Poor oral health and periodontal disease is known to increase risks for respiratory infections, diabetes, stroke and cardiovascular disease.
Despite this awareness, poor oral hygiene continues to play a significant role in pneumonia rates among nursing home residents, particularly those at risk for aspiration.
Aspiration pneumonia, which is typically caused by anaerobic organisms (commonly S. aureus, P. aeruginosa or one of the enteric species) arises from the gingival crevice and seen in both the community and institutionalised settings. Pneumonia develops when pathogens are aspirated from the oropharyngeal cavity and other sites (GI tract, sinuses) into the lower airway.
Increased risks for aspiration pneumonia occur when a sequence of periodontal disease, dental decay and poor oral hygiene is compounded by the presence of dysphagia, feeding problems and poor functional status all of which are found in vulnerable dependent persons.
But modifiable risks of aspiration pneumonia do exist; these include implementation of standardised evidenced based practices (EBP) in oral hygiene, routine oral assessment, mechanical cleansing to reduce biofilm and strict adherence to aspiration precaution proto- cols. Consequently, an urgent need exists to improve the state of oral care for vulnerable and dependent persons, particularly those who are dentate.
Current state of oral health and care
Pamela Stein writing in the AJN noted that many institutionalised persons cannot perform their own oral care with studies in the UK reporting that 72-84% of nursing home residents had difficulty in brushing their own teeth and up to 94% found it difficult to clean their own dentures. Similar studies support the opinion that oral hygiene in long term care facilities are poorly constructed and controlled, not standardised or deemed to be of a priority by staff.
Without question the level of oral care provided by staff is a key indicator on the quality of care that is delivered in general; the appearance of dry cracked lips, coated tongue, vegetation on teeth and halitosis indicate a lack of oral care and flagrant disregard for the well-being and comfort of the dependent person.
Conversely, good and effective oral care reflects a culture of caring and compassion; and as nursing has a 'duty of care' to provide comfort and maintain the health and well-being of those in their charge, poor oral hygiene is the antithesis of the nursing profession.
A study of 71 edentulous elderly persons in Japan assessed 'tongue coating' as a predictor or risk indicator in the development of aspiration pneu- monia; the number of elderly patients developing aspiration pneumonia was larger in patients with a poor TPI score (tongue plaque index) than those with better or good TPI scores. As a result "tongue coating was associated with the number of viable salivary bacterial cells and development of aspiration pneumonia in dentate persons."
Nursing Home executives have conceded that oral hygiene in their facilities are lacking and rated as only "fair to poor" and oral hygiene in many cases, is underrated by staff as to its influence on overall patient health, well-being and nutritional status. In studies of nursing homes in the US and Australia, the 'so-called' barriers to providing good oral care included the lack of assigned personnel to perform oral care, resident non-compliance with care and choice of oral care itself.
Whilst providing oral care may be a challenge in the elderly and disabled, failure can have dire consequences as poor oral care can contribute to serious illness and possibly, death. Terpenning and associates in 2001 wrote of the link between pathogenic oral bacteria and aspiration pneumonia with a sub- sequent study in Japan showing that poor oral hygiene in nursing homes significantly increased the risk of pneumonia and febrile days.
With aspiration pneumonia accounting for 13% to 48% of all infections in nursing homes, growing evidence supports the causal links between oral hygiene, mechanical cleansing, aspiration risks and development of pneumonia in 'high risk' patient populations. However this awareness is not new with literature going back to the 1980s documenting links between poor oral hygiene and illness.
The importance of oral care as a preventative measure in maintaining systemic health has been so compelling that in 2003 the CDC and HICPAC released "Guidelines for Preventing Health Care Associated Pneumonia". This stated that healthcare facilities must...develop and implement a comprehensive oral-hygiene program (that might include use of an antiseptic agent) for patients in acute-care settings or residents in long-term care facilities who are at risk for health- care associated pneumonia (II).
In Australia, The Commonwealth Residential Aged Care Standard set out accreditation requirements for residential care providers. Standard 2.15 Oral and Dental Care requires that "resident's oral and dental health is maintained".
Under this Act, nursing home providers are required to:
- Meet specific standards on oral and dental care (outcome 2.15).
- Refer residents to appropriate health specialists in accordance with the residents' needs and preferences, including dentists.
- Demonstrate that residents' oral and dental health is maintained through documentation According to the ADA in 2004, despite the existence of these standards there has been little enforcement and no strong adherence due to insufficient knowledge regarding oral health, oral care and low priority by staff.