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Elder Oral Assessment And Care.

Traditionally, oral assessment and hygiene have been a low priority for nursing care. Yet, the status of the patient's mouth and oral mucous influence a multitude of functions. The patient's ability to eat, swallow, digest food, or even speak can be adversely affected by poor oral hygiene. Ill-fitting dentures can cause problems with eating or speaking. Problems with oral hygiene can reduce patients' quality of life. Halitosis and changes in facial appearance may alter self-esteem and contribute to social isolation. When nurses fail to identify an existing oral problem, further debilitating problems may result in an already physically compromised person. In some patients, oral infections may even become life threatening. For example, in chemotherapy patients, the mortality rate due to candidemia (systemic candidiasis) is estimated to be as high as 71% to 79% (Shay, Truhlar, & Renner, 1997).

While an above average number of older adults use regular dental services, this population's use of dental care service is the lowest of all adults (Shay, 1994). Because dental care requires leaving the home or institution and is expensive, frail or less economically advantaged elders may not seek needed care or preventative services (Reynolds, 1997). Yet, in older adults, dental caries are the greatest contributor to tooth loss (Lloyd, 1998). According to Lloyd (1998), less than one-third of the older adult population see their dentist annually and almost half have not seen a dentist in 5 years. Patients who are edentulous (without teeth) may erroneously believe they no longer need dental services and are five times less likely to see a dentist than their dentate cohorts. Further, older adults erroneously think that tooth loss is naturally associated with aging and that dental care is expensive and requires frequent and lengthy visits (Reynolds, 1997).

The morbidity and mortality associated with oral health in elderly individuals are significant. It is estimated that approximately 90% of the older adult population have some type or degree of treatable oral disease (Reynolds, 1997). Thirty thousand cases of oral cancer are diagnosed each year and more than 50% of those cases are in patients 65 years of age and older (Reynolds, 1997). Moreover, the incidence of oral cancer increases with age (Feussner, Oddone, & Wong, 1997). In addition to these potentially life-threatening conditions, poor oral health can lead to a number of clinical problems. Chronic diseases and medication reactions can cause xerostomia (dry mouth) that can predispose patients to oral ulceration, candidiasis, and stomatitis. Medications and/or accompanying aging changes may add to variations in taste sensation. Physical, personal, or economic issues may limit adequate oral care and prevent routine dental examination and preventative assessment. This may lead to years of no oral cavity assessment with resulting lesions, pain, dental caries, or late-stage gum disease.

In the elderly, dental health is a complex issue for a variety of reasons. According to Shay (1994), a lifetime of accumulated physiologic disease-related, traumatic, and iatrogenic factors affect dental health, often in unique ways. In addition, specific problems are most often associated with the aged mouth. These problems include numerous restorations in varied states of disrepair; shifting, nonattached, and missing teeth; teeth in poor condition; shrinkage in the pulp space; deterioration in the structure of dentin; and occlusal attrition (Shay, 1994).

A critical oral cavity assessment provides important data regarding the patient's hydration and general dental health, and can lead to the identification of periodontal disease, thrush, oral cancers, and stomatitis. This assessment can be contributory in identifying vitamin deficiencies and anemia and may well provide insight into the patient's general physical condition and overall health status. However, there is a scarcity of literature on both oral assessment and the evaluation of the most effective methods of oral care in hospitalized and community-based older adult patients. In this article, an overview of oral assessment in older adults and suggested treatments for common oral conditions are discussed.

Oral Cavity

A complete oral cavity assessment includes examining the lips, teeth, interior cheeks, anterior surface and base of the tongue, gums, soft and hard palate, tonsil, and posterior aspects of the throat (see Table 1). A comprehensive and systematic oral assessment should include observing the exterior and interior oral structures and status of the mouth plus palpation of interior components. Palpation is a significant component of a thorough oral examination because the lateral aspect of the tongue and the floor of the mouth are where the majority of oral cancus are located (Feussnel et al., 1997). Thus, detection is difficult with routine visual inspection.

Table 1. Oral Cavity Assessment
History

              * Last dental exam
              * Missing, broken, or loose teeth
              * Pain in the mouth, teeth, gums
              * Bleeding gums
              * Dry mouth
              * Sores or lesions in mouth/tongue
              * Difficulty biting, chewing, swallowing
              * Presence of halitosis
              * Altered sense of taste
              * Dentures/partials
                 Sores under dentures
                 Stability during chewing
              * History of head or neck radiation
              * Usual dental/oral hygiene
              * Medications

Assessment

              Lips and Mouth
              * Cracking, lesions, ulcers, swelling,
                discoloration, redness

              Buccal Mucosa
              * Induration, tenderness, abrasions,
                redness/discoloration, hydration,
                hygiene

              Tongue
              * Color, size, coating, tremor, lesions,
                deviation

              Palate
              * Symmetry, lesions, discoloration

              Oropharynx
              * Gag reflex, uvula position, masses,
                exudate, color, lesions

              Gingiva
              * Color, bleeding, edema, exudates,
                hypertrophy, recession from teeth,
                food impaction

              Teeth
              * Caries, root exposure, visible decay,
                missing or loose teeth, mobile and/or
                worn teeth


Black & Matassarin-Jacobs (1997); Forciea & Lavizzo-Mourey (1996); Jarvis (1992); Weber & Kelly (1998).

Additionally, in oral assessment, body system-wide physical signs and symptoms should be assessed and evaluated. General physical signs such as temperature elevation, bleeding anywhere in the oral cavity, increased salivation, malaise, and weakness are important signs of general health as well as clues to oral disease (Beare & Myers, 1990).

A comprehensive and systematic assessment of the oral cavity should be performed on the initial and subsequent assessment of all patients regardless of their clinical status. Gibson and Niessen (1997) report that the buccal cavity is a natural host to numerous species and prone to infection. In patients who are ill, mucous and old blood are excellent media for bacteria (Lewis, Collier, & Heitkemper, 1996). Patient assessment must focus on the patient's ability to perform oral hygiene, including both brushing and dental flossing. It is difficult for patients with uncoordinated or uncontrolled movements of the hands and mouth to perform basic oral hygiene. Additionally, cognitive status may also compromise a patient's ability to follow through on oral hygiene tasks or to report changes in oral condition.

Risk Factors

All older adults are at increased risk for oral problems (see Table 2). Aging changes predispose people to these problems, particularly when additional physical or psychological stressors are added. Medical conditions can directly or indirectly cause oral problems. Renal dysfunction can lead to uremia that results in spontaneous gingival bleeding. In addition, uremia causes the oral mucosa to be red, dry, and covered with a thick, gray exudate with small ulcers on the buccal mucosa and at the mucosocutaneous junction. In uremic patients, the breath has an odor of ammonia and the patient complains of a salty or metallic taste (Beck & Yasko, 1993). Other conditions, such as diabetes, can suppress neutrophil production, alter the structure of the lining of the blood vessels, and cause decreased circulation to the skin and mucous membranes. This results in poor healing of oral ulcerations and an increased potential for secondary infections, especially candidiasis (Beck & Yasko, 1993; Hill, Tan, Pereira, & Embil, 1989; Shay et al., 1997).

Table 2 Risk Factors for Oral Problems
Aging changes       Teeth tend to be darker with stress lines in the
                     enamel
                    Thinner enamel
                    Gingiva, periodontal ligament, and bone recede
                    Mucosa becomes thinner, smoother, and loses
                     elasticity
                    Decreased saliva

Medical
 conditions         Cancer
                    Depressed immune system (eg: AIDS)
                    Renal dysfunction
                    Diabetes
                    Cardiopulmonary alterations (eg: CHF, MI, CVA,
                     COPD)
                    Nutrional deficiencies (especially vitamin B)
                    Orthopedic replacements or implants
                    Endocrine disorders (eg: thyroid, hyperparathy-
                     roid)

Pharmacologic
 agents             Antibiotics
                    Antineoplastic
                    Biologic response modifiers
                    Phenytoin
                    Antihistamines
                    Anticholinergics
                    Reserpine and chlorpromazine
                    Glucocorticosteroids (oral and inhaled)

Functional
 ability            Caregiver ability and knowledge
                    Transportation to dental appointments
                    Decision making ability
                    Institutionalization
                    Impaired dexterity
                    Poor vision
                    Poor care of dentures

Physical, chemi-
 cal, or thermal
 factors            Oxygen theraphy
                    Tachypnea
                    Mouth breathing
                    Oral or nasal suctioning
                    Hot or coarse food
                    Tobacco or alcohol use
                    Radiation theraphy
                    Poor fit of dentures

Finacial ability    Finacial resources
                    Willingness to spend money on dental care

Knowledge and
 priority of
 health care        Education on proper mouth and dental care
                    Cognitive ability
                    Other health care priorities


Cancer can develop in the mouth. Cancer at any site in the body can also depress the immune system and oral infections can develop. Cancer treatments such as radiation and chemotherapy can predispose the older adult to mucosititis, stomatitis hyposalivation, oral yeast infections, gun inflammations, bleeding, and alterations in taste, voice, and ability to swallow. Mucositis is an inflammatory reaction that can affect any mucous membrane (Beck, 1996). It is most often treatment related since it usually occurs secondary to radiation or chemotherapy (Bremer, 1999). Patients at greatest risk are those who are undergoing concurrent radiation and chemotherapy treatment for head and neck cancer (Bremer, 1999). Mucositis ranges from oral erythema to edema, oral ulceration, and severe pain. Pain from mucositis may be severe enough to interfere with the person's ability to eat thus jeopardizing healing.

Similarly, stomatitis is an inflammation of the mouth that can be associated with a variety of conditions. These include viral infections, chemical irritations caused by vomitus, radiation therapy, mouth breathing, paralysis of nerves supplying the oral area, chemotherapy that damages or destroys salivary glands, adverse reactions to medications, and even acute sun damage to lips (Tabers, 1997). One of the most common problems associated with cancer therapy is oral mucositis or stomatitis (Beck, 1996). Oral conditions can be precipitated by other illnesses, treatments, or nutritional problems. The viruses such as herpes simplex, zoster, and Coxsackie can cause painful oral lesions and are frequently associated with systemic illness or a stress/immune response.

Common Problems

While numerous conditions can occur in older adults with poor oral health, xerostomia and infections are most common. In hospitalized or community-based patients, physical conditions contribute to drying of the oral mucous membranes. Cardiopulmonary disorders may result in respiratory intubation or less seriously, can alter breathing patterns, fluid or nutritional status, or the ability to physically do oral hygiene. A dry mouth from mouth breathing oxygen therapy, tachypnea, or medications increases the risk of oral infections, inflammation, bleeding, and/or oral ulceration.

In older adults, a common complaint and risk factor for oral complications is dry mouth. Xerostomia or dry mouth can have major ramifications for oral health including causing oral pain and the inability to wear partial or complete dentures (Forciea & Lavizzo-Mourey, 1996). Dry mouth can lead to difficulty speaking, cracked and painful lips, and reduced taste sensation and problems swallowing. These conditions can predispose the person to additional oral complications (Adams, 1996; Beck & Yasko, 1993).

Saliva is an essential element of oral homeostasis. Moreover, saliva provides mechanical cleansing, lubrication, mineralization, buffering action (Fischer & Ship, 1997), and enables taste acuity (Gibson & Niessen, 1997). Saliva also has antiviral, antibacterial, and antifungal effects (Fischer & Ship, 1997).

Dry mouth can affect the ability to chew and moisten food for beginning digestion. People with xerostomia may avoid foods that require longer mastication (chewy and crunchy) and instead choose foods that are drier, sticker, and sweeter (Forciea & Lavizzo-Mourey, 1997). Consequently, nutritional imbalances as well as dental pathology can result. This further complicates the problem because chewing stimulates saliva production. Without mechanical mastication to stimulate salvia production, problems of xerostomia can occur in home-based or hospitalized patients that are maintained on liquid or soft-food diets.

Large numbers of older adults complain of salivary gland dysfunction and xerostomia. However, it appears that aging does not affect salivary gland function in healthy individuals across the life span (Fischer & Ship, 1997; Lloyd, 1998). What does seem clear is that other factors are responsible for the high incidence of this complaint in the older adult population.

Two major contributors to xerostomia in the older adult population are medications and dehydration. Over 400 medications currently prescribed have xerostomia as an adverse drug affect. All drugs with anticholinergic effects can inhibit salivation (Gibson & Niessen, 1997). However, there are many other categories of medications that can cause or aggravate dry mouth. These medication categories include antihypertensives, anti-inflammatory agents, anticonvulsant drugs, narcotic analgesics, and beta-blockers (McDonald & Marino, 1991). The number of drugs patients are taking is positively correlated with complaints of xerostomia (McDonald & Marino, 1991). Fortunately, with changes in medication or dosing schedule, the xerostomia can be reduced or reversed (Gibson & Niessen, 1997). Other contributing factors to xerostomia include radiation therapy, diabetes, and autoimmune disorders, particularly Sjogren syndrome. Sjogren's syndrome is an autoimmune disorder. In Sjogren's, the body's immune cells attack glands that produce lubrication. This syndrome is characterized by dryness of mucous membranes particularly in the eyes and mouth (National Institute of Neurological Disorders and Stroke, 2001).

In general, the goal in treating xerostomia is to identify the underlying problem causing saliva flow reduction. When able, patients should be given solid foods as quickly as possible so that mechanical mastication can stimulate saliva production naturally (McDonald & Marino, 1991). In alert and oriented patients, sugarless gum or candy can be helpful between meals to provide masticatory stimulation and lubrication. Sugared gum or candy increases the risk for dental caries and should be avoided.

Salivary substitutes containing carboxymethylcellulose (Salivart[R], Xero-Lube[R]) can be used to provide lubrication during sleep and between meals (McDonald & Marino, 1991) Oralbalance[R] (Laclede Research Laboratories, Gardena, CA) is a lubricating gel that contains natural enzymes. It will provide lubrication lasting up to 8 hours in patients who are NPO. Additionally, it can be used safely in patients on nasal or facemask oxygen and can be reapplied as needed.

Synthetic saliva products are the best choice in patients with excessive dryness of the oral cavity. Traditional oral lubricants such as Vaseline[R] and glycerin swabs are no longer recommended because of the limited benefits associated with these products in clinical studies (Beck & Yasko, 1993).

Medication dosing schedules may need to be adjusted to avoid maximum medication levels at night when xerostomia is most often worse (McDonald & Marino, 1991). In addition, a cold air humidifier can provide additional moisture to patients who breathe through their mouth. In any patient, xerostomia can be a precursor environment for oral infection.

Candidiasis is a type of yeast infection that occurs when the skin or mucous membrane is infected with any species of Candida (Tabers, 1997). Yeast is a common flora in the mouth, but under certain circumstances, it can become invasive and problematic. Risk factors that can predispose a person to candidiasis are diet (soft, pureed), mechanical irritants (tobacco, alcohol), dental appliances (ill-fitting dentures), pathological conditions, medications, and other treatments (see Table 2). The development of candidiasis can be the first indication of other problems like AIDS, vitamin deficiencies, or diabetes.

The colonization of the oral and pharyngeal regions by Candida species, especially Candida albicans is extremely common (Shay et al., 1997). C. albicans is also called thrush. Oropharyngeal candidiasis is reported in at least 63% of healthy denture-wearing adults and 70% of denture-wearing adults living in hospice or long-term care facilities (Shay et al., 1997). In normal adults without lesions or dentures, 30% to 45% of the adults have C. albicans in their saliva or oral cavities (Shay et al., 1997).

The results of candidiasis can vary from asymptomatic or mild discomfort, to severe pain, bleeding, infection, and altered nutritional status and quality of life. In people with compromised immune systems, candidiasis can spread to the blood stream, lungs, and upper gastrointestinal tract. Systematic candidiasis, or candidemia, is caused by C. albicans in 60% to 75% of all cases (Shay et al., 1997). It is a serious problem for patients receiving cytotoxic antineoplastic chemotherapy, and it accounts for 70% to 80% of all fungal infections in this population. Candidemia in these patients carries a mortality rate of 71% to 79% (Shay et al., 1997).

Candidiasis can be acute, chronic, or combined with bacteria. The two acute candidiasis are pseudomembranous (thrush) and atrophic (erythematous). Both pseudomembranous and atrophic also can be chronic. Other chronic candidiasis are hyperplastic (candidal leukoplakia), and atrophic (denture stomatitis). Median rhomboid glossitis, angular cheilitis (perleche), and often chronic atrophic candidiasis are mixed bacterial/fungal microflora (Holmstrup & Axell, 1990; Shay et al., 1997) (see Table 3 for a clinical description of each type).

Table 3. Description of Common Oral Conditions
Condition          Description               Treatment

Fungal infec-
 tion:             Discrete, white, often    Fungal Infections:
Acute pseudo-       curd-like patches on     Good oral hygiene
 membranous         the surface of the       Topical or systemic
(thrush, moni-      labial and buccal mu-    antifungal medication
 liasis)            cosa, hard and soft      Topical: (nystatin or
                    palate, periodontal       clotrimazole lozeng-
                    tissues, tongue, or       es). Use for at least
                   oropharynx. Can be         14 days, if not re-
                    wiped off, leaving a      solved in 3-6 weeks,
                    reddened or bleeding      then systemic treat-
                    base. Not usually         ment may be necessary.
                    painful, may feel        Usually used 3-4 times
                    burning.                  per day. Nystatin pow-
                                              der, mixed with water
Fungal infect-                                is recommended for
 ion:              Associated with a          long-term use if pa-
Acute atrophic      burning sensation on      tient has natural
(erythematous)      the tongue or in the      teeth or is diabetic
                    mouth, Tissue is         (suspension high in
                    bright red, often         sucrose). If dental
                    with ill-defined bor-    prosthesis, remove
                    ders. Loss of fili-       prosthesis before
                    form papillae on the     rinsing, soak in dilu-
                    tongue. Denuded areas     ted antifungal
                    look glossy (often       agent for 4-6 hours
                    associated with           daily.
                    AIDS).                   Systemic: (ketocona-
                                              zole, fluonazole, am-
Fungal infect-                                photericin B)
 ion:              Not painful or sore.      Leukoplakia: Rule out
Chronic hyper-      Discrete, raised les-     cancer, remove source
 plastic (can-      ions that vary from       of trauma or friction,
 didiasis or        small, translucent,       excision of lesion if
 buccal leuko-      barely palpable, whi-     necessary.
 plakia) or         tish areas to dense,
Viral infect-       opaque plaques that
 ion:               are rough and hard to
Hairy leuko-        touch. Usually loca-
 plakia             ted on lateral border
                    of tongue or buccal
                    mucosa. Cannot be
                   scraped off easily.
                    Considered pre-malig-
                    nent and associated
                   smoking and AIDS. Can
                    be associated with
                    candidiasis or a
                    virus.

Fungal, bacte-
 rial, gonococ-
 cal or mixed      Localized or genera-      See fungal infections
 infection:         lized erythema and e-     above and bacterial
Chronic atro-       dema. Usually on area     infections below.
 phic               covered by dentures       Nystatin ointment al-
(denture stoma-     (hard palate). Le-        so can be placed
 titis)             sions vary from pin-      under dentures.
                    point reddened areas
                    to severe inflamma-
                    tion of mucosa with
                    very vascular papil-
                    lary nodules. Usually
                    painless or slight
                    soreness. Can have a
                    persistent salty
                    taste.

Fungal, bacte-
 ria, or mixed     Chronic, elevated,        Nystatin ointment is
 infections:        whitish, rectangular      useful. Treat vitamin
Median rhomboid     area of atrophy of        deficiency.
 glossitis          the filiform papillae
                    midline and midsec-
                    tion on the tongue.
                    Not usually painful.
                    May have an aching
                    tongue.

Fungal, bacte-
 ria, or mixed     Reddened fissuring at     Bacterial Infections:
 infections:        one or both corners      Mouth care at least 4
Angular che-        of the mouth. Center      times per day. Good
 litis              is pale with serous       hydration. Salivary
(perleche)          exudate. Periphery        stimulation: sugar-
                    may be raised, red-       less candy or gum,
                    dened, or speckled,       flavored drinks with
                    with bleeding on wide     no caffeine, sugar,
                    opening of the mouth.     or alcohol. Appro-
                    Can be itchy, pain-       priate antibiotic,
                    ful, or painless. Can     often bacitracin,
                    be associated with        neomycin, polymycin B
                   candidiasis, staphylo-     applied topically or
                    coccus epidermidus,       a systemic antibio-
                    or riboflavin defi-       tic.
                    ciency.

Usually bacte-
 rial infec-
 tions:            Varies from mild ery-     See bacterial infec-
Mucositis           thema in the mouth to     tions care. May need
                    ulcerative lesions        antifungal or antivi-
                    extending the length      ral treatment. For
                    of the GI tract. Of-      pain relief: swish
                    ten related to chemo-     and spit mixture of
                    therapy or radiation      kaolin and pectin,
                   and appears 5 to 7         diphenhydramine hy-
                    days after treatment      drochloride and lido-
                    begins. Associated        caine or topical an-
                    with change in voice      esthetics like benzo-
                    and dysphasia. Usual-     caine or diclonine.
                    ly painful. Ulcers        Keep lips well lubri-
                    vary in appearance        cated with petroleum
                    with type of causa-       or water soluble jel-
                    tive organism.            ly. Avoid alcohol,
                                              tobacco, spicy or
                                              acidic foods, and ve-
                                              ry hot or cold foods.

Viral infec-
 tion:             Cluster of vesicles or    Viral Infections:
Herpes simplex      punched-out looking      Acyclovir as a topical
                    ulcers on the lips or     ointment, suspension,
                    mucosa. Very painful      oral, or IV. Prophy-
                    with gingiva inflamed     lactic anti-fungals
                   and swollen. Associa-      may be used.
                    ted symptoms can be
                    fever, myalgia,
                    malaise, or lymphade-
                    nopathy.

Viral infec-
 tion:             Unilateral, often
Herpes zoster       linear strips of
                   painful vesicular
                    lesions that usually
                   follow a branch of the
                    fifth cranial nerve.

Viral infec-
 tion:             Painful vesicular les-
Coxsackie           ions in the posterior
                    oropharynx that often
                    rupture into ulcers.
                    Associated with symp-
                   toms of fever, ma-
                    laise, myalgia. Seen
                    more often in child-
                    ren and in the
                    spring.

Periodontal
 disease:          Inflammation of the       Assess platelet le-
Gingivitis          gums with redness,        vels. Good oral hy-
                    swelling, and a ten-      giene and removal of
                    dency to bleed. Asso-     plaque. Control blee-
                    ciated with poorly        ding with pressure
                    fitting dentures,         from gauze saturated
                    mouth breathing, and      with ice water or
                    vitamin deficiencies.    frozen wet tea bag.
                                              Ice water irrigations
                                              or rinses.


Beck & Yasko (1993); Focazio (1997); Gibson & Niessen (1997); Holmstrup & Axell (1990); Lloyd (1998); Shay et al. (1997).

Chronic hyperplasia is caused by several factors and the candidiasis-related lesion often re-occurs after treatment. The viral or hairy leukoplakia is probably an interaction of the Epstein-Barr and human papilloma viruses. It also may be an early sign of autoimmune deficiency (Beck & Yasko, 1993).

Stomatitis, the inflammation of the mouth that is frequently caused by many of the chemotherapy agents, is one of the most common problems that occurs among patients with cancer. Forty percent of newly diagnosed patients with cancer will develop oral complications related to the disease process and its management (Beck, 1996). Antineoplastic drugs cause cell destruction. The stem cells of the oral mucosa are highly sensitive to the side effects of chemotherapy and can cause erosion of the buccal mucosa. This leads to the altered integrity of the epithelial lining and stomatitis occurs. Other causes of stomatitis include any condition associated with oral trauma including chemical and mechanical irritants such as tobacco, alcohol, and ill-fitting dentures.

Chronic atrophic candidiasis is the most common form of oropharyngeal infection in older adults (Shay et al., 1997). Often called denture stomatitis, it is usually due to Candida but can have multiple causes. Median rhomboid glossitis and angular cheilitis also can have multiple or mixed causes, but are usually due to Candida (Oksoala, 1990). In over 80% of patients with angular cheilitis there is a co-existent denture stomatitis (Oksoala, 1990).

Oral Care Management

For most patients, a simple and effective but often neglected nursing intervention in oral hygiene is toothbrushing using a soft-bristle toothbrush. Brushing the teeth as a part of routine oral hygiene and basic nursing care can be quite effective in preventing oral complications. In addition to toothbrushing, dental flossing helps to maintain a healthy oral environment by eliminating oral bacteria, reducing dental plaque (Beck & Yasko, 1993), and reducing bacteria and plaque near the gingival recessed areas (Lloyd, 1998). Ideally, toothbrushing and flossing should be done at least daily and should be performed after each meal and at bedtime (Pettigrew, 1989). In patients at greater risk for oral complications, assessment and oral hygiene may need to be more frequent.

Denture wearers are also at risk for developing complications related to inadequate oral hygiene. In edentulous patients oral hygiene involves brushing the gums and tongue and rinsing the oral cavity (Pettigrew, 1989). Patients should be reminded or assisted to remove their dentures at night to prevent bacterial accumulation and the development of oral mucosal lesions. Dentures should be cleaned with salt and sodium bicarbonate or a dentifrice and soaked at night and covered with water (Lewis et al., 1996).

Effective oral care entails not only cleaning the teeth and spaces between them, it also requires managing the gums and entire oral mucosa. This includes brushing the tongue (Pettigrew, 1989). Patients who are alert and oriented and have the manual dexterity to perform oral hygiene should be encouraged to routinely examine and brush their tongue. Care planning for capable patients should include and support routine oral hygiene as part of self-care and activities of daily living. For whatever reason, when this self-care practice is not possible every attempt should be made to routinely augment oral hygiene.

Meticulous oral care is particularly important for unconscious patients and those who have impaired gag reflex. This is especially true not only for those who are NPO but also patients who are minimally eating and drinking (Holmes, 1996). These patients do not produce sufficient saliva to maintain a healthy oral environment (Lewis et al., 1996).

Patients who are at risk for aspiration will need foam-stick tools during oral hygiene. The Ora-Swab[R] or other soft foam applicators can be used with a cleansing agent such as sodium bicarbonate or flavored 1.5% solution of hydrogen peroxide (Beck & Yasko, 1993). The Ora-Swab can be connected to a suction apparatus to facilitate aspiration of the cleansing agent and oral secretions. Caution must be exercised when performing oral hygiene and suctioning in patients with impaired gag reflexes. Also, the confused or agitated patient may become frightened and clamp down on oral care devices (Beck & Yasko, 1993).

A special group of patients who need particularly gentle and careful oral hygiene are those suffering from coagulopathy and who are on low platelet care precautions. In patients who have sensitive, fragile oral cavities, the toothbrush may not be the most appropriate tool (Pettigrew, 1989). Patients who are at risk for oral bleeding may best benefit from oral hygiene using the foam stick or other very soft oral cleaning applicators common in most hospitals (Pettigrew, 1989).

Managing Oral Candidiasis

To treat uncomplicated oral candidiasis Shay et al. (1997) recommend adequate oral hygiene and the rinsing with topical anti-fungal agents four times a day for 2 weeks. For edentulous patients, dentures must be removed while rinsing to allow the medication to reach the mucosa. Generally, all types of candidiasis infections are treated with antifungal medication (Gibson & Niessen, 1997). Nystatin is most often used to treat moniliasis (commonly called thrush or oral candidiasis) (Beck & Yasko, 1993) and is the most commonly prescribed topical rinse (Shay et al., 1997). It is available as an oral suspension, ointment, powder, and pastille (Gibson & Niessen, 1997).

For oral candidiasis, nystatin oral suspension (Mycostatin[R]) is usually given to adult patients as 100,000 units per ml and is administered in five milliliter doses four times per day (Lloyd, 1998). The patient is to swish 4 to 6 cc of the solution in the mouth for 2 minutes. The suspension should be swallowed after swishing to assist in treating oralphalangeal candidiasis (Beck & Yasko, 1993; Lloyd, 1998).

Another method of delivering nystatin is via oral troches. These are usually administered 3 to 4 times a day (Gibson & Niessen, 1997; Shay et al., 1997). However, this method requires an alert and oriented patient as the troche should be allowed to dissolve slowly (Beck & Yasko, 1993). The troche contains sugar and should be avoided in diabetic patients or for long-term therapy because of the increase risk of dental caries. Critical to managing oral candidiasis is the need to institute and maintain meticulous oral and denture hygiene.

In edentulous patients with candidiasis, the dentures also should be soaked in nystatin suspension. Patients should remove their dentures at night or for at least 6 hours every day (Shay et al., 1997). One millimeter of nystatin oral suspension should be added to the water used to soak acrylic prostheses (Lloyd, 1998).

Oral candidiasis is a common complication in frail older adults (Shay et al., 1997). To adequately manage a patient with candidiasis, the clinician must have knowledge of the patient's total clinical picture. The clinician must be cognizant of the patient's past and present drug regimen, other oral disorders, and duration of the infection. Moreover, complicated oral conditions occurring as the result of treatment conditions require a multidisciplinary approach to assure early intervention and meticulous assessment and management strategies.

Conclusion

Nurses are leaders in recognizing early changing patient status and problems. Astute assessment and early intervention often prevent serious complications before they can compromise therapeutic outcomes. There is clear evidence that oral conditions and complications can have a major impact on both morbidity and mortality outcomes in older adults. Conscientious assessment and adherence to promoting oral hygiene care can be a significant preventative and therapeutic process for older adults.

References

Adams, R. (1996). Qualified nurses lack adequate knowledge related to oral health, resulting in inadequate oral care of patients on medical wards. Journal of Advanced Nursing, 24, 552-560.

Beare, P., & Myers, J. (1990). Principles and practice of adult health nursing. St. Louis: The C.V. Mosby Company.

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Jane C. Walton, PhD, RN, CS, is Assistant Professor, Rush University College of Nursing, Chicago, IL.

Joanne Miller, PhD, RN, GNP, is Assistant Professor, Rush University College of Nursing, Chicago, IL.

Lydia Tordecilla, MS, RN, CWOCN, is Assistant Professor, Rush University College of Nursing, Chicago, IL.
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Author:Walton, Jane C.; Miller, Joanne; Tordecilla, Lydia
Publication:MedSurg Nursing
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Geographic Code:1USA
Date:Feb 1, 2001
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