms this by stating that a culture of using mouth swabs instead of toothbrushes is common in nursing care out of fear of harming a patient (Berry & Davidson 2006). However a toothbrush is the recommended gold standard and the use of foam swabs is encouraged only when a toothbrush is not feasible, for example for patients suffering from bleeding gums (Berry & Davidson 2006).

Providing mouth care is a complex procedure and integrates the use of other fundamental nursing skills, including infection control through hand washing and personal protective equipment (NICE 2003) and manual handling techniques. For instance it may be necessary to assist a patient to sit up or if bed bound their head must be tilted to prevent the risk of choking (Endacott et al 2009). Furthermore it is essential to gain consent before any procedure and maintain privacy and dignity (DH 2010, NMC 2010).

From a student’s perspective one can respect the value that oral hygiene has on a patient’s wellbeing. By maintaining oral hygiene one is also empowering a patient to undertake other activities such as eating, drinking, smiling and conversing and therefore enhancing their quality of life. However the decisions made to facilitate and provide oral care must be evidence based and patient centred. This can prove challenging when recommendations and cultures adopted are conflicting however by employing critical thinking one can decipher what practice is best to adopt.

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