Professional oral health care prevents mouth-lung infection in long-term care homes: a systematic review.

Background: Nursing home-acquired pneumonia (NHAP) is the leading cause of mortality among residents in long-term care (LTC) homes. Aspiration pneumonia (AP) is one cause of NHAP. Professional oral health care (POHC) and daily mouth care can be effective in decreasing AP risk. Aim: To identify, appraise, synthesize, analyze, and interpret results on the effectiveness of onsite POHC interventions/programs delivered to LTC home residents in reducing oral disease and NHAP. To summarize the findings and provide recommendations for clinical work and future research. Methods: The PICO question addressed was, "In LTC home residents with oral health needs (P), is onsite POHC (I), compared to usual care (C), clinically effective in reducing dental disease and pneumonia/AP (O)?" Databases searched were PubMed, EMBASE (Ovid), CINAHL (Ebsco), Cochrane Library (Wiley), Web of Science, and the databases of the Centre for Reviews and Dissemination. Included were randomized controlled trials (RCTs), non-RCTs, and cross-sectional studies. PRISMA guidelines were followed and GRADE was used to assess the quality of studies. Results: Thirteen clinical effectiveness studies were included: 10 RCTs, 1 non-RCT, and 2 cross-sectional studies. Discussion: Better oral health and respiratory infection outcomes were found in the experimental groups who received an onsite POHC intervention compared to the control groups. Conclusion: There is moderate-to-strong evidence that onsite POHC in LTC homes, provided mostly by dental hygienists, is effective in preventing bacterial mouth infection, pneumonia, and AP.

Contexte: La pneumonie nosocomiale des foyers de soins est la principale cause de mortalité chez les résidents des foyers de soins de longue durée (SLD). La pneumonie par aspiration (PA) est l'une des causes de la pneumonie nosocomiale des foyers de soins. Les soins buccodentaires professionnels et les soins quotidiens d'hygiène buccale peuvent permettre de réduire efficacement le risque de PA. Objectif: Définir, évaluer, résumer, analyser et interpréter les résultats relatifs à l'efficacité des interventions et des programmes de soins buccodentaires professionnels offerts sur place aux résidents des foyers de SLD pour réduire l'incidence des affections buccales et de la pneumonie nosocomiale des foyers de soins. Résumer les constatations et formuler des recommandations pour les travaux cliniques et les études à venir. Méthodes: La question relative aux patients, aux interventions, aux comparaisons et aux résultats était la suivante : « Chez les résidents des foyers de SLD ayant des besoins en santé buccodentaire (patients), les soins buccodentaires professionnels sur place (interventions) sont-ils cliniquement efficaces par rapport aux soins ordinaires (comparaisons) pour réduire l'incidence des affections dentaires et de la pneumonie/de la PA (résultats)? ¼ Les bases de données concernées par les recherches étaient PubMed, EMBASE (Ovid), CINAHL (Ebsco), la Bibliothèque Cochrane (Wiley), la plateforme Web of Science et les bases de données du Centre for Reviews and Dissemination (« Centre des examens et de la dissémination ¼). Des essais cliniques randomisés (ECR), des essais cliniques non randomisés et des études transversales étaient inclus. On a suivi les lignes directrices PRISMA et on s'est appuyé sur le cadre GRADE pour évaluer la qualité des études. Résultats: On a inclus 13 études sur l'efficacité clinique : 10 ECR, 1 étude clinique non randomisée et 2 études transversales. Les membres des groupes expérimentaux qui bénéficiaient d'interventions de soins buccodentaires professionnels sur place avaient de meilleurs résultats en matière de santé buccodentaire et d'incidence des infections respiratoires que ceux des groupes témoins. Conclusion: On constate l'existence de preuves modérées à solides que les soins buccodentaires professionnels offerts sur place dans les foyers de SLD, assurés principalement par des hygiénistes dentaires, sont efficaces pour prévenir les infections bactériennes buccales, la pneumonie et la PA.

Mouth care: why it matters - highlighting a neglected care need.

Oral health care is integral to general wellbeing, allowing people to eat, communicate verbally and socialise without discomfort or embarrassment. In relation to people being admitted to hospital, poor oral health care has been linked to longer hospital stays and increased care costs. It is also associated with an increase in hospital-acquired infections such as pneumonia and can affect nutritional intake, which is vital in supporting recovery. Assistance and encouragement with effective and daily mouth care can prevent deterioration in a patient's oral health, and yet it remains a neglected and overlooked area of care provision. Initiatives have attempted to address this neglected area of care but the pandemic and other priorities have allowed it to be lower on the healthcare agenda. Nurses, healthcare assistants and student nurses form the largest group of the healthcare workforce, providing or supervising the personal care of patients in hospitals and the community. Therefore, oral healthcare assessment and practical skills should be embedded in education and be given a strong focus and leadership to ensure that good practice is consistently implemented across all health and care settings. Mouth care really matters and should be integral to all health and care encounters. Further research and investigation into the important but neglected area of mouth care is also required.

[The realities of hunger and thirst at the end of life]. / Les réalités de la faim et la soif en fin de vie.

Questions about nutrition and hydration are common in the context of the end of life. By end of life, we mean the terminal palliative phase, a particular period of organic fragility. These questions pose difficulties, insofar as the act of eating and drinking as a vital act has a symbolic, cultural and social dimension. They must be clarified with family members or even caregivers who are not familiar with these types of care.

Oral care practices in stroke: findings from the UK and Australia.

AIMS: To examine current practice, perceptions of healthcare professionals and factors affecting provision for oral care post-stroke in the UK and Australia. BACKGROUND: Poor oral care has negative health consequences for people post-stroke. Little is known about oral care practice in hospital for people post-stroke and factors affecting provision in different countries. DESIGN: A cross-sectional survey. METHODS: Questionnaires were mailed to stroke specialist nurses in UK and Australian hospitals providing inpatient acute or rehabilitation care post-stroke. The survey was conducted between April and November 2019. Non-respondents were contacted up to five times. RESULTS: Completed questionnaires were received from 150/174 (86%) hospitals in the UK, and 120/162 (74%) in Australia. A total of 52% of UK hospitals and 30% of Australian hospitals reported having a general oral care protocol, with 53% of UK and only 13% of Australian hospitals reporting using oral care assessment tools. Of those using oral care assessment tools, 50% of UK and 38% of Australian hospitals used local hospital-specific tools. Oral care assessments were undertaken on admission in 73% of UK and 57% of Australian hospitals. Staff had received oral care training in the last year in 55% of UK and 30% of Australian hospitals. Inadequate training and education on oral care for pre-registration nurses were reported by 63% of UK and 53% of Australian respondents. CONCLUSION: Unacceptable variability exists in oral care practices in hospital stroke care settings. Oral care could be improved by increasing training, performing individual assessments on admission, and using standardised assessment tools and protocols to guide high quality care. The study highlights the need for incorporating staff training and the use of oral care standardised assessments and protocols in stroke care in order to improve patient outcomes.

Maintaining and improving mouth care for care home residents: A participatory research project.

BACKGROUND: Many people residing in nursing or residential care homes (also called long-term care facilities) live with physical or cognitive difficulties. Staff working in these environments often help residents (particularly those with more advanced dementia) with their personal care needs, including maintaining mouth care and health. Poor oral health is associated with many difficulties, including increased risk of respiratory problems, pain and discomfort. Yet, concerns have been raised that staff may not have the knowledge and skills to effectively support residents with oral care and health. There is therefore an important gap between what is known about the importance of maintaining oral health (scientific evidence) and daily practice in long-term care environments. OBJECTIVES: To work with care home staff: (1) to create a learning culture to address how to promote mouth care for residents, particularly when a resident resists support with this aspect of care; and (2) to effect mouth care practice changes (if required) using participatory and inclusive research cycles. METHODS AND RESULTS: We conducted a participatory research project to address this important area of care. Four participatory research 'cycles' were conducted. Cycle one explored existing literature to develop accessible guidance on strategies that staff could use to support residents to maintain and improve oral care, particularly when a resident may resist such care. Cycle two built on this review to determine knowledge levels within the care team. This highlighted deficiencies in staff knowledge, skills and competence for providing mouth care and their need for training to address this. Cycle three identified evidence-based strategies to develop staff understanding and knowledge. Cycle four brought together experts from nursing, dentistry, behaviour change, systematic reviews and care homes research to develop a grant application to progress this work further. CONCLUSION: This paper provides an example of the processes undertaken in a participatory research project, bringing together science and practice to improve an essential area of care. IMPLICATIONS FOR PRACTICE: Using participatory research approaches in this setting can allow the effective translation of uncertainties in care and practice into questions that can be addressed by research, leading to meaningful outcomes for those living and working in care homes.

Mouth Care in Assisted Living: Potential Areas for Improvement.

BACKGROUND: Poor oral care may lead to systemic disease, and there is evidence that assisted living (AL) residents lack quality oral care; in AL, poor care may be due to staff knowledge and attitudes, as well as organizational barriers to providing care. OBJECTIVES: Determine AL staff knowledge and attitudes regarding mouth care and barriers to changing care. DESIGN: Self-administered repeated-measures questionnaires completed before and after oral care training. SETTING AND PARTICIPANTS: A total of 2012 direct care staff and administrators from 180 AL communities. METHODS: Nine knowledge questions and 8 attitude and practice intention questions, and open-ended questions regarding training and obstacles to providing oral care. RESULTS: Overall, 2012 participants completed pretraining questionnaires, and 1977 completed posttraining questionnaires. Baseline knowledge was high, but staff were not uniformly aware of the systemic-oral link whereby mouth care affects pneumonia and diabetes. Almost all staff reported learning a new technique (96%), including for residents who resist care (95%). Suggested areas to improve mouth care included having more hands-on experience. The primary perceived obstacles to care centered around residents who resist care and a lack of time. CONCLUSIONS AND IMPLICATIONS: Based on reports of having benefitted from training, AL staff overwhelmingly noted that new knowledge was helpful, suggesting the benefit of skills-based training, especially in dementia care. Mouth care in AL has been sorely understudied, and merits additional attention.

Mouth care training and practice: a survey of nursing staff working in National Health Service hospitals in England.

Background: This study investigated the training and mouth care practice of nursing staff in hospital Trusts across England. Oral health has been found to deteriorate during hospital admission, mouth care standards have been found to be poor. Aims: The objectives of the study were to assess if and what the barriers are to supporting inpatients' mouth care, and to assess how confident nursing staff are in carrying out mouth care assessments and mouth care and see if this is related to previous training. Methods: A cross-sectional descriptive survey was conducted in 33 Trusts in England with 1576 members of the nursing team including nurses and nursing assistants. Nursing staff were asked to complete a questionnaire on previous oral health training and their current practice. Results: Nursing staff reported that they had limited training in mouth care. The main barriers to mouth care were time and patient compliance. Confidence in recognising oral cancer was low. Conclusions: Nursing staff would benefit from mouth care training targeted at assessing the mouth and providing mouth care for all inpatients.

Fidelity and sustainability of Mouth Care Without a Battle and lessons for other innovations in care.

There are countless efficacious interventions that improve outcomes when conducted in controlled situations. Many fewer are effective when implemented in real-world situations, largely because they are not implemented with fidelity. Still fewer are sustained over time, for reasons including lack of institutional support and fit with existing values, among others. It is especially important to examine fidelity and sustainability when efficacious interventions are being implemented, because these interventions are the ones that hold the most promise. This project examined the fidelity and sustainability of Mouth Care Without a Battle (MCWB), an evidence-based program conducted in a two-year cluster randomized trial in 14 nursing homes. Results that triangulated two sources of data indicated that fidelity decreased after the first year; they provide guidance to promote fidelity and sustainability of this and other new care practices in nursing homes, including ongoing education, coaching, evaluation, feedback, and sufficient resources.

Measuring Self-Efficacy and Attitudes for Providing Mouth Care in Nursing Homes.

OBJECTIVES: Mouth care is increasingly recognized as an important component of care in nursing homes (NHs), yet is known to be deficient. To promote quality improvement and inform research efforts, it is necessary to have valid measures of staff self-efficacy and attitudes to provide mouth care. DESIGN: A self-administered questionnaire completed by NH staff, information about the NH obtained from the administrator, and oral hygiene assessments of NH residents. SETTING AND PARTICIPANTS: A total of 434 staff in 14 NHs in North Carolina who were participating in a cluster randomized pragmatic trial of Mouth Care Without a Battle (MCWB). METHODS: Staff in MCWB homes completed the questionnaire at baseline; staff in control homes completed it at 2-year follow-up. The 35-item questionnaire used new items and those from previous measures, many of which were modified for the NH setting. Factorial, construct, and criterion validity were assessed. RESULTS: Exploratory factor analysis identified a 3-factor 11-item self-efficacy scale (promoting oral hygiene, providing mouth care, obtaining cooperation) named "Self-Efficacy for Providing Mouth Care" (SE-PMC), and a 2-factor 11-item attitudes scale (care of residents' teeth, care of own teeth), named Attitudes for Providing Mouth Care (A-PMC). Scores varied significantly across NHs and differentiated them based on profit status, age, and, for the A-PMC, NH size. Scores also differentiated among staff based on age and, for the SE-PMC, years of experience. In NHs where staff scored more highly, residents featured better oral hygiene (P < .001). CONCLUSIONS AND IMPLICATIONS: The SE-PMC and A-PMC are valid, parsimonious, and useful measures for quality improvement and research to improve mouth care in NHs that can be used jointly or individually. Preliminary evidence suggests that these scales may be associated with resident-level plaque and gingival hygiene, making them useful tools to assess promotion of mouth care.

A nationwide survey of confidence and knowledge of assessment and management oral conditions amongst a sample of physicians, United Kingdom.

OBJECTIVE: This study aimed to assess current confidence and knowledge of oral conditions amongst a sample of UK physicians and doctors in training programmes using a web-based survey. RESULTS: 131 survey responses were analysed for doctors from FY1 to consultant grade working within medical specialties. 36.6% and 35.9% of those surveyed expressed that they felt confident diagnosing and managing oral conditions respectively. The median knowledge score was 60%; 65.6% correctly identified the image that demonstrated a squamous cell carcinoma. 91.6% reported that they felt they needed additional training in the diagnosis and management of oral conditions. Neither confidence nor knowledge were affected by grade, specialty, or region of practice.

Dental care in older adults.

Good oral health is an essential part of ageing well. Good mouth care enables people to eat, speak and socialise without pain or embarrassment and contributes hugely to quality of life and general health. Community-dwelling older adults may find access to dental services difficult, and increasing co-morbidities can make self-care a challenge. Older adults are at increased risk of dental disease, and general health complications can make access to dental services and treatment planning difficult. Further, they may find lengthy dental procedures overwhelming. Therefore, there is a need to prevent the decline in oral health in order to maintain general health.

[Preventive approach of oral care for comfort and hydration]. / Approche préventive du soin de bouche de confort et d'hydratation.

The risk of deterioration of oral health is increased in the palliative phase of a disease due to the drying out of the oral mucosa by the treatments. Weakened, the patient drinks and eats little, or not at all. Caregivers therefore need to take over the patient's oral care to ensure hygiene and comfort. As a preventive approach, providing mouth care for hydratation and comfort associated with oral hygiene are essentials.

Oral hygiene and mouth care for older people in acute hospitals: part 2.

Acute hospital admission provides an excellent opportunity to address poor oral health in older people, a group rarely seen by dental professionals and for who oral health activity in hospital is inconsistent and generally suboptimal. This two-part article explores oral hygiene and mouth care provision for older adults in acute hospitals. The first article presented the findings of a literature review exploring oral and dental disease in older adults, the importance of good oral health and mouth care, and the current situation. The second article explores clinical recommendations. A change in philosophy is needed to embed oral care as an essential component of holistic practice. More research is needed to determine the best ways to assess and treat oro-dental problems in older people, and promote and restore their oral health in hospitals. Great potential exists to innovate and develop new ways of providing care to this group.

Oral hygiene and mouth care for older people in acute hospitals: part 1.

The oral health of older people in acute hospitals has rarely been studied. Hospital admission provides a prime opportunity for identification and rectification of problems, and oral health promotion. This two-part article explores oral hygiene and mouth care provision for older adults in acute hospitals. The first article presents the findings of a literature review exploring oral and dental disease in older adults, the importance of good oral health and mouth care, and the current situation. Searches of electronic databases and the websites of relevant professional health service bodies in the UK were undertaken to identify articles and guidelines. The literature shows a high prevalence of oro-dental disease in this population, with many known detrimental effects, combined with suboptimal oral hygiene and mouth care provision in acute hospitals. Several guidelines exist, although the emphasis on oral health is weaker than other aspects of hospital care. Older adults admitted to acute hospitals have a high burden of oro-dental disease and oral and mouth care needs, but care provision tends to be suboptimal. The literature is growing, but this area is still relatively neglected. Great potential exists to develop oral and mouth care in this context. The second part of this article explores clinical recommendations.

Readily Identifiable Risk Factors of Nursing Home Residents' Oral Hygiene: Dementia, Hospice, and Length of Stay.

BACKGROUND/OBJECTIVES: The poor oral hygiene of nursing home (NH) residents is a matter of increasing concern, especially because of its relationship with pneumonia and other health events. Because details and related risk factors in this area are scant and providers need to be able to easily identify those residents at most risk, this study comprehensively examined the plaque, gingival, and denture status of NH residents, as well as readily available correlates of those indicators of oral hygiene, including items from the Minimum Data Set (MDS). DESIGN: Oral hygiene assessment and chart abstract conducted on a cross-section of NH residents. SETTING: NHs in North Carolina (N = 14). PARTICIPANTS: NH residents (N = 506). MEASUREMENTS: Descriptive data from the MDS and assessments using three standardized measures: the Plaque Index for Long-Term Care (PI-LTC), the Gingival Index for Long-Term Care (GI-LTC), and the Denture Plaque Index (DPI). RESULTS: Oral hygiene scores averaged 1.7 (of 3) for the PI-LTC, 1.5 (of 4) for the GI-LTC, and 2.2 (of 4) for the DPI. Factors most strongly associated with poor oral hygiene scores included having dementia, being on hospice care, and longer stay. MDS ratings of gingivitis differed significantly from oral hygiene assessments. CONCLUSIONS: The findings identify resident subgroups at especially high risk of poor oral health who can be targeted in quality improvement efforts related to oral hygiene; they also indicate need to improve the accuracy of how MDS items are completed.

Challenges of improving oral health for adults in care homes.

In 2016 the National Institute for Health and Care Excellence (NICE) published a guideline on oral health for adults in care homes in England. The author was a co-opted member of the NICE oral health for adults in care homes public health advisory committee. This article reviews the NICE guideline as it applies to care homes, and relates it to the results of a survey of oral care practice undertaken in a large care home organisation and the available research literature from the past 20 years. The literature and survey results suggest that, if translated into practice, the NICE guideline could do much to improve oral health for adults in care homes. The survey highlighted that 85% of residents required support from carers to undertake mouth care. It also found that care homes experienced significant difficulties in accessing dental services for residents. The author concludes that providers need to equip staff with the necessary knowledge and skills to undertake mouth care and to give this area of personal care greater priority. Finally, the author suggests that the Care Quality Commission could ensure that the NICE guideline is translated into practice in care homes.

Examination of intensive care unit patients' oral health.

BACKGROUND: Oral health problems are common complications that most intensive care unit patients experience. There are many factors that affect oral health negatively and nurses have important responsibilities in this regard. AIM: The aim of this study was assessment of the intensive care unit patients' oral health and risk factors. METHODS: This study was planned as a descriptive study and conducted between December 2015 and June 2016, with 202 patients in 20 intensive care units of 6 hospitals in Turkey. Data were collected via Data Collection Form and Bedside Oral Exam guide. Oral health assessment of patients was made using a source of light and a tongue depressor. RESULTS: We observed a significant difference in score of the Bedside Oral Exam guide by age, consciousness, type of respiration and feeding, the frequency of oral health, the total number of drugs, and technique of oral care (P < 0.05). None of the intensive care units were using the oral assessment guide. CONCLUSION: The result of this study shows that there are various risk factors that adversely affect the oral health of intensive care unit patients. Nurses should undertake assessments on the basis of oral care protocols for patients at risk and carry out evidence-based individualized oral care applications.

Directly observed daily mouth care provided to care home residents in one area of Kent, UK.

OBJECTIVE: To gather accurate data on the daily mouth care provided in care homes including tooth brushing, oral health assessment, and recording of care provided. BASIC RESEARCH DESIGN: Direct observation and notes review. CLINICAL SETTING: Both nursing and 'regular' care homes. PARTICIPANTS: 365 Residents living in 16 care homes and their carers underwent observation, notes review or data collection in some form. MAIN OUTCOME MEASURES: Provision of mouth morning care. RESULTS: Of 161 residents observed, most (93, 58%) did not have their teeth/dentures brushed. If performed, brushing was often carried out by the resident themselves (36 cases, 53%), rather than by a carer (32 cases, 44%). Carers used a toothbrush to clean inside a resident's mouth in just 7 cases (4.3% of all personal care routines observed). Smaller care homes were no more likely to brush residents teeth than larger care homes, and nursing homes were no more likely to brush teeth than other care homes. Of the 309 sets of notes available for review, 41 (13%) contained a dedicated oral health needs assessment, and 109 (35%) contained a daily oral care chart in some form. Mouth care was often recorded inaccurately (15% of cases). CONCLUSIONS: This is the first observational study in the UK to assess oral care actually provided to residents by carers in care homes. The findings reveal a substantially different picture of daily mouth care than was previously understood and suggest that many of the nation's care home residents may not be receiving adequate, or any, oral health care.

Part 1: Diagnosis of oral diseases in the housebound patient.

Oral disease is common the housebound population ( Tomson et al, 2015 ). There can be a significant impact on the wellbeing of a housebound individuals ( Locker et al, 2000 ), who tend to be elderly, with poorer systemic health ( Qiu et al, 2010 ) and barriers to accessing care ( Freeman, 1999 ). Access to dental care can be limited (Fox, 2010) and prevention of oral disease is therefore paramount. Community nurses are in an excellent position to promote good oral care to the housebound patient and to support family in carers in preventing oral disease. This initial article in a series aims to provide information on common oral conditions with the next focusing on prevention and the role of nursing team.