ORAL CARE AIDES’ EFFECT ON ORAL MICROFLORA
ARTICLE ABSTRACT The oral health status of elderly dependent residents is reported to be poor, as well as difficult to describe. Analysis of oral microbial flora has been suggested as a suitable measurement method. Oral care aides have been shown to have a positive influence on oral health care in nursing. The outcome of an intervention with oral care aides was followed during a two-year period by recording: (a) the proportion of opportunistic microorganisms and bacteria associated with caries (b) whether oral hygiene assistance were given to the residents or not, and (c) individual experiences concerning oral health care among the staff involved. The oral flora and the amount of oral hygiene assistance improved throughout the entire study period, but staff interviews revealed that it took two years for good cooperation and prophylactic routines to be established. An unexpected finding was the positive correlation (p = .0005) between a high proportion of the opportunistic microorganisms and death within one year.
KEY WORDS: oral health, nursing staff, oral microflora, oral care aides
Long-term effects of using oral care aides at a nursing home for elderly dependent residents—a pilot study Inger M. Wårdh, DDS, PhD;1* Maude B. Wikström, DDS, PhD2 1Department
of Dental Medicine, Gerodontics, Karolinska Institute, Huddinge, Sweden; 2Department of Microbiology, Institute of Odontology, Sahlgrenska Academy, Göteborg, Sweden. *Corresponding author e-mail: [email protected] Spec Care Dentist 34(2): 64-69, 2014
Int r od uct ion
The oral health of elderly dependent residents in nursing homes is reported to be poor, as well as difficult to describe and measure. Poor oral health is associated with functional, psycho-social, and discomfort-related limitations and has negative effects on the quality of life among elderly people.1 Masticatory function disability and oral infections may even be fatal for frail elderly subjects.2,3 In a study, which included more than 400 elderly nursing home patients, inadequate dental status was found associated with high overall mortality, with the main cause of death to be respiratory infections.4 In a literature review by Sjögren et al., it was concluded that when aspiration disorders or dysphagia are present in elderly people in nursing homes, pneumonia has its origin in microorganisms present in the oral flora and may be prevented by improved oral hygiene.5 Caries, periodontitis and most oral soft tissue disorders are associated with the presence of specific microorganisms in the oral flora. These microorganisms are generally found with poor oral cleanliness. In a previous study on oral microorganisms and clinical variables in dependent residents in a nursing home, it was found that a high level of bacteria associated with caries was related to functional impairment, which, in turn, was related to nutritional problems.6 Thus, there are more reasons to stress the importance of finding ways to obtain and maintain good oral hygiene routines for elderly dependents in nursing homes. An intervention with oral health coordinators has been found to improve the nursing staff´s oral hygiene priority in long-term care.7 In the 11 month followup study by Peltola et al., hands-on instructions to the nursing staff in oral cleaning issues were found more effective for increasing the oral hygiene in longterm hospitalized elderly, than oral hygiene measures provided by dental hygienists once every 3 week.8 Ishikawa et al., reported a decrease in oropharyngeal bacteria in elderly dependents after weekly professional oral care, performed
64 S p e c C a r e D e n t i s t 3 4 ( 2 ) 2 0 1 4
scd_12009.indd 64
by a dental hygienist, during a 5-month period.9 Oral care aides, with a function similar to that of oral health coordinators, are nurses aides or nursing assistants, specially trained in oral hygiene care tasks. They have previously been found to improve cooperation between nursing and dental teams.7 The long-term effect of their assistance with the residents’ oral health has, however, not been proven and was focused on in the present study. The effects of oral health care intervention using oral care aides were assessed during a two-year period by recording (a) the proportions of the opportunistic microorganisms Candida
© 2013 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12009
19/02/14 12:33 PM
ORAL CARE AIDES’ EFFECT ON ORAL MICROFLORA
albicans, Staphylococcus aureus, enterococci, and enteric rods, associated with risk for/presence of mucosal infection/ impaired general health, and mutans streptococci and lactobacilli, associated with risk for/presence of caries lesions, in the oral flora6 (b) whether oral hygiene assistance was given to the residents or not, and (c) individual experiences concerning oral health care among the staff involved.
M ater ials and me tho ds
The study was approved by the local Ethics Committee and was integrated with a system for dependent individuals in the Swedish Dental Remuneration scheme from 1998.10
Nursing home The nursing home for elderly dependents in a Swedish city where the study took place consisted of three wards, each with twelve beds. The total ward staff consisted of 22.75 nursing assistants and nurses’ aides and 2.5 registered nurses.
Professional support with oral issues The nursing home had an agreement with a dental clinic regarding support with oral issues. A dentist at the clinic, specially trained in elderly care, gave on demand dental care to the residents. Two dental hygienists from the clinic acted as consultants at the nursing home. They also performed the yearly oral health assessments and taught oral health care to the nursing staff. A lesson consisted of a three-hour oral health education giving a brief theoretical background of common oral diseases found in elderly dependents, practical advice and training on how to best carry out the oral hygiene tasks. In connection to the yearly oral health assessment, the dental hygienists collected oral samples for microbial analysis and documented whether the nursing staff assisted the residents in their oral hygiene procedures or not. This was performed at baseline and 1 and 2 years after the introduction of the oral care aides at the wards.
Wårdh and Wikström
scd_12009.indd 65
Oral care aides The staff manager appointed one oral care aide from each of the three wards among the nursing assistants or the nurses’ aides. The oral care aides were given the opportunity to observe dental hygienists and dentists working at the dental clinic mentioned above, for two days. The reason behind observing dentists working was mainly to be acquainted with different prosthetic constructions. The oral care aides were given a written outline of their new duties: (1) To be the primary contact with the dental clinic. (2) To report new residents and ensure they receive an oral health assessment by a dental hygienist and necessary dental care. (3) To ensure that each resident had an oral health care plan developed by a dental hygienist that was well-known by all ward staff. (4) To inform of oral health care issues at staff meetings. (5) To document the oral health care work performed in each resident in a nursing journal. (6) To be available for questions regarding oral health care put by the other staff and residents/their relatives. (7) To be responsible for an “Oral care basket” containing the equipment for oral hygiene care that was recommended by the dental hygienists. (8) To cooperate with the dental hygienist regarding how to find the most efficient oral health care routines at the ward. However, the specific structure of the oral care aides’ work was solved locally, e.g., how to inform and report.
Residents Forty-two of the in total 43 residents, living at the nursing home during the 2-year follow-up period, gave their informed consent to participate in the study. The residents suffered from both physical and mental impairments and were considered totally care dependent. Although the facility was aimed for elderly, an occasional younger individual
was placed there due to lack of space at a proper facility.
Microbial procedures Samples for microbial analysis were collected in duplicate, with 1–2 weeks apart, and a mean of the results was calculated. The samples were collected from supragingival plaque in residents with ≥10 teeth and from the dorsum of the tongue in residents with
ARTICLE ABSTRACT The oral health status of elderly dependent residents is reported to be poor, as well as difficult to describe. Analysis of oral microbial flora has been suggested as a suitable measurement method. Oral care aides have been shown to have a positive influence on oral health care in nursing. The outcome of an intervention with oral care aides was followed during a two-year period by recording: (a) the proportion of opportunistic microorganisms and bacteria associated with caries (b) whether oral hygiene assistance were given to the residents or not, and (c) individual experiences concerning oral health care among the staff involved. The oral flora and the amount of oral hygiene assistance improved throughout the entire study period, but staff interviews revealed that it took two years for good cooperation and prophylactic routines to be established. An unexpected finding was the positive correlation (p = .0005) between a high proportion of the opportunistic microorganisms and death within one year.
KEY WORDS: oral health, nursing staff, oral microflora, oral care aides
Long-term effects of using oral care aides at a nursing home for elderly dependent residents—a pilot study Inger M. Wårdh, DDS, PhD;1* Maude B. Wikström, DDS, PhD2 1Department
of Dental Medicine, Gerodontics, Karolinska Institute, Huddinge, Sweden; 2Department of Microbiology, Institute of Odontology, Sahlgrenska Academy, Göteborg, Sweden. *Corresponding author e-mail: [email protected] Spec Care Dentist 34(2): 64-69, 2014
Int r od uct ion
The oral health of elderly dependent residents in nursing homes is reported to be poor, as well as difficult to describe and measure. Poor oral health is associated with functional, psycho-social, and discomfort-related limitations and has negative effects on the quality of life among elderly people.1 Masticatory function disability and oral infections may even be fatal for frail elderly subjects.2,3 In a study, which included more than 400 elderly nursing home patients, inadequate dental status was found associated with high overall mortality, with the main cause of death to be respiratory infections.4 In a literature review by Sjögren et al., it was concluded that when aspiration disorders or dysphagia are present in elderly people in nursing homes, pneumonia has its origin in microorganisms present in the oral flora and may be prevented by improved oral hygiene.5 Caries, periodontitis and most oral soft tissue disorders are associated with the presence of specific microorganisms in the oral flora. These microorganisms are generally found with poor oral cleanliness. In a previous study on oral microorganisms and clinical variables in dependent residents in a nursing home, it was found that a high level of bacteria associated with caries was related to functional impairment, which, in turn, was related to nutritional problems.6 Thus, there are more reasons to stress the importance of finding ways to obtain and maintain good oral hygiene routines for elderly dependents in nursing homes. An intervention with oral health coordinators has been found to improve the nursing staff´s oral hygiene priority in long-term care.7 In the 11 month followup study by Peltola et al., hands-on instructions to the nursing staff in oral cleaning issues were found more effective for increasing the oral hygiene in longterm hospitalized elderly, than oral hygiene measures provided by dental hygienists once every 3 week.8 Ishikawa et al., reported a decrease in oropharyngeal bacteria in elderly dependents after weekly professional oral care, performed
64 S p e c C a r e D e n t i s t 3 4 ( 2 ) 2 0 1 4
scd_12009.indd 64
by a dental hygienist, during a 5-month period.9 Oral care aides, with a function similar to that of oral health coordinators, are nurses aides or nursing assistants, specially trained in oral hygiene care tasks. They have previously been found to improve cooperation between nursing and dental teams.7 The long-term effect of their assistance with the residents’ oral health has, however, not been proven and was focused on in the present study. The effects of oral health care intervention using oral care aides were assessed during a two-year period by recording (a) the proportions of the opportunistic microorganisms Candida
© 2013 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12009
19/02/14 12:33 PM
ORAL CARE AIDES’ EFFECT ON ORAL MICROFLORA
albicans, Staphylococcus aureus, enterococci, and enteric rods, associated with risk for/presence of mucosal infection/ impaired general health, and mutans streptococci and lactobacilli, associated with risk for/presence of caries lesions, in the oral flora6 (b) whether oral hygiene assistance was given to the residents or not, and (c) individual experiences concerning oral health care among the staff involved.
M ater ials and me tho ds
The study was approved by the local Ethics Committee and was integrated with a system for dependent individuals in the Swedish Dental Remuneration scheme from 1998.10
Nursing home The nursing home for elderly dependents in a Swedish city where the study took place consisted of three wards, each with twelve beds. The total ward staff consisted of 22.75 nursing assistants and nurses’ aides and 2.5 registered nurses.
Professional support with oral issues The nursing home had an agreement with a dental clinic regarding support with oral issues. A dentist at the clinic, specially trained in elderly care, gave on demand dental care to the residents. Two dental hygienists from the clinic acted as consultants at the nursing home. They also performed the yearly oral health assessments and taught oral health care to the nursing staff. A lesson consisted of a three-hour oral health education giving a brief theoretical background of common oral diseases found in elderly dependents, practical advice and training on how to best carry out the oral hygiene tasks. In connection to the yearly oral health assessment, the dental hygienists collected oral samples for microbial analysis and documented whether the nursing staff assisted the residents in their oral hygiene procedures or not. This was performed at baseline and 1 and 2 years after the introduction of the oral care aides at the wards.
Wårdh and Wikström
scd_12009.indd 65
Oral care aides The staff manager appointed one oral care aide from each of the three wards among the nursing assistants or the nurses’ aides. The oral care aides were given the opportunity to observe dental hygienists and dentists working at the dental clinic mentioned above, for two days. The reason behind observing dentists working was mainly to be acquainted with different prosthetic constructions. The oral care aides were given a written outline of their new duties: (1) To be the primary contact with the dental clinic. (2) To report new residents and ensure they receive an oral health assessment by a dental hygienist and necessary dental care. (3) To ensure that each resident had an oral health care plan developed by a dental hygienist that was well-known by all ward staff. (4) To inform of oral health care issues at staff meetings. (5) To document the oral health care work performed in each resident in a nursing journal. (6) To be available for questions regarding oral health care put by the other staff and residents/their relatives. (7) To be responsible for an “Oral care basket” containing the equipment for oral hygiene care that was recommended by the dental hygienists. (8) To cooperate with the dental hygienist regarding how to find the most efficient oral health care routines at the ward. However, the specific structure of the oral care aides’ work was solved locally, e.g., how to inform and report.
Residents Forty-two of the in total 43 residents, living at the nursing home during the 2-year follow-up period, gave their informed consent to participate in the study. The residents suffered from both physical and mental impairments and were considered totally care dependent. Although the facility was aimed for elderly, an occasional younger individual
was placed there due to lack of space at a proper facility.
Microbial procedures Samples for microbial analysis were collected in duplicate, with 1–2 weeks apart, and a mean of the results was calculated. The samples were collected from supragingival plaque in residents with ≥10 teeth and from the dorsum of the tongue in residents with
