Providing oral health care to older adults In: Evidence-based geriatric nursing protocols for best practice


Guideline Developer(s)

Hartford Institute for Geriatric Nursing

Date Released

2012

Evidence Supporting the Recommendations

References Supporting the Recommendations

Chalmers JM, King PL, Spencer AJ, Wright FA, Carter KD. The oral health assessment tool--validity and reliability. Aust Dent J. 2005 Sep;50(3):191-9. PubMed

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for selected recommendations (see the "Major Recommendations" field).

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Chart Documentation/Checklists/Forms
Mobile Device Resources
Resources

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Patient

  • Receipt of oral hygiene a minimum of once every 8 hours while in the acute care or long-term care or home setting
  • Referral of patients and families to dental services for follow-up treatment
  • Education of patients and families on the importance of good oral hygiene and follow-up dental services

Professional Caregiver/Registered Nurse

  • Assessment or evaluation of the oral cavity on admission and every shift
  • Notification of physician and dentist of any abnormalities present in the oral cavity
  • Assessment of what each patient can do independently
  • Observation of aspiration precautions while providing care
  • Provision of oral care and dental care education to patients and families

Institution

  • Provision of access to dental services as appropriate
  • Provision of ongoing education to health care providers
  • Provision of a yearly oral health and dental care in-service to health care providers
Potential Harms

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Methodology

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Although the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument (described in Chapter 1 of the original guideline document, Evidence-based Geriatric Nursing Protocols for Best Practice, 4th ed.) was created to critically appraise clinical practice guidelines, the process and criteria can also be applied to the development and evaluation of clinical practice protocols. Thus, the AGREE instrument has been expanded (i.e., AGREE II) for that purpose to standardize the creation and revision of the geriatric nursing practice guidelines.

The Search for Evidence Process

Locating the best evidence in the published research is dependent on framing a focused, searchable clinical question. The PICO format—an acronym for population, intervention (or occurrence or risk factor), comparison (or control), and outcome—can frame an effective literature search. The editors enlisted the assistance of the New York University Health Sciences librarian to ensure a standardized and efficient approach to collecting evidence on clinical topics. A literature search was conducted to find the best available evidence for each clinical question addressed. The results were rated for level of evidence and sent to the respective chapter author(s) to provide possible substantiation for the nursing practice protocol being developed.

In addition to rating each literature citation as to its level of evidence, each citation was given a general classification, coded as "Risks," "Assessment," "Prevention," "Management," "Evaluation/Follow-up," or "Comprehensive." The citations were organized in a searchable database for later retrieval and output to chapter authors. All authors had to review the evidence and decide on its quality and relevance for inclusion in their chapter or protocol. They had the option, of course, to reject or not use the evidence provided as a result of the search or to dispute the applied level of evidence.

Developing a Search Strategy

Development of a search strategy to capture best evidence begins with database selection and translation of search terms into the controlled vocabulary of the database, if possible. In descending order of importance, the three major databases for finding the best primary evidence for most clinical nursing questions are the Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Medline or PubMed. In addition, the PsycINFO database was used to ensure capture of relevant evidence in the psychology and behavioral sciences literature for many of the topics. Synthesis sources such as UpToDate® and British Medical Journal (BMJ) Clinical Evidence and abstract journals such as Evidence Based Nursing supplemented the initial searches. Searching of other specialty databases may have to be warranted depending on the clinical question.

It bears noting that the database architecture can be exploited to limit the search to articles tagged with the publication type "meta-analysis" in Medline or "systematic review" in CINAHL. Filtering by standard age groups such as "65 and over" is another standard categorical limit for narrowing for relevance. A literature search retrieves the initial citations that begin to provide evidence. Appraisal of the initial literature retrieved may lead the searcher to other cited articles, triggering new ideas for expanding or narrowing the literature search with related descriptors or terms in the article abstract.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence

Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/consensus panels

AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from http://www.agreetrust.org/?o=1397.

Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Not stated

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review
Internal Peer Review

Description of Method of Guideline Validation

Not stated

Identifying Information and Availability

Bibliographic Source(s)

O'Connor L. Oral health care. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editor(s). Evidence-based geriatric nursing protocols for best practice. 4th ed. New York (NY): Springer Publishing Company; 2012. p. 409-18.

Adaptation

Not applicable: The guideline was not adapted from another source.

Guideline Developer Comment

The guidelines were developed by a group of nursing experts from across the country as part of the Nurses Improving Care for Health System Elders (NICHE) project, under sponsorship of the Hartford Institute for Geriatric Nursing, New York University College of Nursing.

Source(s) of Funding

Hartford Institute for Geriatric Nursing

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Primary Author: Linda J. O'Connor, MSN, RNC, GCNS-BC, CLNC, Assistant Administrator for Nursing and Hospital Affairs, Mount Sinai Hospital, New York, NY

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Hartford Institute for Geriatric Nursing Web site.

Copies of the book Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th edition: Available from Springer Publishing Company, 536 Broadway, New York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web: www.springerpub.com.

Availability of Companion Documents

The following are available:

The ConsultGeriRN app for mobile devices is available from the Hartford Institute for Geriatric Nursing Web site.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on June 25, 2013. The information was verified by the guideline developer on August 6, 2013.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Scope

Disease/Condition(s)

Oral health

Guideline Category

Evaluation
Management
Prevention

Clinical Specialty

Family Practice
Geriatrics
Nursing

Intended Users

Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Hospitals
Nurses
Physician Assistants
Physicians

Guideline Objective(s)

To provide a standard of practice protocol to promote oral health through good oral hygiene nursing care

Target Population

Adults age 65 and older

Interventions and Practices Considered

Assessment/Evaluation

  1. Oral assessment or evaluation on admission and every shift
  2. Use of the Oral Health Assessment Tool (OHAT)

Management

  1. Oral hygiene plan of care for the edentulous patient
  2. Dependent mouth care for patients with teeth or partial dentures
  3. Assisted or supervised care
Major Outcomes Considered
  • State of oral health
  • Regular oral hygiene
  • Referral to dental services

Recommendations

Major Recommendations

Levels of evidence (I–VI) are defined at the end of the "Major Recommendations" field.

Parameters of Assessment

  • The registered nurse (RN) conducts an oral assessment or evaluation on admission and every shift. The nurse assesses the condition of:
    • The oral cavity: the oral cavity should be pink, moist, and intact.
    • The presence of or absence of natural teeth and/or dentures: natural teeth should be intact and dentures (partial or full) should fit comfortably and not be moving when the older adult is speaking.
    • Ability to function with or without natural teeth and/or dentures.
    • The patient's ability to speak, chew, or swallow.
    • Any abnormal findings such as dryness, swelling, sores, ulcers, bleeding, white patches, broken or decayed teeth, halitosis, ill-fitting dentures, difficulty swallowing, signs of aspiration, pain are documented by the nurse, and the healthcare team informed.
  • Assessment Tool: The Oral Health Assessment Tool (OHAT) (see the Resources section in the original guideline document for tool) (Chalmers et al., 2005 [Level III]).

Nursing Care Strategies

Oral Hygiene Plan of Care: Dependent Mouth Care of the Edentulous Patient

  • Oral care is provided during morning care, evening care, and as needed (PRN).
  • Wash hands and don gloves.
  • Remove dentures.
  • Brush dentures with toothbrush/toothpaste using up-and-down motion.
  • Clean the grooved area, which fits against the gum with the toothbrush. Rinse with cool water.
  • Brush patient's tongue.
  • Re-insert dentures.
  • Apply lip moisturizer.

Dependent Mouth Care: Patient with Teeth or Partial Dentures

  • Oral care is provided during morning care, evening care, and PRN.
  • Wash hands and don gloves.
  • Place soft toothbrush at an angle against the gum line. Gently brush teeth in an up-and-down motion with short strokes using the toothbrush.
  • Brush patient's tongue.
  • Apply lip moisturizer.
  • For partial dentures, follow procedure for full denture cleaning and insertion.

Assisted or Supervised Care

  • Oral care is provided during morning care, evening care, and PRN.
  • Assess what patient can do and provide assistance as needed.
  • Set up necessary items.

Definitions:

Levels of Evidence

Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)

Level II: Single experimental study (randomized controlled trials [RCTs])

Level III: Quasi-experimental studies

Level IV: Non-experimental studies

Level V: Care report/program evaluation/narrative literature reviews

Level VI: Opinions of respected authorities/consensus panels

AGREE Next Steps Consortium (2009). Appraisal of guidelines for research & evaluation II. Retrieved from http://www.agreetrust.org/?o=1397.

Adapted from: Melnyck, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & health care: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins and Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative reviews in a nursing service. Applied Nursing Research, 11(4) 195-206.

Clinical Algorithm(s)

None provided

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Staying Healthy

IOM Domain

Effectiveness
Patient-centeredness

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