The Purpose of This Policy Is to Promote Good Oral Health for Residents in the Facility

Document Title and Code: / Policy for Oral Hygiene and Dental Care. NHNP-ODC
Version: / 1
Author: / Prepared by Eithne Ni Dhomhnaill, Nursing Matters.
Ratified by: / Education and Steering Committee, Nursing Homes Nursing Projects.
Issue Date: / November 2008
Review date: / November 2010
Authorised by:

1.0Policy Statement:

Good oral health for all residents will be promoted through person centred assessment and care planning for oral hygiene needs on admission, routinely every three months or sooner where the resident’s condition indicates.

2.0Purpose:

The purpose of this policy is to promote good oral health for residents in the facility.

3.0Objectives:

3.1To ensure that residents’ oral hygiene and dental care are addressed in accordance with their needs, known preferences and wishes.

3.2To ensure that where a resident has been identified as having poor oral health, possible underlying causes are investigated and addressed.

3.3To ensure that nurses are knowledgeable in assessment and care planning for resident’s oral hygiene and dental care needs.

3.4To ensure that all care staff are knowledgeable in the delivery of oral hygiene care.

4.0Scope:

This policy applies to all nursing and care staff in the facility.

5.0Definitions:

5.1Oral: refers to the mouth including natural teeth, gingival and supporting tissues, hard and soft palate, mucosal lining of mouth and throat, tongue, salivary glands, chewing muscles, upper and lower jaw, lips (Hartford Institute for Geriatric Nursing, 2008)

5.2Oral Cavity: consists of the cheeks and the hard and soft palate (Hartford Institute for Geriatric Nursing, 2008)

5.3Oral hygiene / Mouth Care:Mouth care is the use of a toothbrush and paste, amouthwash or other mouth cleaning preparation to help thepatient to maintain the cleanliness of his teeth or dentures and toencourage the flow of salvia to maintain a healthy oropharyngealmucosa. ( Jameieson et al ,1998 cited in Midland Health Board, 2003)

5.4Edentulous: toothless.

6.0Quick Reference Guide: Management of Oral Hygiene and Dental Care Needs.

Actions

Responsible Person.

This policy will be disseminated to and read by all nursing personnel involved in assessment and care planning for resident.

Director of Nursing or delegated to another named nurse.

A record will be kept of all those who have signed the policy acknowledgement forms.

Director of Nursing or delegated to another named nurse.

Where a new version of this policy is produced, the previous version will be removed and filed away.

Director of Nursing or delegated to another named nurse.

Every new staff member who will have a role in assessment and care planning will be given an explanation of this policy as part of his/her induction.

Director of Nursing or delegated to another named nurse.

Each new resident will be screened for oral hygiene and dental care needs on admission.

Designated / named nurse.

Resident will have an oral hygiene assessment using a validated screening tool within 48 hours or sooner if indicated by their admission assessment.

Designated / named nurse.

Each resident who has a condition / disease affecting oral hygiene and / or dental care will have a written care plan developed in consultation with him/herself and /or the resident’s representative and other relevant healthcare personnel involved in the resident’s care.

Designated / named nurse.

The resident’s plan of care to meet oral hygiene needs will be communicated to all those providing direct care to the resident.

Designated / named nurse.

Nurses will maintain their competence in assessment for, care planning for and implementation of oral hygiene needs and communicate any competency / knowledge deficits to their line manager/Director of Nursing.

All registered nurses

Care given to residents will be in accordance with the plan of care developed and agreed by the resident and / or representative and other healthcare professionals involved in the resident’s care.

All healthcare staff providing care to residents.

Changes in a resident’s condition will be reported to the senior nurse in charge and changes to care will be documented and communicated to all relevant healthcare professionals.

All nurses, care assistants and other healthcare professionals involved in the resident’s care.

Audit of oral hygiene assessment and care planning will form part of the facilities overall clinical audit plan.

Director of Nursing or other designated nurse.

7.0Protocol for Oral Hygiene Assessment and Care Planning.

7.1Admission Assessment.

7.1.1The admitting nurse should identify the following on admission:

The resident’s ability to carry out oral hygiene care independently.

Level of assistance required for oral hygiene care.

Presence or absence of natural teeth or dentures.

Any known difficulty with swallowing or chewing ability.

Any specific needs related to oral / dental care.

The views and observations of the resident or his/her representative regarding current oral/dental status and oral hygiene care.

7.1.2Based on the above information, the nurse should use his/her professional judgment as to whether or not a physical assessment of the resident’s oral cavity is required at this stage or can be completed as part of the comprehensive nursing assessment.

7.2Comprehensive assessment

7.3Comprehensive assessment of oral hygiene and dental care needs should form part of the residents overall comprehensive nursing assessment.

7.4The nurse should ensure that comprehensive assessment of oral healthcare includes the following:

Past medical history

Past history of oral diseases or infections.

Current medications.

Nutrition and hydration.

Smoking history.

Details of past dental treatments as far as is practicable.

Knowledge and practice of oral and dental care.

Level of assistance required

Presence or absence of natural teeth or dentures.

Natural teeth in tact; broken; decayed; food particles; halitosis.

Ability to function with or without natural teeth or dentures.

Speaking chewing swallowing ability.

7.4.1The nurse should complete an inspection of the oral cavity using a good light (hand held pen torch). For residents with cognitive impairment see below.

7.4.2The nurse should use a screening tool to make a simple assessment of the oral cavity. See appendix 1 and 2 for recognized assessment tools.

7.4.3The nurse should seek the consent of the resident prior to conducting oral assessment and physical inspection of the mouth.

7.4.4Assessment of oral hygiene care should include the preferences of the resident as far as he / she is able.

7.4.5Residents with cognitive impairment are at particular risk of oral disease.

7.4.6For residents with cognitive impairment, the Oral Health Assessment Tool has been found to be a reliable and valid tool (Chalmers et al, 2005).

7.4.7For residents with cognitive impairment, the nurse should try to ensure that the resident’s representative is present where an inspection of the oral cavity is being undertaken.

7.5Care Planning.

7.5.1Care planning for oral hygiene and healthcare needs should be agreed with the resident and/or representative and other relevant healthcare staff involved in the resident’s care.

7.5.2Residents who require referral to a dentist as indicated by their assessment should be referred for dental assessment.

7.5.3Care planning for oral hygiene and healthcare needs should address the following:

Liaising with the resident and / or representative regarding dental appointments.

Assistance to perform oral hygiene care as required with consideration given to any communication and behaviour management needs.

Regular tooth brushing and denture cleaning.

Monitoring and identification of specific requirements to address ‘dry mouth’ caused by polypharmacy and medications with adverse oral effects.

7.5.4The resident’s care needs for oral hygiene and healthcare should be documented in the care plan and communicated to all relevant healthcare staff involved in the resident’s care.

7.5.5The frequency of undertaking oral hygiene care will vary according to the resident’s needs. Residents with gastrostomy tubes should receive oral hygiene care at least four hourly.

7.5.6The care plan should include a review schedule appropriate to their oral healthcare needs.

7.5.7A comprehensive reassessment of oral healthcare should be repeated as part of a comprehensive every three months or more frequently according to the resident’s condition or where there is a significant change in the resident’s care and or condition.

7.6Monitoring and Evaluation.

7.6.1Resident’s oral hygiene and dental care should be reviewed and amended according to specific review schedule.

7.6.2Changes to care / condition should be recorded in the resident’s progress notes.

7.6.3The resident should have a routine reassessment of oral hygiene and dental care needs every three months or sooner where risk factors or residents changing condition indicate.

7.7Oral Hygiene Care for Residents with Dementia:

7.7.1The following communication and behaviour management techniques are recommended for successfully performing oral hygiene care for residents with dementia to increase cooperation and maximize the resident’s own ability.

Develop a routine with oral hygiene care at the same time every day.

Undertake oral hygiene care in a quiet distraction free environment.

Use short simple sentences and directions.

Use task breakdown and one-step instructions.

Use non-verbal cues to reassure.

Use gentle touch to promote trust.

Use reminders and prompts for oral hygiene.

Provide distraction to occupy hands where there is grabbing behaviour.

Use of chaining, bridging and rescuing techniques for communication.

Source: Joanna Briggs Institute, 2004.

7.8Oral Diseases and Adults with Dementia.

Studies indicate that adults with dementia are more prone to oral diseases and conditions. These include:

Decline in salivary gland function.
Greater accumulation of dental plaque and calculus on natural teeth and dentures.
Increased levels of behaviour problems during oral hygiene care.
Increased need for assistance with oral hygiene care.
Higher experience, prevalence and incidence of dental caries.
Increased experience and higher incidence of gum diseases.
Greater dental needs but decreased usage of dental services.
Reduced ability to self care.
Reduced ability to communicate pain and discomfort.

8.0Procedure for Oral Hygiene care.

8.1Obtain permission from the resident and explain the procedure.

8.2Where possible encourage and facilitate patient to carry out his/her own mouth care.

8.3Assist the resident to sit out of bed to chair or in an upright position in bed.

8.4Ensure privacy and dignity is maintained.

8.5Wash and dry hands and put on gloves.

8.6When carrying out oral hygiene, observe for abnormalities such as dry mouth; ulceration; infection; bleeding and so on.

8.7Remove dentures using tissues or guaze.

8.8Provide appropriate oral hygiene as per oral hygiene protocol.

8.9Observe precautions for aspiration.

8.10Clean dentures using a personal toothbrush and water using an up and down motion.

8.11Report abnormalities / refer appropriately (line manager/general practitioner/dentist)

8.12Document any abnormalities and referrals in the residents care plan.

9.0Oral Hygiene Care Protocol.

Oral Hygiene Care Protocol.
Care of person with dentures. /

Clean dentures with individual brush and toothpaste or denture cream under running water

Remove dentures at night, with resident’s permission if possible, clean them and soak in cold water overnight (CREST, 2004)
Ensure each resident has their own denture pot with their name on it.

Care of Natural Teeth. /

Clean with fluoridated toothpaste and soft toothbrush.

Assist resident to rinse following brushing of teeth.

Care of lips. /

Clean with water moistened gauze and protect dry lips with a lubricant such as Oralbalance gel or lip balm.

Care of Oral Mucosa. /

Inspect for abnormalities and report.
Clean mucosa with moistened foam sticks or baby toothbrush. Never use glycerine or lemon swabs.
Clean tongue and palate with a soft toothbrush

Care of resident with dry mouth.
*Not for residents with dysphagia. /

Provide oral lubrication in the form of

Sips of water
Saliva substitutes such Glandosene oral spray
Crushed ice
Provide oral hygiene care as previously outlined.

Care of residents with dysphagia -
Special points /

Sit resident in an upright position

Ideally suction should be available.
Use dry medium textured toothbrush with a smearof fluoride toothpaste.
Clean mucosa with soft toothbrush or water moistened gauzed fingers or foam sticks.

Adapted from CREST, 2004; NHS Quality, Scotland, 2005.

10.0Predisposing Factors for Oral Diseases and Conditions in Older Adults.

Predisposing Factors. / Conditions
Tooth Loss / Poor chewing efficiency.
Altered vocal sounds.
Social inhibition.
Dietary restrictions.
Lower intake of vegetables and fruit.
Less dietary fibre.
Greater carbohydrate intake.
Dry mouth.
Gingival recession.
Impaired oral hygiene.
Oral microbial infection.
Inadequate fluoride
Multiple restorations / Dental Caries.
Calcium channel blockers.
Cancer chemotherapy
Immunosuppressants
Stroke
Dementia
Parkinson’s disease.
Anaemia.
Bleeding disorders.
Diabtetes.
Poor oral care.
Smoking.
Poor nutrition.
Partial dentures. / Periodontal disease.
Stroke.
Parkinson’s disease.
Dehydration.
Diabetes
Stroke.
Anti anxiety agents.
Anti cholinergics.
Anti hypertensives
Anti Parkinson agents.
Anti psychotics.
Chemotherapy. / Xerostomia (Dry mouth)
Salivary dysfunction/
Anti depressant drugs.
Anti psychotic drugs. / Decreased salivary flow.
Xerostomia.
Grinding of teeth and dentures.
Higher prevalence of oral mucosal lesions.

Source: Hartford Institute for Geriatric Nursing, 2005.

11.0References

Joanna Briggs Institute ((2004) Oral hygiene care for adults with dementia in residential care facilities .Best Practice Vol 8(4) pp. 1-6.
Hartford Institute for Geriatric Nursing. Oral Healthcare in Ageing. Accessed 10/03/2008 @
Midland Health Board (2003) Guideline Oral Health accessed 10/3/2008 @
NHS Quality Improvement Scotland (2005) Best Practice Statement. Working with Dependant Older people to Achieve Good Oral Health.
Our Lady’s Hospice, Harolds Cross. Policy on Oral Hygiene Care.
British Society for Disability and Oral health (2000) Nursing standards for oral health in continuing care. UK

Chalmers, J.M. King, P.L; Spencer, A.J. Wright, F Carter, K (2005)The Oral Health Assessment Tool – Validity and reliability. Australian Dental Journal. Vol. 50:(3):191-199

Amendments / Comments to Policy Document for local use.
Document Title and Code: / NHNP-
Version: / 1
Name of Facility.
Issue Date: / 2008
Review date: / 2010
Authorised by:
Point Number / Comments / Amendments to Policy for Local Use.
Point Number / Comments / Amendments to Policy for Local Use.