Explanation
The over-65s age group was estimated to account for 25% of the Japanese population in 2015. Approximately 2 million people in this age group in Japan required nursing care or assistance in 2000, and this number is expected to rise to 5.3 million by 2025. The rapidly increasing numbers of elderly people receiving nursing care need living support aimed at enhancing their quality of life (QoL). In the field of oral health, spread of oral care plays a vital role. This module covers the definitions of and the effectiveness expected from oral care and explains oral health practice and procedures for elderly people requiring nursing care.
Explanation
First, let's look at oral health practice for the increasing number of elderly people receiving nursing care. In this photograph, this patient has left hemiplegia resulting from a stroke, with accompanying retention of food debris in the left side of the mouth. In Japan, strokes are reported to be around 1/3 to 1/4 of causes for bedridden. When a stroke leads to hemiplegia, the person experiences decreased motor function in the mouth, tongue, and buccinator muscle and has difficulty forming a bolus. Unilateral hemiplegia goes beyond a loss of sensation in the affected side; food debris accumulates in the mouth over time due to the paralysis on the affected side. Also, paralysis of the muscle groups involved in swallowing is likely to cause aspiration and at a high risk of aspiration pneumonia. So, oral hygiene requires constant attention and scrupulous oral care. The photograph here was taken at an initial dental examination, and we can infer that oral care had not been done or had been done without sufficient care.
Explanation
Patients with cognitive impairment may have limited capacity for, and awareness of, oral hygiene, and combined with refusal of oral care, the result may be very poor hygiene within the oral cavity. This represents a hazardous state of oral health. For the patient shown here, she wore dentures in throughout a year-long period, resulting in piled up plaques on dentures (denture plaque) as well as plaque accumulated on the teeth with periodontitis. Plaque forms a favorable environment for intraoral bacteria to proliferate. Left unchecked, this condition can become very dangerous because it leaves them prone to aspiration pneumonia. So, patients require scrupulous oral care that covers plaque removal for false teeth and natural teeth. Like the photograph on the previous slide, these photographs here suggest a lack of or inadequate oral care.
Explanation
We face some challenges in promoting oral care. Here we see some results of a study on the current status of oral care and the progress made in promoting it for nurses on a certification program of dysphagia nursing in Aichi prefecture, Japan. In this study, 13% responded that suitable oral care was provided for patients, 3% responded that the current situation for oral care was adequate, and 84% responded that it was inadequate. Nurses are responsible for oral care provided to institutionalized patients, yet the findings suggest that oral care is often be neglected because of nurses' heavy daily workloads.
Explanation
There are currently multiple definitions of oral care from the different aspects. The definition of and perceptions about oral care may differ by profession; for example, the views may differ between physicians and dentists and between nurses and caregivers. Recently, oral care is coming to mean "cure" as well as "care", and when we are considering promoting a team approach for elderly patients, obviously health professionals involved need to grasp the entire concept of oral care.
A variety of definitions and classifications have been proposed for oral care, some of which are outlined here. However, we should remember that oral care is an emerging concept representing an approach that covers all aspects of oral health including structural/functional approach, performance, and psychological aspects, to facilitate smooth oral intake and manage oral hygiene.
Various approaches have also been proposed for the classification of oral care. If we classify oral care according to its content, it can be regarded as either organic oral care (ie, care aimed at preventing oral disease and respiratory tract infection through improving oral hygiene with an emphasis on cleaning) or functional oral care (ie, care aimed at recovering or maintaining oral function). Providers of oral care might use classifications of regular oral care (where the patient and/or caregiver can carry out oral care as normal) and specialist oral care (where it is provided by dental hygienists, nurses, speech therapists, or other professionals with specialist knowledge and experience).
Explanation
Here is a case in which oral care was effective. In this case, oral care was carried the following 4-week protocol.
Clean membranes of the oral cavity with a sponge impregnated with mouth wash (1 min).
Gently apply a tongue brush to the tongue 10 times, brushing from the back to the front of the tongue, to remove coating on the tongue (30 s).
Use an electric toothbrush to clean the teeth, and where necessary, the mucus membranes (2 min 30 s).
Have the patient gargle with a mouthwash (1 min).
Before starting the protocol, the gingiva was swollen and red, and a large amount of food debris had accumulated on the paralyzed right side of the mouth. By the end of the 4-week protocol, the food debris had disappeared and the gingiva had recovered to an almost normal condition. This suggests that the oral care protocol applied once daily was effective.
Explanation
The effectiveness of oral care has been evaluated, as shown here. Pre- and post-treatment plaque and gingival indices were analyzed statistically using the Wilcoxon matched-pairs test. The time points for evaluation were before and 8 weeks after the initiation of oral care, and the analysis revealed significant decreases in both indices, indicating that oral care was helpful substantially improving the intraoral environment.
Explanation
The effectiveness of oral care against aspiration pneumonia has also been reported. With specialist oral care, there was a lower incidence of pneumonia than with conventional oral care. As well as helping to prevent aspiration pneumonia, other studies demonstrated that perioperative oral care in patients with head-and-neck cancer reduced the occurrence of postoperative infections. These findings show the importance of providing specialist oral case on a regular basis.
Explanation
Aged patients visiting dental clinics increase along with growing aged society. To provide oral care safely to patients and prevent perioperative and postoperative complications, we have to determine whether their current oral care is appropriate by identifying the extent of systemic disorders through interviews about the patient's medical history. We must give particular attention to elderly patients because they tend to develop chronic conditions such as underlying disease or lifestyle diseases as their physiological function declines.
An understanding of the underlying disease and current general condition are crucial when oral care is to be provided. This is to prevent oral diseases that can result from systemic conditions and possible complications related to oral care.
Explanation
Oral care is provided as a directly life-maintaining and life-prolonging measure such as prevention of aspiration pneumonia, as well as a living support measure. Oral care is suggested to have the effects outlined here.
Prevention of oral infection:
It prevents dental conditions such as tooth decay and periodontal disease, and oral infections such as Candida-related mouth infections.
Maintenance and recovery of oral function:
It improves chewing and swallowing function, prevents loss of oral function and disuse syndrome, promotes salivary secretion, and enhances the senses of, for example, taste, touch, and temperature perception.
Prevention of systemic infections:
It reduces microbial pathogens for conditions ranging from aspiration pneumonia to infective endocarditis and opportunistic infections, and normalizes the microbiota, thus protecting against systemic infections.
Enhancement of QoL and general condition:
It enhances activities of daily living, improves general condition, and strengthens physical condition and motivation through its effects in promoting oral feeding and protecting against malnutrition and dehydration.
Recovery of communication function:
It allows the patient to improve and maintain the ability to articulate sounds, thus promoting recovery of communication function.
Socioeconomic effect:
It improves the general condition of elderly people and people requiring care, enabling a reduction in total nursing and care burden, as well as resultant increase in social productivity. It is expected to reduce healthcare costs through its preventive effect against systemic disorders such as aspiration pneumonia.
References
- Sumi Y., Uematsu H.: Oral Care Deliverable in Five Minutes - A Nurse-friendly Oral Care System (in Japanese). Ishiyaku Publications, Inc.
- Sumi Y.: Oral Care for the Elderly Made Possible for Anyone (in Japanese). Video, Chuohoki Publishing Co., Ltd.
- Sumi Y.: Learning Clinical Techniques for Tooth Extraction from Scratch (in Japanese). Ishiyaku Publications, Inc.
- Michiwaki Y., Sumi Y., Miura H., Nagaosa S., Yoneyama T.: Cost-Effectiveness Analysis of Oral Health Care for Depended Elderly (in Japanese). Ronen Shika Igaku (Japanese Journal of Gerodontology) 17(3), 275-280, 2003
- National Hospital for Geriatric Medicine, NCGG official web site (http://www.ncgg.go.jp/hospital/): Dentistry and Dental/Oral Surgery Clinic. "Oral Care Manual for Providers of Primary Care" (in Japanese).
