Oral Care: Education for Nurses

Posted by | January 4, 2011 | Articles, Dyphagia Evaluation

Speech pathologist play a pivotal role in preventing aspiration pneumonia.  Oral care is a crucial part of the patient’s medical management.  Adequate oral care can help to prevent pneumonia, especially in the elderly and when individuals are unable to care for themselves.  Patients who are critially ill or who lack adequate oral care, may develop colonization or multiplication of bacteria in the oral cavity.  Aspiration of certain oral pathogens can lead to pneumonia and possibly death.  Respiratory infection from aspiration is the second most common infection occurring in long-term nursing facilities (Medina-Walpole &Katz, 1999).  Hospitals should have a protocol for oral care in place to help improve the compliance of oral care.

NORMAL ORAL ENVIRONMENT:

The oral cavity comprises of over 500 species of florae.  The makeup depends on the individuals age, nutrition, genetics, gender, and stress.  But overall, the florae remain relatively the same throughout a healthy individual’s life (Todar, 2002).  The florae, or pathogens, are primarily bacteria and are a normal makeup of the oralpharyngeal environment.  However, under the right circumstances, these bactreia are capable of producing disease.  Certain oral pathogens are beneficial.  They protect against infection by invading microbes and providing nutritional and digestive functions.

Role of Saliva:

Saliva is produced by three pairs of major and many minor salivary glands scattered throughout the mouth and together they are capable of producing up to one litre of saliva a day.  Saliva plays a very important role in food preparation, digestion and preventing tooth decay.

The first and most obvious role of saliva for most people is its value as a lubricant. This property is largely due to the mucins, which are characterised by low solubility, high viscosity, elasticity and adhesion to the oral mucosa, which enables them to lubricate and protect the epithelial cells lining the mouth. It is these properties that make speech and eating possible.  Serous fluid helps prevent oral pathogens from attaching and colonizing on the orapharyngal surfaces, assisting in preventing oral infections.

A second mechanical property of saliva is its binding ability, which enables food to be formed into a bolus for swallowing. In addition, the salivary mucins absorb water and coat the oral mucosa, effectively waterproofing the surface and preventing loss of fluid from the epithelial cells below.

An important role of salivary mucins, which is often overlooked, is their ability to protect the epithelial surface from the many noxious substances that may enter the mouth, including nicotine, alcohol and other chemicals.  They also protect the oral epithelium from the proteolytic enzymes, largely produced by organisms of the dental plaque and those excluded from the gingival crevice if periodontal disease is present. Finally, one of the most important roles of saliva is its ability to dilute and buffer the acid generated from the plaque from dietary sugars, the first stage from the carious process.

EFFECTS OF ILLNESS ON THE ORAL ENVIRONMENT

A serious illness may stress the individual, which can alter the immune system.  Response to a stressful event, stimulates the sympathetic nervous system.  One of the responses is reduction in salivary gland output, which reduces oral immune properties.  This can increase the chances of a bacterial colonization (McEwen & Lasley, 2002).  The greater the severity of the illness, the greater the likelihood more bacteria will colonize in the oral cavity.  If the patient also has difficulty swallowing, all the bacteria in the patients mouth has a high chance of being aspirated.  This is where aspiration pneumonia is very common (Skerrett, Niederman, Fien, 1989). Medications can also cause changes in salivary output, particularly xerostomia (drying of the oral tissues.)

ORAL CARE PROCEDURES

Proper oral care of those who are unable to care for themselves in nursing institutions is inadequate.  Most of these patients are elderly and those approaching the end of life.  Standardized practices and protocols across care facilities have not been adopted nationally.  Many facilities have informal protocols, and thus the patients do not receive regular cleanings.  In most settings, nursing and nursing assistants are the responsible parties to make sure that oral hygiene has been completed.  Oral care is often neglected by a busy staff.  Nursing assistance report that they recieve little formal instruction in providing oral care.  Nursing may lack educational training and managment commitment (Shay, 2007).  Speech-language pathologists must train nursing and nursing assistance in the importance of oral care, particulary knowledge that inadequate oral care frequently leads to pneumonia.

Sample Oral Care Protocol

Mechanical Regimens

Mechanical and/or pharmacological regimens can be used for oral care.  Mechanical care includes toothbrushes, foam swabs, lemon glycerine swabs, rinses, and other devices to clean the mouth.  Toothbrushing is the most common practice.  Powered, rotary toothbrushes have been shown to remove plaque and reduce dental cavities more effectively than manual brushes.

Foam sponge swabs and lemon glycerine swabs are commonly used with patients who are unable to care for themselves.  These have become part of clinical practice.  However, multiple studies have shown that foam sponges provide mucousal stimulation, but do not adequately remove dental plaque and should not be used for that purpose (Munro & Grap, 2004).  There is mixed effectiveness of lemon glycerine swabs to moisten the oral mucosa.  They report that lemon glycerine swabs initially moisten the mouth, but the citrus acidity causes mucosa drying with repeated use.  Another study showed that lemon glycerine swabs initially dried the oral mucosa, but with continued use, the mucosa began to respond with increased secretions between day 4 and 5 (Foss-Durant and McAfee, 1997).  Lemon glycerine swabs are not effective for oral care.

Pharmacological Agents

Antigingivitis and antiplaque products can be administered as a mouthwash. Chlorhexidine is a antibacterial prescription drug and is effective for reducing oral bacteria.  It reduces respiratory infection rates in CABG, other heart patients, intubated patients, and patients on mechanical ventilators (Fourrier et al., 2000).

Oral care is essential, particularly in the elderly population and patients with disease or medications that increase pathogen colonization.  Dysphagia and increased upper respiratory pathogens sets the stage for a patient to develop aspiration pneumonia.  A daily routine of oral cleaning using a mechanically powered toothbrush, toothpaste containing fluoride, and mouth rinses (including chlorhexidine) will reduce bacteria in the oral cavities.  Speech-language pathologists can help to educate nursing and nursing assistants for better oral health care.

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Foss-Durant, A.M. & McCafee, A. (1997). A comparison of three oral care products commonly used in practice. Clinical Nursing Research, 6, 90-104.

Fourrier, F., Cau-Pottier, E., Boutigny, H., Roussel-Delvallez, M., Jourdain, Ml, & Chopin, C. (2000). Effects of dental plaque antiseptic decontamination on bacterial colonization and nosocomial infections in critically ill patients.. Intensive Care Medicine, 26, 1239-1247.

McEwen, B.S., & Lasley, E.N. (2002). Ehte end of stress as we know it. Washington, DC: Joseph Henry.

Medina-Walpole, A.M. & Katz, P.R., (1999). Nursing home-acquired pneumonia. Journal of the American Geriatric Society, 47, 1005-1015.

Shay, K. (2002). Infectious complications of dental and periodontal disease in the elderly population. Clinical Infectious Diseases, 34, 1215-1223.

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