TITLE: Improving the oral hygiene of older psychiatric patient living in a long term psychiatry setting

Dear Sir/Madam, Please can you use this as a guide for both Part A and B of the Reasearch.
TITLE: Improving the oral hygiene of older psychiatric patient living in a long term psychiatry
setting.
Introduction and Background
Improving the oral hygiene of older psychiatric patients living in a long term psychiatry setting is an
issue of interest in the area of mental health nursing because researched evidence has being widely
shown that poor oral hygiene is most common in older people with psychiatric illness which can
consequently leads to general health complications within the pop ulation group (Kumar, Chandu and
Shafiulla 2006; Malkin 2009). Due to the general health complications that can be caused by poor oral
hygiene within the population group, the importance of improving oral hygiene within the population
cannot be over-emphasise in mental health nursing as this will aids their recovery in achieving optimum
health as highlighted by the mental health commission (2005). According to Huskinson and Lloyd (2009)
Oral hygiene is the act whereby the mouth is taken care of by cleaning so as to avoid decaying of the
teeth and gums which in turns minimize the risk of oral diseases and promotes oral health. Due to the
overlap of oral health and oral hygiene concepts, the two terms will be used interchangeably in this
review.
Poor Oral hygiene is a frequent condition that is always manifested and experienced in older patients
with mental health diagnoses in a long term psychiatry setting because having a mental health problem
for a long time can lead to deterioration in their independent abilities within the population group
(Bloomfield and Pegram 2012). Also, older patients in a long term psychiatry setting are likely to have
poor oral hygiene due to some risk factors such as the age, side effects of some medications, lack of
awareness in relation to oral hygiene, low motivation, poor dietary and fluid intake(Kumar, Chandu and
Shafiulla 2006).Thus, this becomes an important issue for psychiatric nurses as poor oral hygiene can
lead to various kinds of oral infections such as gingivitis, marginal and apical periodontitis disease
(Ellefsen et.al 2009). Hence, the act of poor oral hygiene within the older psychiatric patients in a
long term setting is a major apprehension to psychiatric nurses in relation to their duty of care or
nursing roles as poor oral hygiene may lead to decreased in the quality of life of the patient while
hindering the recovery process of the affected patients (Walker and Kiyak 2007).
Therefore, nurses have an important role in all aspects of managing and supporting the patient’s daily
oral hygiene and this is a vital part of comprehensive nursing care which affects the total well-being
of the patients (Harris et al 2008; Freer 2000). Thus, improving the oral hygiene of older psychiatric
patients within the long term setting should be vital for psychiatric nurses working in the setting. As
a result of this vitality in improving oral hygiene of the population group give rise to the following
research question;
RESEARCH QUESTION
“How can nurses improve oral hygiene in older psychiatric patients living in a long term psychiatric
setting?’
In a long term psychiatric setting, improving oral hygiene of the older patients should be one of the
main goal of psychiatric nurses as this can prevent serious health complications within the population
group while increasing the quality of life of the patients (Tang et.al 2004). This goal of improving
oral hygiene is consistent with Orem self-care need model in relation to personal hygiene of patients
and in which the model encourages individuals to care for themselves, but in circumstances where they
are unable to attend to themselves, nurses should assist them holistically in their care (An Bord
Altranais 2009;Orem et.al 2003).
However, if steps are not taken to improve the oral hygiene of the older psychiatric patients living in
the long term psychiatric setting, the oral health status of this population group may affect the
overall physical health; the ability to eat and talk comfortably, speech impediments, self-esteem and
standard of life (Chalmer, Carter and Spencer 2004). Thus, in a search to know how oral hygiene can be
improved in older patients in a psychiatric setting, the following search strategy was applied.
SEARCH STRATEGY
The article search was conducted on electronic database in CINAHL, Pub med, and Wiley online and
Science direct. Other resources such as Dublin City University library and Journal A-Z were also
accessed for relevant information. The search was limited to articles published in English language
studies between 2000 and 2012. In order to identify the article suitable for answering the research
question, the following keywords combined with Boolean phrase of ‘and/or/not’ were used in the search
terms. The key words used were; oral health, oral care, oral hygiene, psychiatric patients, older
patients, oral health problem, nurse’s role, dental care and assessment tools, nursing care. After
extensively searching the database, the search brought up many articles and articles that were
considered useful in answering the research question were chosen, reviewed, appraised critically using
relevant published literatures and then grouped into themes based on their contents. The three themes
that appeared from the grouping of the reviewed articles were:
• Effects of poor oral hygiene in older people with psychiatric illness
• Assessment of oral hygiene in older psychiatric patients
• Nursing interventions to improve oral hygiene
The themes were respectively and critically discussed in the literature review below.
Effects of poor oral hygiene in older people with psychiatric illness
As poor oral hygiene is common in people with psychiatric illness, thus most of the studies from the
chosen articles dealt with the effect of poor oral hygiene within the population group. Kossioni,
Kossionis and Polychronopoulou (2012) in their structured interview studies that was based on the oral
hygiene status of the older psychiatric patients found out that oral hygiene of the older psychiatric
patients were poor which results in edentulous and decayed tooth on higher percentage of the sample
size. Even though, one limitation to the study was that some patients were excluded due to lack of
cooperation and which can thus bias the findings. Despite this limitation, the effect that poor oral
hygiene has on this population group was also reflected in the findings of a previous study by Kumar
Chandu and Shafiulla (2006). Their qualitative survey of 220 psychiatric patients revealed that low
percentage of the clients are living with untreated decay where poor oral hygiene status was also shown
to be increasing with ageing and an average number of the older patients with mental illness had one or
more missing teeth. Their findings showed that older patients with psychiatric illness have poor oral
hygiene predisposing them to several diseases which include dental decay, Stomatitis and periodontitis.
Similarly to this two findings by Kossioni, Kossionis and Polychronopoulou 2012; Kumar Chandu and
Shafiulla 2006 was the finding of Lewis et al. (2001) who carried out a study assessing the oral
hygiene in 469 psychiatric older psychiatric patients in which the result showed that the population
that had edentulous was higher as a result of poor oral hygiene. Also, this poor oral hygiene among the
older psychiatric patients consistently leads to increase amount of plaque on both the teeth and
artificial teeth which have been linked with aspiration pneumonia (Stein and Henry 2009; Pearson and
Chalmers 2004). However, in direct contrast to higher percentages of older psychiatric patients
population recorded with effects of poor oral hygiene was Person et.al (2009) that conducted a
descriptive study through a structured interview of 113 patients in a psychiatric setting. Result in
Person et.al (2009) study showed that less than half of the patients had poor oral hygiene status
whereas higher population of poor oral health in the older psychiatric patients was recorded in
Kossioni, Kossionis and Polychronopoulou (2012). Therefore knowing the effect that poor oral hygiene
has on older psychiatric patients can assist the nurse in improving oral hygiene of the population
group. This is because knowing the effect of poor oral hygiene can guide nurses in the through
assessment of oral hygiene in the older psychiatric patients.
Assessing oral hygiene in older psychiatric patients
Improving oral hygiene of older patients in a long term psychiatric setting commences with a thorough
assessment. Even though, most oral hygiene assessment depends on a patient’s capability to narrate
dental symptoms which they are experiencing. This can be a serious issue for many older psychiatric
patients due their apathetic nature of their illness (Rivett 2006). However, from the reviewed
articles, there are various tools and assessment guides that can be of help to the nurses towards
improving oral hygiene in older psychiatric patients. Such assessment guide was found in a study
conducted by Sjorgen and Nordstorm (2000) which aimed to determine oral hygiene status of psychiatric
patients using ‘oral assessment guide’ as a tool in assessing the oral hygiene status of the population
group. Findings from this study showed that the ‘oral health assessment guide’ used in long-term
psychiatric care is valuable in assessing and recognizing the oral hygiene needs of the patients which
was evidenced from the result of the study as the ‘oral health assessment guide’ used in the study
highlighted the poor oral hygiene in the sample size of the older patient. Furthermore, the findings of
Sjorgen and Nordstorm (2000) which showed the importance of ‘oral assessment guide’ as an assessment
tool in identifying the oral hygiene of older patients was also reiterated in the study conducted by
Lynch et al. (2005) where the ‘oral assessment guide’ was also used in identifying the oral hygiene
needs of psychiatric patients in a long term stay. Lynch et al. (2005) findings after using the guide
also showed poor oral health status of psychiatric patients in the long term setting and thus
complimented the findings of Sjorgen and Nordstorm (2000). Although, Lynch et al. (2005) findings might
have being limited as a result of non-probability convenience sampling used in the study as convenience
sampling has a greater risk of bias (Wood and Haber 2010). Nevertheless, it is important for the
psychiatric nurse assessing the older psychiatric patients to use such valuable ‘oral assessment
guide’ as a tool as this will help to identify and to improve the state of oral hygiene in the
population group for more intervention that may then be applied (Pearson and Chalmers 2004).
Furthermore, Index of Activities of daily living oral hygiene (ADOH) can also be used as an assessment
tools by the psychiatric nurses in assessing the oral hygiene of the older patients as highlighted in
Bauer (2001) and Chalmers (2004). The ADOH was found out from their reviewed literatures to be useful
in assessing and monitoring the oral hygiene of older adults. Chalmers et al (2009) in their study also
highlighted oral health assessment tool (OHAT) in assessing older patients in a long term care as being
a reliable and a valid screening tool in assessing oral hygiene status of older patients.
Thus, using all these aforementioned researched tools by the nurses in assessing the oral hygiene
status of the older psychiatric patients living in a long term setting will help to identify and
improve their oral hygiene while this will help to implement the most appropriate care plan (Johnson
and Chalmer 2001). Moreover, as suggested by Bloomfield and Pegram (2012) that oral assessment and
appropriate interventions to maintain oral hygiene are important in all mental health setting,
therefore, in optimising the oral hygiene of people in their care, psychiatric nurses have important
roles.
Nursing Roles/interventions in improving oral hygiene
Improving oral care in psychiatric older patients can be challenging, however, psychiatric nurses has
an important roles and interventions in improving the oral hygiene of the older patients. Most of the
chosen and reviewed articles researched the effectiveness of different nursing roles/interventions that
can be used in improving the oral hygiene of the older patients. Such nursing roles/interventions
include encouraging preventative measures such as tooth brushing with fluoride tooth paste, soaking of
dentures overnight and dietary sugar intake restrictions which are seen to improve oral hygiene of the
patients (Pearson and Chalmer 2004). Furthermore, in some of the reviewed articles, education is seen
as part of a nursing professional role in improving the oral hygiene of older patients. Though, the
finding of MacEntee et al. (2007) in their study found out that educational approach did not improve
the oral hygiene of older patient in the sample size. However, the results of MacEntee et al. (2007)
may be less generalized outside the chosen settings due to sample size and randomized method of
selection. Contrary to MacEntee et al. (2007) was Park and Choi-Kwon (2011) quasi-experimental study
that investigated the effect of oral care education towards improving the oral hygiene of older
patients in their findings showed that oral care education programmes as part of nursing professional
role are effective in improving the oral hygiene of older patients. Similarly to this finding was a
previous study carried out by Nicol et al. (2005) in which their findings validated the effectiveness
of education in improving the oral hygiene of older patients as there are significant improvement in
the oral hygiene of the sample size. Moreover, in Gil-Montaya et al. (2006) study findings showed that
the role of a nurse in quick detection of oral diseases and referral to a dental service improves the
oral hygiene of patients. Other roles/interventions of psychiatric nurses in improving the oral hygiene
of older patients living in a long term setting that were deemed to improve the oral hygiene of older
patients from the reviewed articles include ensuring that patients have adequate equipment needed to
meet their oral hygiene needs, such as toothbrush and toothpaste, encouraging and assisting patients in
removing and thoroughly cleaning of their dentures while carrying out a effective oral assessment on
the older patients using assessment tools and assessment guides(Chalmers et al. 2009; Stein and Henry
2009; Chalmer and Pearson 2005; Lynch et al. 2005 and Sjorgen and Nordstorm 2000).
Further studies have identified barriers that can affect older patients in providing good oral hygiene
care, such as; uncooperative patient, lack of motivation and poor communication (Balwant 2008;
Kilbourne et al. 2007; Ramon et al. 2003). In lieu of these studies, nurses have a vital role to play,
by ensuring that this patient group are properly cared for and also advocate for them where necessary
even at the multidisciplinary meeting.
Discussion
Evidence from the literature review showed that oral diseases are the major source of problem among
older psychiatric patients living in a long term setting. Thus the importance of improving oral hygiene
among older psychiatric patients is very essential because older patients with psychiatric illness are
at the risk of increased vulnerability to oral diseases and other complications (Ellefsen et al. 2009;
Malkin 2009; Kumar, Chandu and Shafiulla 2006 ). Although different risk factors such as lack of
motivation, uncooperativeness, apathetic nature of their illness, fear of treatment as well as poor
communication were given for poor oral hygiene in older psychiatric patients (Kumar, Chandu and
Shafiulla 2006). Nevertheless, nurses have important role in improving oral hygiene of older
psychiatric patients (Harris et al. 2008; Freer 2000). Findings from the reviewed literatures showed
that poor oral hygiene has a negative effect on older psychiatric patients living in long term setting
in which they were predisposed with several oral diseases ( Kossioins and Polychronopoulou 2012; Kumar,
Chandu and Shafiulla 2006; Lewis et al. 2001).This oral diseases were also linked with medical
conditions such as aspiration pneumonia( Stein and Henry 2009; Pearson and Chalmers 2004). Therefore,
oral hygiene problems need to be improved by psychiatric nurses through thorough assessment using
various tools and assessment guide that can be of assistance in identifying the oral hygiene status of
older psychiatric patients. Findings from the reviewed literatures showed the importance of using
these tools and guides as this will assist in identifying poor oral hygiene in the older psychiatric
patients which will consequently lead to early intervention that may then be applied ( Lynch et al.
2005; Pearson and Chalmers 2004; Bauer 2001; Sjorgen and Nordstrom 2000).
Furthermore, findings from literatures reviewed have shown that oral hygiene of this population group
can be optimised through different nursing roles which include encouraging this population group in
using preventative measures such as tooth brushing, overnight soaking dentures, dietary intake sugar
restrictions and appropriate referral to a dental services (Gil-Montaya et al. 2006; Pearson and
Chalmers 2005).Additionally, education was also seen as part of professional role of nurses in
improving the oral hygiene of older psychiatric patients. Even though the role of education in
improving oral hygiene of this group of patients was disputed in MacEntee et.al (2007) findings whereas
other literature reviewed validated the importance of education in improving oral hygiene of older
psychiatric patient living in long term setting (Park and Choi-kwon 2001; Nicol et al. 2005). From the
reviewed literatures the aforementioned nursing roles were deemed useful in improving oral hygiene of
older psychiatric patient living in long term setting.
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