EMPIRICAL STUDIES
doi: 10.1111/scs.12230
Hospitalisation impacts on oral hygiene: an audit of oral hygiene in a metropolitan health service Rachael Danckert DipOralHlthTher (DentHyg), DipOralHlthTher (DentTher) (Dental Team Leader)1, Anna Ryan PGCertHlthSerMan,BSpPath (Hon) (Senior Speech Pathologist)2, Virginia Plummer PhD, MSc (HlthPol&Man), BN (Assoc Prof Nursing Research)3,4 and Cylie Williams PhD, MHlthSc(HlthEd&Prom), BAppSc(Pod) (Research & Evaluation Coordinator)1,4 Peninsula Health – Community Health, Frankston, Vic., Australia, 2Peninsula Health – Speech Pathology Department, Frankston, Vic., Australia, 3Peninsula Health – Continuing Education Development Unit, Frankston, Vic., Australia and 4Monash University – Faculty of Medicine, Nursing and Health Sciences, Frankston, Vic., Australia
1
Scand J Caring Sci; 2016; 30; 129–134 Hospitalisation impacts on oral hygiene: an audit of oral hygiene in a metropolitan health service
Background: Poor oral health has been associated with systemic diseases, morbidity and mortality. Many patients in hospital environments are physically compromised and rely upon awareness and assistance from health professionals for the maintenance or improvement of their oral health. This study aimed to identify whether common individual and environment factors associated with hospitalisation impacted on oral hygiene. Methods: Data were collected during point prevalence audits of patients in the acute and rehabilitation environments on three separate occasions. Data included demographic information, plaque score, presence of dental hygiene products, independence level and whether nurse assistance was documented in the health record.
Introduction Good oral hygiene is essential for general health and well-being. Ageing and illness often impacts on independence, and many people in hospital find themselves reliant on carers and healthcare professionals for activities of daily living including oral hygiene (1). Poor oral health has been associated with difficulties in swallowing, poor nutritional intake, impacting speech clarity and infections (2). There are also physiological changes in the body resulting in a slowing of saliva production with age (3) while illness and medications also change the mouth flora. These changes in the mouth often lead to an Correspondence to: Cylie Williams, Peninsula Health – Community Health, PO Box 52, Frankston, Vic. 3199, Australia. E-mail: [email protected] © 2015 Nordic College of Caring Science
Results: Data were collected for 199 patients. A higher plaque score was associated with not having a toothbrush (p = 0.002), being male (p = 0.007), being acutely unwell (p = 0.025) and requiring nursing assistance for oral hygiene (p = 0.002). There was fair agreement between the documentation of requiring assistance for oral care and the patient independently able to perform oral hygiene (ICC = 0.22). Conclusion: Oral hygiene was impacted by factors arising from hospitalisation, for those without a toothbrush and male patients of acute wards. Establishment of practices that increase awareness and promote good oral health should be prioritised. Keywords: audit, dental, hospital, independence, nursing, plaque, quantitative. Submitted 14 October 2014, Accepted 24 February 2015
increase in bacterial numbers within the plaque build-up (4). Dental plaque is an accumulation of debris that naturally occurs over the teeth and is most commonly associated with poor dental hygiene. It is a type of biofilm that contributes to the natural defence mechanisms in the mouth (4). Plaque composition and microflora are affected by diet, oral hygiene and saliva flow. A change or disturbance in these factors often has a negative affect on the plaque composition and amount (4). The most common method of controlling plaque build-up is through mechanical removal with a toothbrush. Plaque build-up has been associated with systemic infections (5, 6), cardiovascular disease (7), adverse pregnancy outcomes (8), respiratory diseases (9) and aspiration pneumonia (10). The physical inability to brush teeth during illness, hospitalisation or with functional decline can also 129
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contribute to the challenge of mechanically removing plaque. In a systematic review of the literature on the preventative effect of oral hygiene, it was found that approximately one in every 10 cases of pneumoniarelated death in nursing home residents may have been prevented with assisted oral hygiene (11). Many patients in the hospital setting have physical, cognitive or environmental challenges to performing oral hygiene and must rely upon hospital staff for the maintenance or improvement of their oral hygiene. This study aimed to identify whether common individual and environment factors associated with hospitalisation impacted on oral hygiene as measured by the amount of plaque accumulation.
Methodology Study design This was a cross-sectional study.
Participants and setting Patients were invited to participate in the oral hygiene audit if they were aged 18 or over, able to consent, had one or more natural teeth or regularly wore full or partial denture and were an inpatient of the health service for more than three consecutive days. The health service provides inpatient care across four sites. This audit was conducted at both acute hospitals and rehabilitation hospitals over a 12-month period in 2013. No patients were invited to participate in more than one point prevalence audit if they transitioned from acute to rehabilitation during the audit times. The study was undertaken by an interprofessional team of dentist, dental hygienist, speech pathologist, nurse and researcher.
Measurements General participant demographics were collected from the health record including age, gender, length of stay, acute or rehabilitation environment, level of independence with activities of daily living (independence on getting to bathroom without assistance and/or ability to hold and manipulate a toothbrush), and who was the provider of oral hygiene recorded within the health record. Participants were asked whether they had a toothbrush and toothpaste present in hospital. Type of dentition (natural dentition and/or dentures) was visualised by the researchers. The Plaque Index (12) was used for recording the amount of plaque present. The Plaque Index is a four-point scale from zero to three and is the most commonly used scale within dental clinical practice internationally, to describe the accumulation of plaque on teeth. The score of 0 indicates no plaque is present, and a score of 3 means the
majority of the tooth is covered in plaque. The Plaque Index has good to excellent intrarater reliability dependent on the level of periodontal disease (r = 0.47–0.83) (13).
Procedure Following consent, the participant’s details were recorded and the participant was asked whether they had brushed their teeth that day and whether they had toothbrush and toothpaste with them in hospital. If the participant was unable to leave their bed or required assistance to go to the bathroom, they were recorded as dependent on nursing staff for oral hygiene. Similarly, they were also recorded as dependent on nursing staff if they had an upper body injury or other physical condition that prevented them from brushing their teeth. The health record was audited to determine whether it was documented that the participant required nursing assistance to perform oral hygiene or this was independently performed. The Functional Measure of Independence (FIM) (14) was additionally recorded for those participants within the rehabilitation setting. The FIM measure is taken on admission and at discharge as a reliable measure of functional independence and is routinely used within the rehabilitation setting to guide health professionals on personal care assistance required. In acute care wards, nursing care pathways are used to prompt and record the requirement for nursing assistance with oral hygiene, but these recording measures were not reliably used within the acute setting. There were a large number of care pathways found within nursing documentation, and not all included dental hygiene as an element of care to be provided by nursing staff if the patient was unable to do so themselves. For example, oral hygiene prompts were absent from the generic surgical care pathway but present in palliative care, stroke, generic medical and specific surgical pathways such as total hip replacement. To ensure consistency in recording, a single dentist visually inspected each participant’s mouth and recorded the Plaque Index. The Human Research Ethics Committee of Peninsula Health approved this study.
Analysis Data were analysed using STATA IC (version 11) (15). Differences between the populations were initially calculated with t-tests and chi-squared analysis. A univariable analysis was undertaken to examine whether a single variable influenced the plaque score recorded by dental staff. A multivariable regression analysis was undertaken to examine whether multiple variables influenced the plaque score or whether a combination of these factors together increased the plaque score. The multivariable regression analysis used a backward stepwise method and © 2015 Nordic College of Caring Science
Hospitalisation impacts on oral hygiene the nonsignificant variables removed at each step (16). Variables in the final model were significant at the level of p < 0.05. Agreement between the documentation of dependence and measured dependence was determined via the Kappa statistic. The level of agreement was scaled where 0 was the amount of agreement that would be accepted by chance and 1 was the perfect agreement, a value above 0.70 was considered to be adequate.
Results There were a total of 199 participants within the acute and rehabilitation settings from a total of 234 patients who were eligible to participate. Table 1 displays a breakdown of demographics between the two groups and the univariable analysis results for each of the variables. When comparing the populations from each setting, there were more males (p = 0.016), a higher mean plaque score (p = 0.004), more younger patients (p = 0.016) and more patients documented as requiring nursing assistance (p < 0.001) within the acute setting compared to the rehabilitation setting. Table 2 displays the multivariable analysis and found that participants were more likely to have a higher Plaque Index score if they had one or more of the following variables: were in the acute setting, were male, did not have a toothbrush and were audited as dependent on nursing staff to perform oral hygiene. There was only fair agreement between the documentation within nursing records of participants who required support with oral hygiene and those audited as being unable to perform oral hygiene independently without nursing assistance (Kappa = 0.22).
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Discussion This study determined that individual factors related to having the poorest oral hygiene amongst hospital inpatients were being acutely unwell, dependent on nursing staff for assistance, being male and not having a toothbrush present. This is the first study that has specifically looked at these factors as being associated with oral health. As oral health is linked to overall health, systemic disease and all-cause mortality, hospital setting needs to encourage good mouth, teeth and gum cleaning. By having a lower plaque score and good oral hygiene, a patient will have fewer bacteria in the mouth. Oral hygiene is also linked to patient nutrition and recovery, which is a primary focus for hospital discharge. It was unsurprising to find some of the environmental factors that were identified as being associated with poor oral health. Participants who had no access to a toothbrush and toothpaste showed a higher plaque score. Brushing teeth regularly with a toothbrush and toothpaste either autonomously (17) or by a care giver (18) is an effective method of removing plaque. Having oral hygiene products available to patients on request or noted absence of dental hygiene products or prompting the patient or a family member to bring a toothbrush and tooth paste into the hospital may be an easy, effective and cost-effective way to reduce the plaque score. This study determined that the hospital environment can have an effect on people’s oral hygiene if the acutely unwell patients have not been able to bring in their own toothbrush or their toothbrush is located in a place that they are unable to access without additional support. Consideration should be given to prioritising the supply,
Table 1 Demographics and association between variable and plaque score Acute
Number of participants Age (years) Gender (male) Length of stay (days) Plaque Index Participants with partial or full dentures Participants with toothpaste Participants with toothbrush Recorded in health record as requiring nursing assistance to perform dental hygiene Participants assessed as requiring assistance to perform dental hygiene
Rehabilitation
Mean or n
SD or %
Range
115 71.85 58 11.83 1.85 69
15.69 50% 12.50 0.93 60%
19–100
101 101 31
69
© 2015 Nordic College of Caring Science
Association between variable and Plaque Index Coeff, [95% conf], p value
Mean or n
SD or %
Range
84 76.74 28 13.48 1.5 57
11.22 33% 10.25 0.69 68%
58–100
88% 88% 27%
73 74 0
87% 87% 0%
0.669 [0.315, 1.022], p < 0.001 0.522 [0.170, 0.875], p = 0.004 0.428 [ 0.751, 0.104], p = 0.10
59%
41
36%
0.480 [ 0.710,
3–91 0–4
6–77 0–4
0.352 [ 0.589, 0.116], p = 0.004 0.002, [ 0.006, 0.011], p = 0.618 0.358 [ 0.594, 0.123], p = 0.003 0.0021 [ 0.012, 0.008], p = 0.682 0.041 [ 0.176, 0.094], p = 0.551
0.250], p < 0.001
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Table 2 Multivariant Regression analysis determination of association between variables and plaque score
Variable Environment (i.e. acute vs. rehabilitation) Gender Toothbrush Requiring assistance
Plaque score Coeff, [95% conf], p value 0.257 [ 0.482, 0.32], p = 0.025 0.308 [ 0.531, 0.085], p = 0.007 0.556, [0.214, 0.897], p = 0.002 0.366, [ 0.591, 0.141], p = 0.002
prompting the location or providing a toothbrush to patients and determining whether they are unable to brush their own teeth or if assistance is required. Plaque scores were higher in the acute setting: therefore, in people assessed as being more unwell or medically unstable than those in a rehabilitation setting. This is the first time this has been reported within the literature. This higher plaque score may be associated with higher dependency on staff for care and patients who may have less routine whilst an inpatient, compared to those in a rehabilitation ward. Factors in nursing staff attitudes, knowledge and culture may also influence practices in oral care between wards; however, these were not measured within this project. During times of acute illness, an increase in transfers between wards or other specialty units for tests, visiting specialists or health service providers may make it difficult for patients to self-care or nursing to assist with care. There were different documentation methods between the environments, and this may have resulted in different prompts and records for care. Poor oral health has been associated with infection and systemic disease; therefore, hospitals should endeavour to minimise the risk of these amongst all patients, but particularly those in acute settings as they may be considered more medically vulnerable. The dependency status of the patient on nursing staff also impacted oral hygiene, and there was only fair correlation between what was recorded by nursing as independence levels and patients’ ability to independently perform oral hygiene. Dependency on nursing staff for oral hygiene has been explored within nursing home settings (19), patients with dementia (20) and patients who are in intensive care (21, 22). Recommendations from these studies included increased nursing education on the importance of oral hygiene and documentation within health records to support nursing staff in undertaking oral hygiene for patients. However, there have not been any studies exploring the dental hygiene within general hospital wards with acutely unwell patients. Based on the results within this study, a process that includes oral hygiene when classifying patients’ levels of independence with activities of daily living would be useful for nursing and allied health staff to use. When a patient’s dependency on nursing staff is accurately
recorded by either nursing or allied health staff to reflect their capabilities, nursing staff can provide appropriate levels of assistance for their patient’s teeth cleaning. Nursing staff have previously been found to have negative attitudes about performing oral hygiene with dependent patients; however, understanding how oral hygiene impacts health has been found to minimise this risk and actively engage in oral care (23, 24). A limitation of this project was that there were no baseline data of patient oral hygiene prior to admission or review of oral hygiene across the hospital stay. Another was that medication lists were not included within the audit. While daily brushing will remove plaque, there is a potential for medication interference with normal oral pH and/or saliva production. This may have an effect on oral hygiene and plaque accumulation. The data of patients who were unable to provide consent were also not captured. This group of patients are often more dependent on healthcare staff and may be at increased risk of poor oral health, and therefore, audit results may under-represent the true incidence of poor oral hygiene within the inpatient hospital environment (25). Future research should consider documentation changes together with education about the importance of oral hygiene for nursing staff. These changes should be evaluated for effectiveness of impact on oral hygiene, especially for those patients within the higher risk groups (the acutely unwell, older males). Mapping the patient journey may also be another way to determine the relationship between the individual factors and environmental factors on oral hygiene in the health service. Different time points and changes in dependency levels across the continuum of care would assist understanding of changes in oral hygiene during illness. Medication reviews during these audits would also assist in understanding any potential impact of mouth pH and saliva changes on plaque during times of illness. There is also the potential that hospital administration and systems can impact the oral hygiene of patients by implementing strategies to encourage people to bring in their toothbrush and toothpaste or to supply patients without oral hygiene equipment at the bedside and on admission. A standardised hospital-wide process for regularly reviewing a patient’s dependency for tasks including oral care would assist nursing staff to accurately support the patient in all aspects of their care and recovery.
Conclusion In this study, those most likely to have poor oral hygiene were patients within the acute care environment, those more dependent on nursing staff for activities of daily living, those without a toothbrush and males. Oral hygiene can significantly impact on health, © 2015 Nordic College of Caring Science
Hospitalisation impacts on oral hygiene
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and systems should be put in place to support patients to brush their teeth.
drafted the manuscript and approved the final version of the manuscript to be published.
Acknowledgements
Ethical approval
Dr. Niranjan Shekar assisted in the data collection methodology and ethics application, Dr. Lily Milczarek-Todorovska undertook the audit, Ms. Susan McKinlay provided backfill of clinical load to allow clinicians undertake the project.
This research project was approved by the Human Research Ethics Committee of Peninsula Health, Victoria, Australia (LNR/13/PH/2).
Funding Nil.
Author contribution RD and AR conceived the study and collected the data. CW analysed the data. All authors interpreted the data,
References 1 Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: “She was probably able to ambulate, but I’m not sure”. JAMA 2011; 306: 1782–93. 2 Bissett S, Preshaw P. Guide to providing mouth care for older people. Nurs Older People 2011; 23: 14–21. 3 Percival RS, Challacombe SJ, Marsh PD. Flow rates of resting whole and stimulated parotid saliva in relation to age and gender. J Dent Res 1994; 73: 1416–20. 4 Marsh PD. Dental plaque as a biofilm and a microbial community - implications for health and disease. BMC Oral Health 2006; 6(Suppl 1): S14. 5 Scannapieco FA, Bush RB, Paju S. Associations between periodontal disease and risk for nosocomial bacterial pneumonia and chronic obstructive pulmonary disease. A systematic review. Ann Periodontol 2003; 8: 54–69. 6 Li X, Kolltveit KM, Tronstad L, Olsen I. Systemic diseases caused by oral infection. Clin Microbiol Rev 2000; 13: 547–58. 7 Scannapieco FA, Bush RB, Paju S. Associations between periodontal disease and risk for atherosclerosis, cardiovascular disease, and stroke. A systematic review. Ann Periodontol 2003; 8: 38–53. 8 Scannapieco FA, Bush RB, Paju S. Periodontal disease as a risk factor for adverse pregnancy outcomes. A systematic review. Ann Periodontol 2003; 8: 70–8. 9 Scannapieco FA, Ho AW. Potential associations between chronic
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10
11
12
13
14
15
16
respiratory disease and periodontal disease: analysis of National Health and Nutrition Examination Survey III. J Periodontol 2001; 72: 50–6. Terpenning MS, Taylor GW, Lopatin DE, Kerr CK, Dominguez BL, Loesche WJ. Aspiration pneumonia: dental and oral risk factors in an older veteran population. J Am Geriatr Soc 2001; 49: 557–63. Sjogren P, Nilsson E, Forsell M, Johansson O, Hoogstraate J. A systematic review of the preventive effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes: effect estimates and methodological quality of randomized controlled trials. J Am Geriatr Soc 2008; 56: 2124–30. Silness J, Loe H. Periodontal disease in pregnancy. Ii. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand 1964; 22: 121–35. Kingman A, Loe H, Boysen H. Errors in measuring parameters associated with periodontal health and disease. J Periodontol 1991; 62: 477–86. Hamilton BB, Laughlin JA, Fiedler RC, Granger CV. Interrater reliability of the 7-level functional independence measure (FIM). Scand J Rehabil Med 1994; 26: 115–9. StataCorp: Stata Statistical Software: Release 13. In., vol. 11. 2013, StataCorp LP, College Station, TX. Hosmer DW, Hosmer T, Le Cessie S, Lemeshow S. A comparison of goodness-of-fit tests for the logistic regression model. Stat Med 1997; 16: 965–80.
17 Crocombe LA, Brennan DS, Slade GD, Loc DO. Is self interdental cleaning associated with dental plaque levels, dental calculus, gingivitis and periodontal disease? J Periodontal Res 2012; 47: 188–97. 18 Le P, Dempster L, Limeback H, Locker D. Improving resident’ oral health through staff education in nursing homes. Spec Care Dentist 2012; 32: 242–50. 19 Fitzpatrick J. Oral health care needs of dependent older people: responsibilities of nurses and care staff. J Adv Nurs 2000; 32: 1325–32. 20 Nordenram G, R€ onnberg L, Winblad B. The perceived importance of appearance and oral function, comfort and health for severely demented persons rated by relatives, nursing staff and hospital dentists. Gerodontology 1994; 11: 18–24. 21 Grap MJ, Munro CL, Ashtiani B, Bryant S. Oral care interventions in critical care: frequency and documentation. Am J Crit Care 2003; 12: 113–8. 22 Alhazzani W, Smith O, Muscedere J, Medd J, Cook D. Toothbrushing for critically Ill mechanically ventilated patients: a systematic review and meta-analysis of randomized trials evaluating ventilator-associated pneumonia. Crit Care Med 2013; 41: 646–55. 23 Czarkowski G, Allroggen S, KosterSchmidt A, Bausback-Schomakers S, Frank M, Heudorf U. Oral health hygiene education programme for nursing personnel to improve oral health of residents in long-term care facilities 2010 in Frankfurt/Main,
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Germany. Gesundheitswesen 2013; 75: 368–75. 24 Wardh I, Andersson L, Sorensen S. Staff attitudes to oral health care. A
comparative study of registered nurses, nursing assistants and home care aides. Gerodontology 1997; 14: 28–32.
25 Pearson A, Chalmers J. Oral hygiene care for adults with dementia in residential aged care facilities. JBI Reports 2004; 2: 65–113.
© 2015 Nordic College of Caring Science
doi: 10.1111/scs.12230
Hospitalisation impacts on oral hygiene: an audit of oral hygiene in a metropolitan health service Rachael Danckert DipOralHlthTher (DentHyg), DipOralHlthTher (DentTher) (Dental Team Leader)1, Anna Ryan PGCertHlthSerMan,BSpPath (Hon) (Senior Speech Pathologist)2, Virginia Plummer PhD, MSc (HlthPol&Man), BN (Assoc Prof Nursing Research)3,4 and Cylie Williams PhD, MHlthSc(HlthEd&Prom), BAppSc(Pod) (Research & Evaluation Coordinator)1,4 Peninsula Health – Community Health, Frankston, Vic., Australia, 2Peninsula Health – Speech Pathology Department, Frankston, Vic., Australia, 3Peninsula Health – Continuing Education Development Unit, Frankston, Vic., Australia and 4Monash University – Faculty of Medicine, Nursing and Health Sciences, Frankston, Vic., Australia
1
Scand J Caring Sci; 2016; 30; 129–134 Hospitalisation impacts on oral hygiene: an audit of oral hygiene in a metropolitan health service
Background: Poor oral health has been associated with systemic diseases, morbidity and mortality. Many patients in hospital environments are physically compromised and rely upon awareness and assistance from health professionals for the maintenance or improvement of their oral health. This study aimed to identify whether common individual and environment factors associated with hospitalisation impacted on oral hygiene. Methods: Data were collected during point prevalence audits of patients in the acute and rehabilitation environments on three separate occasions. Data included demographic information, plaque score, presence of dental hygiene products, independence level and whether nurse assistance was documented in the health record.
Introduction Good oral hygiene is essential for general health and well-being. Ageing and illness often impacts on independence, and many people in hospital find themselves reliant on carers and healthcare professionals for activities of daily living including oral hygiene (1). Poor oral health has been associated with difficulties in swallowing, poor nutritional intake, impacting speech clarity and infections (2). There are also physiological changes in the body resulting in a slowing of saliva production with age (3) while illness and medications also change the mouth flora. These changes in the mouth often lead to an Correspondence to: Cylie Williams, Peninsula Health – Community Health, PO Box 52, Frankston, Vic. 3199, Australia. E-mail: [email protected] © 2015 Nordic College of Caring Science
Results: Data were collected for 199 patients. A higher plaque score was associated with not having a toothbrush (p = 0.002), being male (p = 0.007), being acutely unwell (p = 0.025) and requiring nursing assistance for oral hygiene (p = 0.002). There was fair agreement between the documentation of requiring assistance for oral care and the patient independently able to perform oral hygiene (ICC = 0.22). Conclusion: Oral hygiene was impacted by factors arising from hospitalisation, for those without a toothbrush and male patients of acute wards. Establishment of practices that increase awareness and promote good oral health should be prioritised. Keywords: audit, dental, hospital, independence, nursing, plaque, quantitative. Submitted 14 October 2014, Accepted 24 February 2015
increase in bacterial numbers within the plaque build-up (4). Dental plaque is an accumulation of debris that naturally occurs over the teeth and is most commonly associated with poor dental hygiene. It is a type of biofilm that contributes to the natural defence mechanisms in the mouth (4). Plaque composition and microflora are affected by diet, oral hygiene and saliva flow. A change or disturbance in these factors often has a negative affect on the plaque composition and amount (4). The most common method of controlling plaque build-up is through mechanical removal with a toothbrush. Plaque build-up has been associated with systemic infections (5, 6), cardiovascular disease (7), adverse pregnancy outcomes (8), respiratory diseases (9) and aspiration pneumonia (10). The physical inability to brush teeth during illness, hospitalisation or with functional decline can also 129
130
R. Danckert et al.
contribute to the challenge of mechanically removing plaque. In a systematic review of the literature on the preventative effect of oral hygiene, it was found that approximately one in every 10 cases of pneumoniarelated death in nursing home residents may have been prevented with assisted oral hygiene (11). Many patients in the hospital setting have physical, cognitive or environmental challenges to performing oral hygiene and must rely upon hospital staff for the maintenance or improvement of their oral hygiene. This study aimed to identify whether common individual and environment factors associated with hospitalisation impacted on oral hygiene as measured by the amount of plaque accumulation.
Methodology Study design This was a cross-sectional study.
Participants and setting Patients were invited to participate in the oral hygiene audit if they were aged 18 or over, able to consent, had one or more natural teeth or regularly wore full or partial denture and were an inpatient of the health service for more than three consecutive days. The health service provides inpatient care across four sites. This audit was conducted at both acute hospitals and rehabilitation hospitals over a 12-month period in 2013. No patients were invited to participate in more than one point prevalence audit if they transitioned from acute to rehabilitation during the audit times. The study was undertaken by an interprofessional team of dentist, dental hygienist, speech pathologist, nurse and researcher.
Measurements General participant demographics were collected from the health record including age, gender, length of stay, acute or rehabilitation environment, level of independence with activities of daily living (independence on getting to bathroom without assistance and/or ability to hold and manipulate a toothbrush), and who was the provider of oral hygiene recorded within the health record. Participants were asked whether they had a toothbrush and toothpaste present in hospital. Type of dentition (natural dentition and/or dentures) was visualised by the researchers. The Plaque Index (12) was used for recording the amount of plaque present. The Plaque Index is a four-point scale from zero to three and is the most commonly used scale within dental clinical practice internationally, to describe the accumulation of plaque on teeth. The score of 0 indicates no plaque is present, and a score of 3 means the
majority of the tooth is covered in plaque. The Plaque Index has good to excellent intrarater reliability dependent on the level of periodontal disease (r = 0.47–0.83) (13).
Procedure Following consent, the participant’s details were recorded and the participant was asked whether they had brushed their teeth that day and whether they had toothbrush and toothpaste with them in hospital. If the participant was unable to leave their bed or required assistance to go to the bathroom, they were recorded as dependent on nursing staff for oral hygiene. Similarly, they were also recorded as dependent on nursing staff if they had an upper body injury or other physical condition that prevented them from brushing their teeth. The health record was audited to determine whether it was documented that the participant required nursing assistance to perform oral hygiene or this was independently performed. The Functional Measure of Independence (FIM) (14) was additionally recorded for those participants within the rehabilitation setting. The FIM measure is taken on admission and at discharge as a reliable measure of functional independence and is routinely used within the rehabilitation setting to guide health professionals on personal care assistance required. In acute care wards, nursing care pathways are used to prompt and record the requirement for nursing assistance with oral hygiene, but these recording measures were not reliably used within the acute setting. There were a large number of care pathways found within nursing documentation, and not all included dental hygiene as an element of care to be provided by nursing staff if the patient was unable to do so themselves. For example, oral hygiene prompts were absent from the generic surgical care pathway but present in palliative care, stroke, generic medical and specific surgical pathways such as total hip replacement. To ensure consistency in recording, a single dentist visually inspected each participant’s mouth and recorded the Plaque Index. The Human Research Ethics Committee of Peninsula Health approved this study.
Analysis Data were analysed using STATA IC (version 11) (15). Differences between the populations were initially calculated with t-tests and chi-squared analysis. A univariable analysis was undertaken to examine whether a single variable influenced the plaque score recorded by dental staff. A multivariable regression analysis was undertaken to examine whether multiple variables influenced the plaque score or whether a combination of these factors together increased the plaque score. The multivariable regression analysis used a backward stepwise method and © 2015 Nordic College of Caring Science
Hospitalisation impacts on oral hygiene the nonsignificant variables removed at each step (16). Variables in the final model were significant at the level of p < 0.05. Agreement between the documentation of dependence and measured dependence was determined via the Kappa statistic. The level of agreement was scaled where 0 was the amount of agreement that would be accepted by chance and 1 was the perfect agreement, a value above 0.70 was considered to be adequate.
Results There were a total of 199 participants within the acute and rehabilitation settings from a total of 234 patients who were eligible to participate. Table 1 displays a breakdown of demographics between the two groups and the univariable analysis results for each of the variables. When comparing the populations from each setting, there were more males (p = 0.016), a higher mean plaque score (p = 0.004), more younger patients (p = 0.016) and more patients documented as requiring nursing assistance (p < 0.001) within the acute setting compared to the rehabilitation setting. Table 2 displays the multivariable analysis and found that participants were more likely to have a higher Plaque Index score if they had one or more of the following variables: were in the acute setting, were male, did not have a toothbrush and were audited as dependent on nursing staff to perform oral hygiene. There was only fair agreement between the documentation within nursing records of participants who required support with oral hygiene and those audited as being unable to perform oral hygiene independently without nursing assistance (Kappa = 0.22).
131
Discussion This study determined that individual factors related to having the poorest oral hygiene amongst hospital inpatients were being acutely unwell, dependent on nursing staff for assistance, being male and not having a toothbrush present. This is the first study that has specifically looked at these factors as being associated with oral health. As oral health is linked to overall health, systemic disease and all-cause mortality, hospital setting needs to encourage good mouth, teeth and gum cleaning. By having a lower plaque score and good oral hygiene, a patient will have fewer bacteria in the mouth. Oral hygiene is also linked to patient nutrition and recovery, which is a primary focus for hospital discharge. It was unsurprising to find some of the environmental factors that were identified as being associated with poor oral health. Participants who had no access to a toothbrush and toothpaste showed a higher plaque score. Brushing teeth regularly with a toothbrush and toothpaste either autonomously (17) or by a care giver (18) is an effective method of removing plaque. Having oral hygiene products available to patients on request or noted absence of dental hygiene products or prompting the patient or a family member to bring a toothbrush and tooth paste into the hospital may be an easy, effective and cost-effective way to reduce the plaque score. This study determined that the hospital environment can have an effect on people’s oral hygiene if the acutely unwell patients have not been able to bring in their own toothbrush or their toothbrush is located in a place that they are unable to access without additional support. Consideration should be given to prioritising the supply,
Table 1 Demographics and association between variable and plaque score Acute
Number of participants Age (years) Gender (male) Length of stay (days) Plaque Index Participants with partial or full dentures Participants with toothpaste Participants with toothbrush Recorded in health record as requiring nursing assistance to perform dental hygiene Participants assessed as requiring assistance to perform dental hygiene
Rehabilitation
Mean or n
SD or %
Range
115 71.85 58 11.83 1.85 69
15.69 50% 12.50 0.93 60%
19–100
101 101 31
69
© 2015 Nordic College of Caring Science
Association between variable and Plaque Index Coeff, [95% conf], p value
Mean or n
SD or %
Range
84 76.74 28 13.48 1.5 57
11.22 33% 10.25 0.69 68%
58–100
88% 88% 27%
73 74 0
87% 87% 0%
0.669 [0.315, 1.022], p < 0.001 0.522 [0.170, 0.875], p = 0.004 0.428 [ 0.751, 0.104], p = 0.10
59%
41
36%
0.480 [ 0.710,
3–91 0–4
6–77 0–4
0.352 [ 0.589, 0.116], p = 0.004 0.002, [ 0.006, 0.011], p = 0.618 0.358 [ 0.594, 0.123], p = 0.003 0.0021 [ 0.012, 0.008], p = 0.682 0.041 [ 0.176, 0.094], p = 0.551
0.250], p < 0.001
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Table 2 Multivariant Regression analysis determination of association between variables and plaque score
Variable Environment (i.e. acute vs. rehabilitation) Gender Toothbrush Requiring assistance
Plaque score Coeff, [95% conf], p value 0.257 [ 0.482, 0.32], p = 0.025 0.308 [ 0.531, 0.085], p = 0.007 0.556, [0.214, 0.897], p = 0.002 0.366, [ 0.591, 0.141], p = 0.002
prompting the location or providing a toothbrush to patients and determining whether they are unable to brush their own teeth or if assistance is required. Plaque scores were higher in the acute setting: therefore, in people assessed as being more unwell or medically unstable than those in a rehabilitation setting. This is the first time this has been reported within the literature. This higher plaque score may be associated with higher dependency on staff for care and patients who may have less routine whilst an inpatient, compared to those in a rehabilitation ward. Factors in nursing staff attitudes, knowledge and culture may also influence practices in oral care between wards; however, these were not measured within this project. During times of acute illness, an increase in transfers between wards or other specialty units for tests, visiting specialists or health service providers may make it difficult for patients to self-care or nursing to assist with care. There were different documentation methods between the environments, and this may have resulted in different prompts and records for care. Poor oral health has been associated with infection and systemic disease; therefore, hospitals should endeavour to minimise the risk of these amongst all patients, but particularly those in acute settings as they may be considered more medically vulnerable. The dependency status of the patient on nursing staff also impacted oral hygiene, and there was only fair correlation between what was recorded by nursing as independence levels and patients’ ability to independently perform oral hygiene. Dependency on nursing staff for oral hygiene has been explored within nursing home settings (19), patients with dementia (20) and patients who are in intensive care (21, 22). Recommendations from these studies included increased nursing education on the importance of oral hygiene and documentation within health records to support nursing staff in undertaking oral hygiene for patients. However, there have not been any studies exploring the dental hygiene within general hospital wards with acutely unwell patients. Based on the results within this study, a process that includes oral hygiene when classifying patients’ levels of independence with activities of daily living would be useful for nursing and allied health staff to use. When a patient’s dependency on nursing staff is accurately
recorded by either nursing or allied health staff to reflect their capabilities, nursing staff can provide appropriate levels of assistance for their patient’s teeth cleaning. Nursing staff have previously been found to have negative attitudes about performing oral hygiene with dependent patients; however, understanding how oral hygiene impacts health has been found to minimise this risk and actively engage in oral care (23, 24). A limitation of this project was that there were no baseline data of patient oral hygiene prior to admission or review of oral hygiene across the hospital stay. Another was that medication lists were not included within the audit. While daily brushing will remove plaque, there is a potential for medication interference with normal oral pH and/or saliva production. This may have an effect on oral hygiene and plaque accumulation. The data of patients who were unable to provide consent were also not captured. This group of patients are often more dependent on healthcare staff and may be at increased risk of poor oral health, and therefore, audit results may under-represent the true incidence of poor oral hygiene within the inpatient hospital environment (25). Future research should consider documentation changes together with education about the importance of oral hygiene for nursing staff. These changes should be evaluated for effectiveness of impact on oral hygiene, especially for those patients within the higher risk groups (the acutely unwell, older males). Mapping the patient journey may also be another way to determine the relationship between the individual factors and environmental factors on oral hygiene in the health service. Different time points and changes in dependency levels across the continuum of care would assist understanding of changes in oral hygiene during illness. Medication reviews during these audits would also assist in understanding any potential impact of mouth pH and saliva changes on plaque during times of illness. There is also the potential that hospital administration and systems can impact the oral hygiene of patients by implementing strategies to encourage people to bring in their toothbrush and toothpaste or to supply patients without oral hygiene equipment at the bedside and on admission. A standardised hospital-wide process for regularly reviewing a patient’s dependency for tasks including oral care would assist nursing staff to accurately support the patient in all aspects of their care and recovery.
Conclusion In this study, those most likely to have poor oral hygiene were patients within the acute care environment, those more dependent on nursing staff for activities of daily living, those without a toothbrush and males. Oral hygiene can significantly impact on health, © 2015 Nordic College of Caring Science
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and systems should be put in place to support patients to brush their teeth.
drafted the manuscript and approved the final version of the manuscript to be published.
Acknowledgements
Ethical approval
Dr. Niranjan Shekar assisted in the data collection methodology and ethics application, Dr. Lily Milczarek-Todorovska undertook the audit, Ms. Susan McKinlay provided backfill of clinical load to allow clinicians undertake the project.
This research project was approved by the Human Research Ethics Committee of Peninsula Health, Victoria, Australia (LNR/13/PH/2).
Funding Nil.
Author contribution RD and AR conceived the study and collected the data. CW analysed the data. All authors interpreted the data,
References 1 Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: “She was probably able to ambulate, but I’m not sure”. JAMA 2011; 306: 1782–93. 2 Bissett S, Preshaw P. Guide to providing mouth care for older people. Nurs Older People 2011; 23: 14–21. 3 Percival RS, Challacombe SJ, Marsh PD. Flow rates of resting whole and stimulated parotid saliva in relation to age and gender. J Dent Res 1994; 73: 1416–20. 4 Marsh PD. Dental plaque as a biofilm and a microbial community - implications for health and disease. BMC Oral Health 2006; 6(Suppl 1): S14. 5 Scannapieco FA, Bush RB, Paju S. Associations between periodontal disease and risk for nosocomial bacterial pneumonia and chronic obstructive pulmonary disease. A systematic review. Ann Periodontol 2003; 8: 54–69. 6 Li X, Kolltveit KM, Tronstad L, Olsen I. Systemic diseases caused by oral infection. Clin Microbiol Rev 2000; 13: 547–58. 7 Scannapieco FA, Bush RB, Paju S. Associations between periodontal disease and risk for atherosclerosis, cardiovascular disease, and stroke. A systematic review. Ann Periodontol 2003; 8: 38–53. 8 Scannapieco FA, Bush RB, Paju S. Periodontal disease as a risk factor for adverse pregnancy outcomes. A systematic review. Ann Periodontol 2003; 8: 70–8. 9 Scannapieco FA, Ho AW. Potential associations between chronic
© 2015 Nordic College of Caring Science
10
11
12
13
14
15
16
respiratory disease and periodontal disease: analysis of National Health and Nutrition Examination Survey III. J Periodontol 2001; 72: 50–6. Terpenning MS, Taylor GW, Lopatin DE, Kerr CK, Dominguez BL, Loesche WJ. Aspiration pneumonia: dental and oral risk factors in an older veteran population. J Am Geriatr Soc 2001; 49: 557–63. Sjogren P, Nilsson E, Forsell M, Johansson O, Hoogstraate J. A systematic review of the preventive effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes: effect estimates and methodological quality of randomized controlled trials. J Am Geriatr Soc 2008; 56: 2124–30. Silness J, Loe H. Periodontal disease in pregnancy. Ii. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand 1964; 22: 121–35. Kingman A, Loe H, Boysen H. Errors in measuring parameters associated with periodontal health and disease. J Periodontol 1991; 62: 477–86. Hamilton BB, Laughlin JA, Fiedler RC, Granger CV. Interrater reliability of the 7-level functional independence measure (FIM). Scand J Rehabil Med 1994; 26: 115–9. StataCorp: Stata Statistical Software: Release 13. In., vol. 11. 2013, StataCorp LP, College Station, TX. Hosmer DW, Hosmer T, Le Cessie S, Lemeshow S. A comparison of goodness-of-fit tests for the logistic regression model. Stat Med 1997; 16: 965–80.
17 Crocombe LA, Brennan DS, Slade GD, Loc DO. Is self interdental cleaning associated with dental plaque levels, dental calculus, gingivitis and periodontal disease? J Periodontal Res 2012; 47: 188–97. 18 Le P, Dempster L, Limeback H, Locker D. Improving resident’ oral health through staff education in nursing homes. Spec Care Dentist 2012; 32: 242–50. 19 Fitzpatrick J. Oral health care needs of dependent older people: responsibilities of nurses and care staff. J Adv Nurs 2000; 32: 1325–32. 20 Nordenram G, R€ onnberg L, Winblad B. The perceived importance of appearance and oral function, comfort and health for severely demented persons rated by relatives, nursing staff and hospital dentists. Gerodontology 1994; 11: 18–24. 21 Grap MJ, Munro CL, Ashtiani B, Bryant S. Oral care interventions in critical care: frequency and documentation. Am J Crit Care 2003; 12: 113–8. 22 Alhazzani W, Smith O, Muscedere J, Medd J, Cook D. Toothbrushing for critically Ill mechanically ventilated patients: a systematic review and meta-analysis of randomized trials evaluating ventilator-associated pneumonia. Crit Care Med 2013; 41: 646–55. 23 Czarkowski G, Allroggen S, KosterSchmidt A, Bausback-Schomakers S, Frank M, Heudorf U. Oral health hygiene education programme for nursing personnel to improve oral health of residents in long-term care facilities 2010 in Frankfurt/Main,
134
R. Danckert et al.
Germany. Gesundheitswesen 2013; 75: 368–75. 24 Wardh I, Andersson L, Sorensen S. Staff attitudes to oral health care. A
comparative study of registered nurses, nursing assistants and home care aides. Gerodontology 1997; 14: 28–32.
25 Pearson A, Chalmers J. Oral hygiene care for adults with dementia in residential aged care facilities. JBI Reports 2004; 2: 65–113.
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