The need for interdisciplinary collaboration to ensure dental hygiene is present in hospitals
by B. Michelle Strange, RDH, MSDH
Periodontal patients are a predominantly elderly population and tend to spend more time in hospitals than other demographics. When those patients return for periodontal maintenance appointments, they often demonstrate a decline in oral health since their previous appointment one month to six months earlier. When I ask patients about the change in their oral health, they generally tell me about a recent hospital stay and the resulting inability to perform their normal oral care regimen.
After years of carrying on this frustrating conversation with patient after patient, I began to envision a dental hygiene position in hospital intensive care units where oral assessments and proper oral care became part of the standard of care. This idea drove me to initiate a research study looking into the type of oral care performed on patients in the ICU. During the process of this study, I discovered that dental and medical care moved along parallel, closely linked paths that did not cross unless necessary. Further research continues to show just how strong a relationship exists between a patient's oral health and his or her overall health. The ability to fight infection is an important component for health professionals to understand.
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Medical professionals, such as nurses, understand the importance of oral health in disease prevention, but performing oral care is not an obvious nursing task.1 Each patient's healthcare needs could be too complex for any single discipline. Oral care in hospitalized patients often is omitted because nurses do not like performing oral care, lack the time, or are unaware of proper technique.2 Negative views regarding oral health have been documented by nursing professionals that "include fear, disgust … attitudes that such care is unpleasant, burdensome, unrewarding, problematic and trivial." 1
This research study did not intend to denigrate nursing education programs or oral care performed by health-care professionals. Instead, the research aimed to find if oral care performed by health-care professionals on hospitalized patients, primarily critically ill patients, met the standard of care recommended by the American Association of Critical-Care Nurses (AACN). Proper oral care during a hospital stay could help to decrease the rate of oral candidiasis, denture stomatitis, denture irritation, gingival hyperplasia, and traumatic ulceration. These conditions all can occur with poor oral care.3 Also, if the patient suffers from a sore mouth, he or she is less likely to resume proper nutrition, which can affect his or her recovery time.
Providing oral care to ill patients is an important element in the standard of care. Based on the findings of this study, positions could be identified and developed that would promote interdisciplinary healthcare and education. This study also could identify the need for positions for dental hygienists who are interested in branching out of private clinical practice and could be entering hospitals, nursing homes, and assisted-living facilities.
Survey and Results
This study used a survey to obtain information on current oral healthcare practices. The results were reported as descriptive statistics and were compared to the recommended standards from the AACN. Additional questions in the survey examined the healthcare professional's outlook for oral care, comfort level, and interest in having a dental hygienist available to help with oral care.
The survey was sent to 282 staff members working within six intensive care units, or ICUs, at a medical university. The survey found that the majority of respondents were registered nurses between the ages of 22-40 with bachelor's degrees. The results found that over half of respondents (59.7%) learned oral care from in-service seminars. Nursing education programs were the second most common means for learning about oral care, at 41.6%. When asked if oral care was included in job orientation, 85.5% of respondents answered "yes," but the extent of oral care education remains unknown. What was found is that in-service meetings and new-employee orientation programs present an opportunity to include a dental hygienist as an instructor who could address the impact of oral health on systemic health and recovery. Employees with questions could ask the hygienist in person, beginning a relationship between dental hygienists and healthcare professionals in ICUs.
The survey went on to ask who should be responsible for cleaning the oral cavity of intubated patients. Most respondents felt that dental hygienists should not be responsible (92.1%). In a separate question, when participants were asked if they would like a dental hygienist to perform oral care, the majority said "no." However, nearly half of the survey participants said they did not feel comfortable identifying gingivitis, oral abscesses, and other abnormalities of the mouth.
According to literature review, assessing a patient's mouth is an important nursing function; however, 34.3% of participants responded that this is not part of their routine. The survey also identified that over 80% of nurses reported that oral care for ventilated patients was a high priority, and over 90% of them felt comfortable performing the necessary care. However, less than half of respondents were comfortable handling patients' dentures, partials, and retainers, while just about half agreed that the oral cavity is a difficult area to clean and is a somewhat unpleasant task.
As you can see, these are very contradicting results. Though participants did report oral care as a priority and reported feeling comfortable performing the task, they also reported finding it difficult and unpleasant. Survey respondents said they perform oral assessments but aren't comfortable identifying problems commonly found in the oral cavity, such as gingivitis or abscesses. Dental hygienists are comfortable cleaning the oral cavity and, in addition, have education and training to find abnormalities in the mouth. With the collaboration of dental hygienists, nurses could increase a patient's standard of care while decreasing nosocomial infections.
By incorporating a dental professional -- such as a hygienist -- who believes that oral care is a priority and is comfortable with performing this task, hospitals could allocate a task that is important but often overlooked in the ICU. As a result, patients would receive a higher standard of care. Nurses and other professionals are educated to the best of their abilities in overall patient care; however, with so many tasks monopolizing their time while caring for critically ill patients, healthcare professionals could benefit from the assistance of a professional who specializes in the oral cavity.
After performing this research, I discovered that integrating a dental hygienist into a hospital setting will take time. With health-care reform and other changes occurring in the medical field, health professionals might fear losing job security if tasks are taken from them. Also, nurses who must defend their patient care on a daily basis to doctors, other staff, and a patient's family, may be less likely to discuss change to current tasks being performed or taught. In-service meetings and new employee orientation programs would be a great stepping-stone for dental hygienists to begin collaborating with medical professionals. It seems it will take time to develop a position on the ICU floor for a dental hygienist because of the fear of job loss. There is also concern regarding the budget-driven nature of hospitals.
Therefore, a study to examine the cost effectiveness of oral care performed by a dental hygienist is recommended. Without evidence to show that incorporating a dental hygienist could decrease nosocomial infections (and thereby justify the position's salary), hospitals likely will disregard this recommendation. Further research regarding the use of a dental hygienist in other units, such as an emergency room or a trauma center, is also a recommended investigation.
B. Michelle Strange, RDH, MSDH, is a practicing clinician in a private periodontal office, as well as serving as an adjunct faculty member at Trident Technical College in Charleston, S.C. She can be reached at MichelleRDH05@aol.com.
1. Coleman P. Opportunities for nursing-dental collaboration: Addressing oral health needs. Nursing Outlook, 2005. 53: p. 33-39.
2. McNeill HE. Biting back at poor oral hygiene. Intensive Crit Care Nurs, 2000. 16(6): p. 367-72.
3. McAuliffe A. Nursing students' practice in providing oral hygiene for patients. Nursing Standard, 2007. 21(33): p. 35-39.
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