Improving Oral Care Practice in Long-Term Care

November 2012   Comments

At Deer Lodge Centre, oral care practice for adult dependent patients often included the use of sponge swabs and liquid mouth rinse, but the facility had no formal policy outlining best practice. The authors sought to develop such a policy by answering two main questions: Are sponge swabs effective in cleaning the oral cavity? What oral care is required for individuals with dysphagia and those who depend on others for oral care? After a review of the literature for pertinent guidance, a new protocol for oral care, based on tooth brushing and use of antibacterial gel, was implemented for one care unit. Patients showed improvements in oral health, specifically reductions in tartar, swollen and bleeding gums, ulcerations, debris and severe halitosis. Staff members were initially resistant to change, but resistance declined as they witnessed the benefits of tooth brushing. The use of sponge swabs also declined. This intervention confirmed that tooth brushing is appropriate as the gold standard of good oral care and showed that sponge swabs are ineffective for removing plaque. These principles have become the foundation of oral care policies and care plans at this facility.

The management of oral hygiene declines in the long-term care setting because of lack of access to professional dental care and lack of affordability (Petersen & Yamamoto, 2005). Poor oral health has been linked to serious systemic illnesses including diabetes mellitus, stroke, hypertension, myocardial infarction and aspiration pneumonia (Sarin, Balasubramaniam, Corcoran, Laudenbach, & Stoopler, 2008; Stein & Henry, 2009). Conversely, improvements in oral hygiene led to better diabetes control and reduced the rate and progression of respiratory tract disease (Azarpazhooh & Leake, 2006; Taylor & Borgnakke, 2008). Such serious consequences and potential benefits reinforce the importance of oral care guidelines, training, education, oral assessments and proper supplies.

Considering that tooth brushing is the gold standard of good oral care (Stein & Henry, 2009), it is surprising that the average time spent providing this type of care to seniors in long-term care facilities was only 16.2 seconds per session (Coleman & Watson, 2006). Many caregivers use sponge swabs for oral care, but a swab does not remove plaque as effectively as a toothbrush (Pace & McCullough, 2010). Insufficient education for caregivers also contributes to poor oral care (Stein & Henry, 2009). All of these factors contribute to increased bacteria in the mouth, which in turn lead to oral care concerns, such as gum disease and caries, and poorer overall health (Pace &McCullough, 2010).

Staff and administrators at Deer Lodge Centre in Winnipeg recognized these issues as pertinent to their institution. This 431-bed facility provides long-term care, chronic care and geriatric rehabilitation to patients with various degrees of dependency. Oral care practice for dependent patients included routine use of sponge swabs and a liquid mouth rinse, but the facility had no formal oral care policy or operational directive outlining best practice in this area. In May 2010, a small interprofessional team met to consider questions relating to oral care practice for the facility’s patient population. The group consisted of a clinical nurse specialist, oral health promotion specialist, clinical educator, clinical resource nurses, infection control practitioner, clinical dietitian and speech-language pathologist. The group was also concerned about two critical incidents in which the sponge end of a swab had separated from the stick and dropped to the back of a patient’s throat, representing a choking hazard. Using both a search of the literature and a quality improvement initiative, we sought to develop an oral care policy based on answers to the following questions: Are sponge swabs effective for cleaning the oral cavity? What oral care is required for individuals with dysphagia and those dependent on others for oral care? An additional goal was to find a safer alternative to sponge swabs.

Practice change in oral care

Study population. For this project, we targeted a chronic care unit of 42 patients, ranging in age from 21 to 82, many of them dependent on others for their oral care. These patients (35 having at least some natural teeth) received feeding by tube and/or by mouth, and many were at risk for aspiration due to dysphagia. All of the patients were involved in the intervention described here, whether they were initially using sponge swabs moistened with an alcohol-free mouth rinse (n = 35) or toothbrushes (n = 7) for oral care.

Initial assessment. An oral health promotion specialist performed an initial on-site assessment of oral health status (using the Oral Health Assessment Tool, as modified by Ontario’s Halton Region Health Department) and evaluated each patient’s ability to conduct independent oral care. The assessment focused on five aspects of oral health: lips, tongue, gums and tissues, saliva and oral cleanliness. It was also designed to identify cooperation issues, oral conditions such as dry mouth and the oral care products that the person would need, as well as the risk of any systemic conditions such as aspiration pneumonia (Sarin et al., 2008). During these assessments, the specialist also identified the following problems: tartar, swollen or bleeding gums, ulcerations related to tartar formation, debris and severe halitosis.

Intervention. Our quality improvement intervention involved discontinuing routine use of sponge swabs and introducing a twice-daily oral hygiene protocol, to be performed by staff members. Kits containing appropriate tools and products, based on information from the literature and clinical experience, were provided. Each kit contained three bottles of thickened antibacterial gel (cetylpyridinium chloride 0.05% in glycerine), two soft, small-headed toothbrushes with large rubberized handles (one to be used for propping) and one end-tufted brush for cleaning between the teeth. Cetylpyridinium chloride is effective in controlling dental plaque and gingivitis (Silva, dos Santos, Stewart, DeVizio, & Proskin, 2009), and in thickened form, it was assumed to carry a lower risk for aspiration than foaming toothpastes. The glycerine gel helps to soften and lubricate the oral cavity, particularly for those who do not receive nutrition by mouth and those with xerostomia (dry mouth). Staff members provided oral care to all 42 patients on the chronic care unit.

Project outcomes. We began using the new protocol in early June 2010. Three weeks later, the oral health promotion specialist performed a reassessment and found that all patients had substantial improvements in the status of their oral cavity. More specifically, patients showed improvements in four of the five categories of oral health assessed (Figure 1), with substantially more patients having healthy scores for lips, gums and tissues, saliva and oral cleanliness. In addition, fewer instances of tartar, swollen or bleeding gums, ulcerations, debris and severe halitosis were recorded.

Trousse d’outils et de produits d’hygiène buccodentaire prête à être utilisée au Deer Lodge Centre.
Courtesy of Deer Lodge Centre

The oral health promotion specialist also audited the dental charts of 13 of the patients involved in this initiative to determine their oral care status from June 2007 to October 2011. Of specific interest were the patients’ records of periodontal screening, general oral health status, levels of plaque and tartar, and gingival pocket depth, as well as any comments pertaining to improvement that appeared in the charts. The metrics assessed for these 13 patients generally showed some improvements in oral health. Improvements were more notable, particularly in terms of reductions in plaque, for the more challenging cases: for instance, those in which the patient might typically not receive attention to dental care because of behavioural issues. Since implementation of the new protocol, the comments of dental hygienists providing care to these patients have been mostly positive, which further indicates improvements in oral hygiene.

We surveyed 46 nursing staff (registered nurses, licensed practical nurses and health-care aides) from the trial unit six months after implementation, in early December 2010 (46% response rate), and again in late October 2011 (37% response rate). The survey consisted of six questions, with responses rated on a Likert-type scale. In October 2011, survey respondents reported increased acceptance of the new protocol, for example with regard to the clinical acceptability of discontinuing use of sponge swabs (Figure 2). All six respondents to the first survey who provided spontaneous comments (not related to a specific question) stressed the need to retain the use of sponge swabs for safety reasons; they wanted to avoid placing their fingers into patients’ mouths. Of the three respondents to the second survey who made additional spontaneous comments, none advocated retaining the use of sponge swabs.

The new protocol has affected usage of sponge swabs. Before the quality improvement initiative, the trial unit was using 500-600 sponge swabs per week or about 29,000 swabs per year. During the one-year period following implementation (from June 2010 to June 2011), use of sponge swabs on the unit declined to 16,000. At June 2012, usage had further declined to 7,000 swabs.

Policy development
Before implementation of the new protocol, nursing staff could consult a dental professional to guide oral care if they had concerns, but no policy was in place outlining the standard of oral care that nurses were to follow. Given the improvements in oral health realized by the new protocol, we developed an oral hygiene policy to extend these oral care standards to the entire facility. This policy focused on four goals: (1) to ensure that patients’ oral hygiene needs are met according to their individual and clinical needs; (2) to effectively remove plaque and debris and to ensure that oral structures and tissues are kept in optimal condition; (3) to ensure that each patient’s mouth is clean, functional, comfortable and free of infection; and, (4) to provide oral hygiene using safe and appropriate products that take into account the needs of those at risk of aspiration. An operational directive and a care plan were developed specifically for individuals with difficulty swallowing or managing secretions and those unable to participate in their own oral care. This care plan, which was made available at the bedside, provided step-by-step instructions on managing the two-toothbrush brushing and propping technique for applying the gel product. The oral hygiene policy was adopted in December 2011.

Education strategy
All staff are receiving education and training regarding the new protocol. The educational tools include a DVD showing correct oral care techniques using the new resources. Copies of the DVD were distributed to all patient care units, and viewing of the DVD is mandatory for all nurses and health-care aides. Information about the policy and protocol has now been incorporated into the general orientation for all new staff, as well as the Deer Lodge annual mandatory Education Day for nurses and health-care aides. Train-the-trainer sessions were offered to designated nurses and health-care aides, who acted as resource personnel in supporting the centre-wide launch of the protocol and who now participate in ongoing education on their units.

Next steps
To build upon the progress realized to date, we will continue to highlight oral hygiene as an essential part of daily care for patients in our facility and to find ways to support use of the new protocol with staff, patients and their family members.

Current best practice suggests that screening be repeated at least quarterly (Sarin et al., 2008), and so we plan to educate nurses on the use of a tool for repeat assessments of oral health. The information obtained during these assessments will be used to update patients’ daily care plans. We also plan to explore newly available gelled products containing fluoride.

Moving forward, we will provide additional training to health-care aides to build their capacity to provide specific aspects of oral care such as tonsil suctioning, a task that is currently carried out by nurses. Once the new protocol for oral care is well established, we will be offering additional staff assistance to patients who are partially independent in performing their own oral care.

There has been a substantial decline in overall use of sponge swabs at the facility. It should be noted that although the new policy for oral care advocates the use of toothbrushes rather than sponge swabs for removing tartar, sponge swabs continue to be used in the context of end-of-life care, for keeping the oral tissues moistened.

Good daily oral care is more than just cleaning the teeth and freshening the mouth; it also enhances quality of life. After implementing a protocol specifically designed to provide effective oral care (through appropriate products, education and support), our staff have noted that patients’ quality of life has improved. In addition, they are showing greater willingness to provide daily oral care to patients. Ongoing education and promotion will be required to achieve full acceptance of the new protocol.

The authors thank Jo-Ann Lapointe-McKenzie, chief nursing officer, Deer Lodge Centre, for reviewing drafts of this manuscript; Nicole Baskerville, speech and language pathologist, Deer Lodge Centre, and Ellen Ross for their contributions; and the staff and patients on the Lodge 5 unit for their involvement.
Azarpazhooh, A. & Leake, J. L. (2006). Systematic review of the association between respiratory diseases and oral health. Journal of Periodontology, 77(9), 1465-1482.

Coleman, P., & Watson, N. M. (2006). Oral care provided by certified nursing assistants in nursing homes. Journal of the American Geriatrics Society, 54(1), 138-143.

Pace, C. C., & McCullough, G. H. (2010). The association between oral microorganisms and aspiration pneumonia in the institutionalized elderly: Review and recommendations. Dysphagia, 25(4), 307-322.

Petersen, P. E., & Yamamoto, T. (2005). Improving the oral health of older people: The approach of the WHO Global Oral Health Programme. Community Dentistry and Oral Epidemiology, 33(2), 81-92.

Sarin, J., Balasubramaniam, R., Corcoran, A. M., Laudenbach, J. M., & Stoopler, E. T. (2008). Reducing the risk of aspiration pneumonia among elderly patients in long-term care facilities through oral health interventions. Journal of the American Medical Directors Association, 9(2), 128-135.

Silva, M. F., dos Santos, N. B., Stewart, B., DeVizio, W., & Proskin, H. M. (2009). A clinical investigation of the efficacy of a commercial mouthrinse containing 0.05% cetylpyridinium chloride to control established dental plaque and gingivitis. Journal of Clinical Dentistry, 20(2), 55-61.

Stein, P. S., & Henry, R. G. (2009). Poor oral hygiene in long-term care. American Journal of Nursing, 109(6), 44-50.

Taylor, G. W., & Borgnakke, W. S. (2008). Periodontal disease: Associations with diabetes, glycemic control and complications. Oral Diseases, 14(3),191-203.
Daryl Dyck, RN, Mn

Daryl Dyck, RN, Mn, is a Clinical Nurse Specialist, Deer Lodge Centre, Winnipeg, Man.

Mary Bertone, Rdh,

Mary Bertone, Rdh,, is an Oral Health Promotion Specialist, Faculty of Dentistry, University of Manitoba, Winnipeg.

Kim Knutson, RN, Bn, Gnc(c)

Kim Knutson, RN, Bn, Gnc(c), is a Chronic Care Clinical Resource Nurse, Deer Lodge Centre.

Amy Campbell, Rd

Amy Campbell, Rd, is a Clinical Dietitian, Deer Lodge Centre.

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