Oral Care: Part 6b Oral Care Techniques

1. Oral Care: Part 6bOral 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

2. 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

3. 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

4. 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

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

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

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

8. A Best Practices Approach to Oral Care in LTC homes • Care Planning Strategies • 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

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

10. Dry Mouth (Xerostomia) • Medicationside effect of a dry mouth • is the most common cause of Xerostomia • More than 250 medications can cause a dry mouth • 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

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

12. Dry Mouth: What to Look For and What You Can Do • What You Can Do: • Review of current medication • Sip water or suck on ice chips • Rinse mouth with club soda • Use special mouth moisturizing products • such as artificial saliva • Use special toothpastes • Apply water-based lip lubricant • Use sugar-free gum/candies • Use a cool mist humidifier, especially • at night • Consult with an oral health professional What to Look For: • Dry, irritated, cracked lips, corners of mouth, tongue • Trouble chewing, swallowing, eating, speaking, • Lips that stick to teeth or dentures • Red gums that bleed easily • Bad breath • Stringy, thick saliva • Problems wearing dentures • 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

13. 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

14. 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

15. 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

16. 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

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

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

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

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

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

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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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 21st 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

29. 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