Collaboration of Nursing and Dentistry

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Collaboration of Nursing and Dentistry

Summary

Introduction

In May 2000, Oral Health in America: A Report of the Surgeon General documented profound and consequential disparities in the oral health status of Americans, with the elderly at particularly high risk (Table 1). The Report called for critical dialogue and collaboration across health professions to decrease identified disparities in oral health care for older individuals. While the nursing profession generally recognizes the importance of oral health in older populations (Coleman, 2002; Holmes, 1998), it has not played a prominent role in oral health promotion and disease prevention for this vulnerable segment of the population, nor has there been a tradition of collaboration with the field of dentistry. This summary provides a rationale for interdisciplinary collaboration between nursing and dentistry to address oral health disparities in the elderly population, and suggests recommendations to foster collaborative practice and education between these two disciplines.

Rationale for Nursing-Dental Collaboration

The American Academy of Nursing (AACN) (1995) and the Pew Health Professions Commission (1993) challenge nursing and all health care disciplines to work collaboratively with each other, as the complex needs of society exceed the capability of any single discipline. Excellence in geriatric healthcare demands effective collaboration among disciplines, and this is particularly true regarding oral healthcare. Several interacting factors contribute to the thorny challenge of providing quality oral healthcare to an increasingly complex and diverse elderly population, and point to the need for collaborative relationships between nursing and dental health professionals.

Demographic Trends

Since 1900, the percentage of Americans age 65 and over has more than tripled, and increasingly more elderly are retaining their natural teeth at all ages. Yet, older adults report many more primary health care provider visits annually than dental visits, which are often not covered by health insurance for seniors. Dentate elderly thus remain at risk for oral disease and disability. The fastest growing segment within the older-adult cohort is people age 85 and older. This group is more likely to be frail, dentate, reside in nursing homes, and have a profound need for oral health care assistance by nursing and dental staff, which is often limited. Indeed, data from the United States and abroad clearly indicate that oral health of individuals in nursing home settings is consistently substandard. Rates of total tooth loss (edentulism) have declined, but there are sharp differences in prevalence by race and income, with Blacks and low income elders more likely to be edentulous. Edentulism has obvious negative esthetic and functional (speech, chewing/eating, nutritional) consequences, and the emotional impact of total tooth loss can be profound. In addition, longer life expectancy is associated with chronic disease burden, and many elders take multiple prescriptions and over-the-counter drugs. It is not uncommon for these medications to have side-effects which are detrimental to their oral health. For example many medications reduce salivary flow, resulting in dry mouth, which can cause difficulty with taste perception, chewing, speaking, denture-wearing, and swallowing, as well as increase caries risk and soft tissue problems. Since the typical patient a nurse cares for today is an older adult, nurses must play a more visible role in the oral health care of elders who are least likely to access dental services.

Self-Care Deficits and Diminished Capacity

Even in healthy seniors, self-care deficits related to sensory (e.g., vision), cognitive (e.g., dementia), mobility (e.g., manual dexterity; range-of-motion) and endurance deficits present challenges to maintaining and preserving good oral health. In the nursing home setting, over 83% of residents are impaired in three or more activities of daily living, and require assistance with oral care. Yet provision of oral care by nursing staff is customarily inadequate and frequently eliminated. Cognitive and behavior problems are also prevalent in the nursing home setting, and the impact of dementia on oral health is profound. Individuals with dementia are more likely than non-demented elders to have impaired oral health as a result of poor oral hygiene, including high dental and denture plaque loads, calculus, gingival bleeding, caries and tooth loss. Moreover, resistive behaviors are frequently encountered by caregivers, which typically discourage this care. Dentists often refuse to care for compromised residents in long-term care facilities due to lack of geriatric training and interest, low reimbursement and poor treatment facilities. Additionally, only a minority of physicians caring for nursing home residents view the oral cavity as important. These perceptions demonstrate the need for greater communication, training and support between dentistry and nursing to attain mutual goals for geriatric oral healthcare.

Oral and Systemic Health

There is increasing evidence linking oral health to general health. Poor oral health has been associated with cardiovascular disease, risk of ischemic stroke, peripheral vascular disease, poor nutrition, and respiratory infection in compromised elderly. In a recent study, daily oral hygiene care reduced the risk of pneumonia among elderly nursing home residents (Yoneyama et al, 2002). Further, common systemic diseases and their treatments can adversely affect geriatric oral health, including diabetes, HIV, Alzheimer's disease and depression. Evidence suggests that a straightforward and familiar nursing intervention, brushing teeth, can yield important health benefits and improve quality of life for nursing home residents. A better understanding of the oral implications of systemic disease is needed by both dental (Ghezzi & Ship, 2000) and nursing professionals.

Gaps in Nursing Education

There is a recognized shortage among all healthcare professionals educated to care for older persons. Fewer than 1% of nurses are certified in geriatric nursing, and only 3% of advanced practice nurses specialize in care of the older adult. In 1999, only 1,800 nurses were certified as geriatric nurse practitioners, and slightly more than 500 as gerontology clinical nurse specialists, according to the American Nurses Credentialing Center. A 1999 study found that only 23% of baccalaureate nursing programs had a required course in geriatric nursing (Rosenfeld et al., 1999). In this educational environment, future nurses will have difficulty developing the skills necessary to care for a growing population that is characterized by aging and chronic illness. The current educational curricula in nursing schools and nursing assistant training programs contain limited integration of oral health content, and are inadequate to meet the oral health goals of Healthy People 2010. Only one-half hour or less of the total professional nursing curricula is devoted to geriatric oral health (Jones, Fulmer & Wetle, 1988), and nursing assistant curricula is similarly inadequate (Logan, Ettinger, McLeran & Casko, 1991). Negative perceptions about oral healthcare are numerous: e.g., descriptions that include fear, disgust, and harm; and attitudes that such care is unpleasant, burdensome, unrewarding, problematic, and trivial. Since most older patients are more likely to see a primary care provider than a dentist, the need for oral health content is critical. Nurses must be sufficiently conversant with oral health needs to have an impact on this aspect of care. Oral health educational programs directed at caregivers by dentists and dental hygienists have shown some promise in achieving short-term oral health benefits for elders in the long-term care setting, in addition to improving caregiver knowledge and attitudes. Additionally, collaborative interactions with dental hygienists have improved nurses' knowledge and abilities related to oral care in the intensive care unit (ICU) (Fitch, Munro, Glass & Pelligrini, 1999). To help nurses increase their knowledge and their commitment to oral healthcare and disease prevention, more formal systematic collaboration between nursing and dental health professionals in educational curricula is needed.

Lack of Protocols to Meet Current Standards

It is hardly surprising that oral health gaps in nursing education are reflected in geriatric nursing practice, where oral care frequently fails to meet established standards. Federal regulations, as well as guidelines issued by The American Society for Geriatric Dentistry (Helgeson & Smith, 1996), have promulgated standards for oral health care in long-term settings that include the provision of regular oral hygiene and assessment. But current nursing practice falls short of these expectations. For example, federal regulations require that all long-term care facilities with Medicare and Medicaid reimbursement complete a comprehensive health assessment for each resident (known as the Minimum Data Set, MDS), which includes oral health. Registered nurses are required to complete the two sections of the MDS that pertain directly to oral health (sections K and L) and responses may indicate oral health problems, resulting in "triggers" requiring intervention, care-planning and thus possible improvements in oral health. Recent studies, however, suggest that use of the MDS to detect oral health concerns is limited, as nurses' assessments identify few oral health or hygiene problems via the MDS (Thai et al., 1997). Further, current oral care practice by nurses is not evidence-based, and does not include a defined mechanical component. In both healthy and institutionalized populations (Day, Martin & Chin, 1998), toothbrushes are most effective for plaque removal, but foam swabs are most commonly used for brushing teeth, even though swabs are not effective for plaque removal (Pearson, 1996). In a survey of nurses in a respiratory ICU, most nurses used a foam swab dipped in water or mouthwash, and this practice varied from patient to patient (Grap, Munro, Ashtiani & Bryant, 2003). Nurse's aides and hospital nurses typically use foam swabs rather than toothbrushes to brush client's teeth (Adams, 1996; Chalmers et al., 1996).

Fear, perceived difficulty, lack of knowledge, uncooperative residents, lack of supplies, lack of time and lack of staff are reported as barriers to oral care. Possible solutions to overcome these barriers exist. Toothbrushing assistance or supervision to an elder with poor neuromuscular strength or coordination may not reduce plaque optimally. Recent studies comparing ultrasonic and conventional manual brushes in care-dependent and outpatient elderly populations have demonstrated improvement in oral health indices (e.g., plaque levels, gingival health) for ultrasonic devices. Cost, in addition to resident and caregiver compliance, may be a concern, however, especially for cognitively impaired elders. Chemical control of plaque using chlorhexidine (CHX) (e.g., Peridex, PerioGard) preparations (mouthrinses/sprays/gels/swabbing) has been used to improve oral hygiene in elderly populations (Clavero et al., 2003; Weitz et al., 1992). Similarly, CHX-impregnated gum can improve oral health indices in nursing home elders (Simons et al., 2002), but gum has limited application in residents who cannot chew secondary to functional or cognitive impairment. Importantly, CHX preparations are prescription, have local side effects (reversible teeth staining; altered taste perception), and require monitoring by nursing home staff, factors that can further limit their feasibility.

Currently, no extensively tested evidence-based oral care protocols exist for the institutionalized elderly. Moreover, within the dental profession itself, practice guidelines have not been fully developed or implemented (Strayer & Henry, 1996). While no "best practices" have yet been established for maintaining oral health care for elderly individuals, protocols developed and tested collaboratively between nursing and dentistry offer a "best practices" approach to improving oral health care. More fundamentally, working together will ultimately benefit the elder as any dental treatment or restoration will fail in the long-term if not maintained through preventive and regular oral care provided by nursing.

Recommendations

National attention to the issues of oral health disparities has been fostered by the Surgeon General's first ever report on Oral Health, but grassroots efforts and academic dialogue must fuel the energy sparked by that historic document. Nurses play an important role in helping clients access preventive health services, including oral healthcare. The following recommendations are suggested to encourage and stimulate dialogue between the professions of nursing and dentistry to improve oral health care for the elderly.

Address educational gaps in oral health education and training for professional nurses at both the graduate and undergraduate levels. By not insisting on quality oral health care, whether reflected in our practices, our curricular decisions, or both, we reinforce the idea that the oral cavity has minimal impact on the body. This has particular relevance for nursing home elderly, whose are less able to tolerate inadequacy. Raising awareness about the importance of oral health is an essential first step. Evidenced-based core professional nursing curricular content focused on primary and secondary preventive interventions, as well as skills, should be emphasized. Content on geriatric oral health could be integrated into familiar areas of concern to nursing, such as nutrition, host protection, health promotion, health assessment, psychosocial and palliative care. Curricular mapping and discussions about essential content, knowledge and skills should be done in collaboration with dental professionals.
Critically evaluate the content and methodology of oral health care training for CNAs. While it is a national requirement for all nursing assistants to be certified to work in a long-term care facility, there are no national standards that mandate the specific practice expectations, content or competencies for preparation of the CNA to provide oral care to residents. Each state defines the standard for oral care and its implementation in the nursing home. Typically, oral health content is very sketchy. Content should explore caregivers' attitudes, experiences about their own oral/dental health, and their expectations about achieving optimum oral health for elders. The program must demonstrate the practical realities of providing oral care to residents who are cognitively, functionally and behaviorally impaired, and must be supported by the facility dental and nursing team. Relating the content to the difficulties CNAs experience may foster increased self-efficacy skills for oral care. Experience from training programs indicates that use of small groups, multiple teaching formats and a venue free from interruptions are important to success.
Establish community and institutional partnerships with nursing and oral health professionals. The lack of interaction between dentistry and nursing fosters professional isolation of the two disciplines, but by working together they can more effectively foster the integration of oral health into general health. Dental education programs could partner with schools of nursing to promote interdisciplinary training and service learning opportunities. Community-based nursing centers and clinics could similarly partner with dental education programs. Unfortunately, little published data on collaborative efforts between nursing and dentistry exist. Two articles were found that described collaborative practices between dental hygienists and nurses to improve oral health services for children in the community (Fellona & DeVore, 1999; Kraus, Connick & Morgan, 2002). Experiences from both settings indicated that the availability and support of dental professionals helped nurses to integrate oral health screening, prevention, education and referrals. In another study, a nurse researcher and her research team, working alongside dental colleagues, demonstrated the value of collaboration in accomplishing dental examinations and care in severely demented nursing home elders (Kayser-Jones, Bird, Redford, Schell & Einhorn, 1996). Collaborative efforts such as these could spawn the development and implementation of "best practices" for oral health care in nursing homes and other settings. It is also important for nurses to work with dentists to obtain federal funding to train nurses to deliver and integrate preventive oral health services to those in greatest need. In addition, appointing a nursing representative on the American Dental Association's council that deals with interprofessional relations may help facilitate collaborative efforts.
Develop and Promote Institutional Strategies to Raise the Profile of Oral Healthcare. New initiatives can be effective but their impact typically unravels if the nursing home does not weave the new information into the day-to-day fabric and daily routine of the facility. Sustaining best practices is challenging in nursing homes. Oral health initiatives can be bolstered by casting a wider educational net, developing a greater sensitivity to time and resource requirements to complete oral care, and identifying a "champion" to encourage oral health initiatives. Education should be directed to all stakeholder groups, including administrators, physicians, family members, and residents as appropriate. Typically educational approaches target CNAs exclusively, who have little decision-making power to implement practice changes. Obtaining a formal commitment from administrators for dedicated time, resources and space for the training will acknowledge the importance and value of this education. The dentist or the dental hygienist should actively participate in the care-planning process for residents; their involvement is necessary to provide expertise, teaching and formulation of oral health goals. Bedside rounds with selected residents who present challenges to oral care should be made with the facility dentist, dental hygienist, nurse practitioner and/or nursing staff to provide help and suggestions. Incorporating systematic audit and feedback strategies that involve evaluation by both nursing and dentistry can foster communication about the quality of care and improvements that may be needed. There is strong evidence indicating that nursing homes do not have enough CNAs to provide good care even when they are well-trained (Schnelle, Alessi & Simons, 2002). Lack of time and staff are consistently reported as barriers to oral care in the frequently busy and understaffed nursing home. We need to know the time and resource requirements for implementing new skills and knowledge gained from oral care programs, and how to integrate this care into current workloads. Finally, the "oral care champion," an individual within the organization with special training who is able to transmit her/his expertise to others, may be a useful model to raise the profile of oral health care in the nursing facility (Wardh, Hallberg, Berggren, Andersson & Sorensen, 2003).

Conclusion

Research confirms the prevalence and serious risks of poor oral health among the elderly, demonstrating the vital importance of good oral health to the general health and well-being of this population. But we have yet to translate our knowledge into more informed practice in geriatric care. Collaboration between nursing and dental professionals offers great promise for increasing awareness, improving education and training, and promoting higher standards of oral care for elder patients.

Table 1. Summary of Oral Disease Burden: Older Adults

Twenty-three percent of 65-to 74-year olds have periodontal disease. Also, at all ages men are more likely than women to have more severe disease, and at all ages people at the lowest socioeconomic levels have more severe periodontal disease.
About 30 percent of adults 65 years and older are edentulous, compared to 46 percent 20 years ago. These figures are higher for those living in poverty.
Oral and pharyngeal cancers are diagnosed in 30,000 Americans annually; 8,000 die from these diseases each year. These cancers are primarily diagnosed in the elderly. Prognosis is poor. The 5-year survival rate for white patients is 56 percent; for blacks, it is only 34 percent.
Most older Americans take both prescription and over-the-counter drugs. In all probability, at least one of the medications will have an oral side effect, usually dry mouth. The inhibition of salivary flow increases the risk of oral disease because saliva contains antimicrobial components as well as well as minerals that can help rebuild tooth enamel after attack by acid-producing, decay-causing bacteria. Individuals in long-term care facilities are prescribed an average of eight drugs.
At any given time, 5 percent of Americans aged 65 and older (currently some 1.65 million people) are living in a long-term care facility where dental care is problematic.
Many elderly individuals lose their dental insurance when they retire. The situation may be worse for older women, who generally have lower incomes and may never have had dental insurance. Medicaid funds dental care for the low-income and disabled elderly in some states, but reimbursements are low. Medicare is not designed to reimburse for routine dental care.
Nursing homes have limited capacity to deliver needed oral health services.

Source:

Oral Health in America: a Report of the Surgeon General. Rockville, MD: U.S.
Department of Health and Human Services, National Institute of Dental and Craniofacial
Research, National Institutes of Health, 2000.

References

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