The Importance of Oral Care in the Hospitalized Older Adult

Kim Valentine, BSN, RN

Indeed, we can't deny that we work with reduced staff in high acuity settings in our current health care environment. These workload pressures cause us to prioritize elements of care. But should we dismiss the significance of oral care? Perhaps if we truly understand the implications of the lack of oral assessment and care, we may reconsider our prioritization.

Who is at the most risk?

By and large, our patients at most risk are older adults over 65. According to the CDC, adults over 65 comprise 16% of the total population in the United States. But in 2018, they comprised over 35% of hospital admissions. People in this age group are more likely to have existing chronic and comorbid diseases. Due to their aging immune systems, older adults are more susceptible to life-threatening infections. In addition, this age group often depends on health care workers to assist them with the most basic activities of daily living, especially early in their hospital admission¹.

What are the risks?

Research shows that shortly after admission to the hospital, a seriously ill older adult patient will colonize bacteria in oral secretions due to changes in the normal flora and side effects of medications². If not removed by regular oral care, this bacterium will place the older adult patient at greater risk of developing more severe illnesses such as aspiration pneumonia².

If the basics like oral care are not offered or provided, this can lead to other physical complications³.

Ongoing neglect of oral care will lead to periodontal disease, which can be a direct or contributing cause of⁴:

Cardiovascular Disease
Dementia
Memory loss and confusion
Pneumonia
Oral cancer
Hypertension
Renal Disease
Rheumatoid Arthritis
Diabetes

Apart from the physical concerns, there is also the potential for a psychosocial impact. For example, a lack of appropriate oral care can cause difficulty in communication. When a person cannot communicate their needs, delay in treatment, depression, and a poor sense of well-being can result. In addition, oral care is a key comfort measure for the person who is bedbound due to severe illness or receiving palliative care. For example, one study on oral hygiene over one year in hospitalized patients showed that incidents of hospital-acquired pneumonia fell by 92% with twice daily oral care⁴.

Prioritizing Oral Care

As much as we, as nurses, believe that oral care for our patients is our responsibility to ensure, it is often not a top priority. Barriers to oral care in hospitals include lack of awareness, knowledge, time, equipment, and staffing. In addition, the oral examination is often not part of the head-to-toe assessment of our patients. Sometimes it has been noted that nurses find this task particularly unpleasant and may contribute to procrastination. Other times delays are due to confused, combative, or uncooperative patients. Perhaps learning strategies would enable nurses to address this aspect of care more effectively.

Strategies for the patient with complex behaviors:

When possible, ensure the environment is quiet and has few distractions.
Approach the patient with a calm demeanor at eye level.
Engage in pleasant conversation, and don't seem rushed.
Involve the patient to complete the task as able and encourage self-care.
Use the hand-over-hand method to guide mouth care.
If the patient becomes resistant to care, use distraction methods.

Oral Assessment

Including an oral cavity examination as part of the head-to-toe assessment at the beginning of our shift is an excellent place to start.

General assessment may include analysis of:

Lips: Are they smooth or dry and cracked?
Teeth or Dentures: Are they clean or covered in plaque film?
Gums/Mucous Membranes/Palate: Are they moist, inflamed, or dry?
Tongue: Is it pink and wet or coated and cracked?
Saliva: Thick, thin, or no saliva at all?

If your institution does not have a resource, there is a Best Practice Guideline entitled "Oral Health: Supporting Adults Who Require Assistance,” with assessment templates.

Suppose your organization does not provide toothbrushes or other proper oral care supplies. In that case, you may go to your manager with evidence-based information about the importance of good oral care and make a supply request (it can't hurt to try). Most often, foam swabs are supplied for oral care to swab and remove particles in the mouth. Still, critical incidents have been documented as a choking hazard when the foam has become dislodged during care provision so it may be too risky to use⁵. Likewise, glycerine swabs are not advisable as they have been found to erode tooth enamel due to their acidic properties.

Tools for Oral Care

Toothbrushes and toothpaste. If your patient doesn't have any with them on admission, ask families to purchase/provide. Instruct family members to assist and promote oral care for the patient.
Oral rinses. Rinsing follows mechanical tooth cleaning, from simple saline solutions and fluoride mouth rinsing to ones with an antimicrobial or broad-spectrum antiseptic as part of the oral care routine.
Tongue Cleaner: A tongue scraper is a dental tool used to help clean your tongue that can reduce bacteria, but many people use a toothbrush.
Routine: Oral care provided/encouraged after every meal or at least twice a day. Oral care before sleep is essential to reduce the bacterial load since, at night, there is a lower flow of saliva.

The older adult patient in the hospital with complex health issues is particularly vulnerable. They often depend on nurses to provide complex treatments and the very basics of their care. Oral care is an integral part of primary care that, when neglected, can lead to serious health consequences such as aspiration pneumonia. Prioritizing oral care can provide the comfort needed during stressful hospital admission, prevent severe illness, and reduce the prolonged length of stay.

References

¹CDC: Persons with hospital stays in the past year, by selected characteristics: United States, selected years 1997–2018

²Today's Geriatric Medicine: Oral Health and Aspiration Pneumonia

³Journal of Medicine and Life: Potential role of periodontal infection in respiratory diseases - a review

⁴Reducing missed oral care opportunities to prevent non-ventilator associated hospital acquired pneumonia at the Department of Veterans Affairs

⁵International Affairs and Best Practice Guidelines: Oral Health: Supporting Adults Who Require Assistance