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					   Oral Care: Part 6b
     Oral Care Techniques

Using a Best Practice
    Approach in
  Long-Term Care

February 2008   Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
    Introduction:
    Learning Objectives
• Learn about
  • A best practices approach to oral hygiene care
  • Implementing general oral hygiene care techniques
        •      Dry mouth and swallowing problems
        •      Palliative oral hygiene care




   February 2008     Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
          Evidence-Based Approach to
          Oral Care for Older Adults from IOWA

                                                                    This evidence-based
                                                                    model of the importance
                                                                    of oral hygiene care and
                                                                    dental treatment on
                                                                    maintaining oral health
                                                                    from IOWA highlights
                                                                    several key areas:
                                                                    •Regular daily oral care
                                                                    •Preventive oral care
                                                                    •Assessment
                                                                    •Secondary & tertiary
                                                                    dental care
                                                                              
                                                                           Impacts
                                                                    •Systemic health
                                                                    •Nutrition
                                                                    •Quality of life
                                                                    •Overall well-being
February 2008   Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
            Develop an Individualized
            Oral Hygiene Care Plan
An individualized Oral
Hygiene Care Plan
enables care providers
to focus on appropriate
oral care interventions
for the resident

Oral Hygiene Care Plan
should be developed on
admission, quarterly
and as a resident’s oral
status or self care
abilities, cognitive or
functional impairment
changes

   February 2008    Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
         RNAO Oral Health BPG
         Care Planning




February 2008   Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
         RNAO Oral Health BPG
         Care Planning




February 2008   Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
         RNAO Oral Health BPG
         Care Planning




February 2008   Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
         A Best Practices Approach to
         Oral Care in LTC homes

Care Planning Strategies
6. Implement general oral hygiene care strategies
          •     Preparing for oral care
          •     Toothpaste and toothbrush tips: Natural teeth
          •     Denture care
          •     Communication techniques for oral care
          •     Techniques for getting in the mouth
          •     Handling responsive behaviours
          •     Handling communication, cognition & functional issues
               Dry mouth and swallowing problems
               Palliative oral hygiene care


February 2008     Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
           Dry Mouth (Xerostomia)

• The sensation of a dry mouth is medically termed xerostomia
• Residents with low salivary flow experience many problems such as:
    o Xerostomia (dry mouth)
    o Increased tartar deposits and dental decay
    o Difficulty clearing food and bacteria into the throat
    o Pain - mucosal soreness, gingivitis, cheilitis in the corners of the mouth,
      fissuring on the tongue, burning in the mouth
    o Salivary duct infections, yeast infections
    o Difficulty chewing, speaking, swallowing, and wearing dentures

• It’s important to remember that saliva plays a key role in the
    • Maintaining oropharyngeal health: oral cleansing, pH balance, speech, taste
    • Many functions of the gastrointestinal environment: swallowing and digestion


  February 2008     Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
         Dry Mouth (Xerostomia)

 • Medication side effect of a dry mouth
    o is the most common cause of Xerostomia
    o More than 250 medications can cause a dry mouth
                o Medications with oral side effects include antidepressants,
                  narcotics, antipsychotics, antiparkisonian, antiasthmatics,
                  antihypertensives

 • Residents who are taking medications which can cause
   xerostomia are at increased risk for plaque-related diseases
   and tooth decay
    • In a dry mouth, the oral environment is more acidic, oral
      bacteria thrive as there is less saliva for counteracting them,
      causing the rate of tooth decay and oral infections to
      increase

February 2008          Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
         Dry Mouth (Xerostomia)




February 2008   Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
         Dry Mouth: What to Look
         For and What You Can Do
What to Look For:                               What You Can Do:
 Dry, irritated, cracked lips,                 •   Review of current medication
  corners of mouth, tongue                      •   Sip water or suck on ice chips
 Trouble chewing, swallowing,                  •   Rinse mouth with club soda
  eating, speaking,                             •   Use special mouth moisturizing products
                                                    such as artificial saliva
 Lips that stick to teeth or dentures
                                                •    Use special toothpastes
 Red gums that bleed easily                    •   Apply water-based lip lubricant
 Bad breath                                    •   Use sugar-free gum/candies
 Stringy, thick saliva                         •   Use a cool mist humidifier, especially
 Problems wearing dentures                         at night
                                                •   Consult with an oral health professional
What to Avoid:
• Avoid lemon/glycerin swabs, mouth-rinses and toothpastes that contain alcohol,
sodium lauryl sulfate (most brands) or flavouring agents, candies or mints, sweet/spicy
or bulky foods, caffeine, tobacco, and avoid mouth breathing.
  February 2008      Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
       Swallowing Problems

• Dysphagia is an uncomfortable, frightening and
  potentially life-threatening condition because it
   • interferes with the oral intake of food and liquids;
   • can lead to aspiration, choking, suffocation,
     dehydration, malnutrition, decreased quality of life;
     and frustration for residents, family and staff; and
   • Interferes with oral care
• Up to 70% of residents will have signs of swallowing
  problems >> creating oral care challenges


February 2008   Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
       Swallowing Problems:
       Oral Care Tips
• Positioning
    • In a supine position (back) at about 45° or
    • Lying on their side with towel placed on pillow
       (this allow fluids to pool in the cheeks rather than being at risk of aspirating them)

• Check the mouth – look inside -to remove debris around teeth
    • Use propping devices when necessary but make sure there are no
      loose or broken teeth
    • May not be able to spit very well or clear their throat
• Place resident’s chin in neutral position to help prevent choking
  or aspiration
• Depending on the severity of the dysphagia or swallowing
  problem, the resident may require the use of
    • Suctioning as necessary
    • A suction-type toothbrush            (can’t use toothpastes as it blocks the suctioning)

February 2008         Central South/South West     Best Practice Coordinator in Long-Term Care Initiative
       Swallowing Problems:
       Oral Care Tips
• Toothbrush with water or mouthwash
   • Regular soft toothbrush should be dipped into water or mouthwash
     to brush teeth, clean tongue and gums
       • Gently massage gums and palate
       • Never use sponges or toothettes
   • Preferable to not use toothpastes
       • If toothpaste is used, select a non-foaming toothpaste
   • Water is also used for flushing the suction toothbrush if needed
   • Make sure debris and liquid is cleaned out of the mouth, may need
     to use a thin cloth such as a J-cloth
   • Apply non-petroleum lip balm

February 2008   Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
       Oral Care for
       Palliating Residents
 • 2 Ontario palliative clinical guidelines that include
       • mouth care guidelines that promote oral comfort and
         oral care for palliating residents with dry mouth,
         mucositis/stomatitis, candida/ herpes/bacteria infections



   http://www.ccac-ont.ca/Upload/esc/General/Palliative_Care_Managment_Tool_v3.2.pdf




 http://www.hpcconnection.ca/tools/pdf/clinical_practice_guidelines.pdf



February 2008         Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
       Oral Care for
       Palliating Residents




February 2008   Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
       Oral Care for
       Palliating Residents




February 2008   Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
       Oral Care for
       Palliating Residents




February 2008   Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
       Oral Care for
       Palliating Residents




February 2008   Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
       Resource Tools




February 2008   Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
       Resource Tools




February 2008   Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
       Resource Tools

                                                                     Halton Region Health
                                                                     Department’s Dental
                                                                     Health Division has
                                                                     developed an extensive
                                                                     oral care education
                                                                     program called “K.I.S.S.”
                                                                     for LTC staff
                                                                     -to assist staff to develop
                                                                     better oral care
                                                                     techniques
                                                                     - with full explanations
                                                                     and picture-based step-
                                                                     by-step instructions



February 2008   Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
       Resource Tools

                                               Registered Nurses
                                               Association of Ontario

                                               DVD I: Oral Care for
                                               Residents with Dementia
                                               (Spring 2007)

                                               DVD II: Oral Care for
                                               Xerostomia, Dysphagia and
                                               Mucositis
                                               (Spring 2008)

                                               www.rnao.org


February 2008   Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
        Resources
Canadian:

The Registered Nurses Association of Ontario (2008) . Oral health. Nursing assessment and interventions.
    Toronto, ON: Author. www.rnao.org (Recommendations Fall 2007).

The Registered Nurses Association of Ontario and Halton Region Health Department (Summer 2007). Oral
    care for resident with dementia (DVD)Toronto, ON: Author. www.rnao.org or phone Dir: (416) 907-
    7965 Fax:(416) 907-7962 $15 CDN

ML van der Horst (April 2007). The BP Blogger. Myth busting: The mouth issue. Monthly newsletter for
   LTC that dispels care myths with evidence from best practice guidelines. Available at: www.rgpc.ca

Halton Region Health Department (2006). Dental health manual for LTC home staff. Halton oral health
    outreach project. Oakville, ON: Author.

Centre for Community Oral Health- Long Term Care Fact Sheets. Nov 2006
    www.umanitoba.ca/faculties/dentistry/ccoh

Best Practice Coordinators in Long-Term Care Initiative – Central South/South West (February 2008). Best
     Practices Approach to Oral Care Resource Kit. www.rgpc.ca

Oral Care.ca www.oralcare.ca
February 2008            Central South/South West     Best Practice Coordinator in Long-Term Care Initiative
           Resources
Others:

The University of Iowa College of Nursing (2002). Oral hygiene care for functionally dependent and
    cognitively impaired older adults. Evidence-based practice guideline. Iowa City, Iowa:
    Author/Gerontological Nursing Interventions Research Center. www.nursing.uiowa.edu

Joanna Briggs Institute (2004). Oral hygiene care for adults with dementia in residential aged care
    facilities. Best Practice, 8(4). Adelaide, Australia: Author. www.joannabriggs.edu.au




   February 2008          Central South/South West   Best Practice Coordinator in Long-Term Care Initiative
             References

Fallon, T., Buikstra, E., Cameron, M., Hegney, D., Mackenzie, D., March, J., Moloney, C., & Pitt, J. (2006).
     Implementation of oral health recommendation into two residential aged care facilities in a regional Australian city.
     International Journal of Evidence-Based Healthcare, 4, 162-119.
Federal, Provincial and Territorial Dental Directors. (2005). A Canadian oral health strategy. Accessed January 4, 2007.
    Available at: http://www.fptdd.ca/Canadian%20Oral%20Health%20Strategy%20-%20Final.pdf.
Frenkel, HF., Harvey, I., & Needs, KM. (2002). Oral health care education and its effect on caregivers’ knowledge and
    attitudes: a randomised controlled trial. Community Dentistry and oral Epidemiology, 30, 91-100.
Frenkel, H., Harvey, I., & Newcombe, RG. (2001). Improving oral health in institutionalised elderly people by educating
    caregivers: a randomised controlled trial, 29, 289-297.
Nicol, R., Sweney, MP., McHugh, S., & Bagg, J. (2005). Effectiveness of health care worker training on the oral health of
    elderly residents of nursing homes. Community Dentistry and Oral Epidemiology, 33, 115-124.
Pearson, A. & Chalmers, J. (2004). Oral hygiene care for adults with dementia in residential aged care facilities.
    Systematic review. JBI Reports, 2, 65-113.



    February 2008             Central South/South West      Best Practice Coordinator in Long-Term Care Initiative
            References

Seniors Oral Health Collaboration for the Nova Scotia Department of Health (SOHC). (2006). The oral health of seniors
    in Nova Scotia. Policy Scan and Analysis: Synthesis report. Accessed January 15, 2007. Available at:
    http://www.ahprc.dal.ca/oralhealth/Reports/FINAL.pdf
Thorne SE, Kazanjian A, & MacEntee. (2001). Oral health in long term care: The implications of organisational culture.
    Journal of Aging Studies, 15, 271-283.

US Department of Health and Human Services (US DHHS) (2000). Oral Health in America: A Report of the Surgeon
    General. Rockville, MD: National Institute of Dental and Craniofacial Research, National Institutes of Health.
    Accessed January 15, 2007. Available at: http:/www.nidr/nih.gov/sgr/oralhealth.asp
Wardh, I., Hallberg, L., Berggren, U., & Sorensen, S. (2003). Oral health education for nursing personnel: experiences
   among specially trained oral care aides: One-year follow-up interviews with oral care aides at a nursing facility.
   Scandinavian Journal of Caring Science, 17, 250-256.
WHO. (2003). The world oral health report. Continuous improvement of oral health in the 21 st century – the approach of
  the WHO Global Oral Health Programme. Geneva, SW: author. Accessed: January 15, 2007. Available at:
  http://www.who.int/oral_health/publications/report03/en/


    February 2008            Central South/South West      Best Practice Coordinator in Long-Term Care Initiative
          For more information:
Mary-Lou van der Horst, RN, BScN, MScN, MBA
Regional Best Practice Coordinator Long-Term Care
Central South Region-Ministry of Health and Long-Term Care
 Village of Wentworth Heights LTC Home
1620 Upper Wentworth Street, Hamilton, ON Canada L9B 2W3
  email: mvanderhorst@oakwoodretirement.com
    tel: 905.541.0656
   fax: 905.575.4450                                 LTC Best Practice Resource Centre:
                                                            www.rgpc.ca
Donna Scott, RN, BScN, CHRP                                 www.shrtn.on.ca
Regional Best Practice Coordinator Long-Term Care
Southwest Region-Ministry of Health and Long-Term Care
Parkwood Hospital
801 Commissioner's Road East
London, ON Canada N6C 5J1
Email: donna.scott@sjhc.london.on.ca
Tel: 519-685-4292 x42337
.
   February 2008      Central South/South West   Best Practice Coordinator in Long-Term Care Initiative

				
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