Oral hygiene entails ensuring that mouth or oral cavity is kept clean to prevent the occurrence of dental problems or even worsen already existing problems. Research studies are a necessity in determining the effectiveness of different oral cleaning methods in maintaining oral hygiene. Standard protocols for nursing activities such as oral hygiene are based on peer reviewed studies. In hospitalized patients, oral hygiene is an important issue since some patients may not be able to perform the activity as efficiently as the standards require. This is where a practicing nurse comes in handy.
In critically ill patients, systematic oral care programs have a positive effect on the oral hygiene of such patients. This goes a long way in preventing the occurrence of nosocomial respiratory tract infections. The availability of standard protocols may not imply that they are been adhered to the latter as it has been demonstrated in related studies. Some elderly patients in nursing home care who need assistance in oral hygiene do not receive such support predisposing them to dental problems. Therefore, research studies are indispensable in ensuring the best nursing clinical practice.
Evidence-Based Practice and Its Significance in Oral Hygiene
Evidence-based practice pertains the integration of the best empirical information acquired from quality study findings with clinical expertise to fulfill patient needs and maintain their value, or address a specific problem (Burns & Grove 2011, p. 4). An expert research team, policy makers and healthcare professional generate the best research evidence that is utilized in creating standard protocols for clinical practice (Burns & Grove 2011, p. 4).
Oral hygiene is the routine practice of sustaining the structures and tissues of the cavitas oris in a normal functioning state that is free from disease. To maintain this healthy state, standard oral cleansing activities are paramount. Accredited research articles and reports are available that form the basis of recommended oral care techniques.
In one multicenter primary study done by Ames et al. (2011), the primary objective was to examine the impact of a systematic oral care program on oral health status in critically ill patients (p.e103). From the study outcome, it was concluded that the systematic oral care protocol implemented significantly improved oral assessment scores, that is, Mucosal-Plaque Score (MPS) and Beck Oral Assessment Scale (BOAS). The study excluded patients less than 18 years, patients with significant facial or oral trauma, edentulous patients, and those clinically diagnosed with pneumonia (Ames et al. 2011, p. e107).
The nurses in the critical care unit initially used unit based oral care with no standard care across the hospital units selected. During the study, a systematic oral care plan, incorporating step-wise assessment and cleaning, was introduced and taught to the critical care nurses (Ames et al. 2011, p. e108). Thereafter, the program was embraced by the respective units. From the study results, patients who were on the unit-based oral care plan had higher oral assessment score indicating poor oral health status compared to patients on the systematic program (Ames et al. 2011, p. e110). The positive study outcome showed that the new program was better and effective, thus; it was adopted by the respective hospitals.
A different primary research study was done by Dharamsi et al. (2009) regarding provision of daily mouth care practices to frail elderly patients in long-term care (LTC) facilities (p.581). Residential care aides (RCAs) and nurses tasked with the responsibility were assessed using questioners. The questions majored on their perception about Geriatric Dentistry Program (GDP) education program, personal practices and views concerning daily oral care, and the prevailing protocols and standards regarding daily oral care for residents (Dharamsi et al. 2009, p. 583).
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In fact, 80% of RCAs indicated that a heavy workload, cognitive and physical impairment posed challenges to their provision of the activity. There was evident knowledge gap among all the RCAs with 32% incorrectly believing that tooth brushing is not significant in dental plaque removal; 51% misunderstanding tooth loss to be a natural process, and 72% misbelieving that mouth care is impossible in unconscious residents (Dharamsi et al. 2009, p. 584). The study outcome shows that GDP’s education program did not fully empower the RCAs and nurses in provision of oral care. Therefore, GDP has to review its teaching tactics to emphasize on hands-on professional education, and avail optimum staff to provide the services. Without the research, the challenges affecting the implementation of the prescribed oral nursing care activities would not have been identified.
However, oral care skills alone are not sufficient in preventing the dissemination of bacteria into the bloodstream that result in respiratory tract infections. Hence, it may require utilization of antiseptic medicines to suppress some pathogenic microbes. A review of articles, with levels I and II evidence consisting of meta-analysis of several controlled studies and individual experimental studies respectively, carried out by Beraldo and Andrade (2008) in Brazil on the use of 0.2% to 2% chlorhexidine in prophylaxis against ventilator associated pneumonia (VAP) illustrates this (p.708).
The results of the review show that 50% of the samples, including randomized clinical trials (RCT) and meta-analysis, suggested a statistical significant reduction in the incidence of VAP, and 80% of RCT demonstrated a reduction in the incidence of oral plaque (Beraldo & Andrade 2008, p. 712). Therefore, it can be recommended that chlorhexidine be used in prophylaxis against VAP and oral plaque. However, it is not strongly suggested since the results observed were mostly based less on level I evidence article and more on level II evidence articles. More level I evidence is required to fortify the evidence on the efficacy of the antiseptic solution.
Standard protocols for performing oral care are important to provide a streamlined practice. A descriptive, cross-sectional web based survey by Feider, Mitchell and Bridges (2010), demonstrated that, without the standard protocols, differences exist in the form of oral care administered to critical care patients. The study participants were registered nurses working in adult critical care unit and members of the American Association of Critical-Care Nurses (Feider, Mitchell & Bridges 2010, p. 176). From the results obtained, 50% and 42% of nurses performed oral care every two and four hours respectively. Percentages of nurses who identified policies in their units indicating use of toothbrush, toothpaste, foam swabs, chlorhexidine gluconate, air cavity suctioning and oral cavity assessment were 72%, 63%, 40%, 90%,49%, 84% and 73% respectively (Feider, Mitchell & Bridges 2010, p. 179). From the results, it is highly possible that there is a lack of standard protocols for oral care hence the disparities in the methods used. This study outcome emphasizes the need for further research to help generate standard oral care protocols.
This last study done in Sweden suggests that not all patients in an institution such as nursing home who need help with daily oral hygiene receive the care. The study by Forsell, Sjogren and Johansson (2009) incorporated 22453, 65 year-old and above elderly patients who had been certified as requiring assistance performing daily oral care (p.241). The study outcome shows the average of patients that required support to be 77.5%, but only a total of 6.9% of those patients received the required assistance (Forsell, Sjogren & Johansson 2009 p. 242). This implies that even with some protocols in place, measures have to be instituted to make sure that every patient in need of assistance is assisted. Otherwise, the policies will not impact positively on general dental hygiene of patients.
Effective and improved patient oral care requires standard protocols in place to facilitate the activities. The best and effective oral care protocols can only be generated with sufficient primary peer reviewed research advocating for a given method or protocol. More research should be done to fill the gaping flaws in standard oral care activities. Policies directing the performance of the care activity should be adhered to in practice. Finally, the nurses tasked with the responsibility should make sure that every patient who needs care receives it.