Oral hygiene of hospitalised older patients with lower limb fracture

Introduction

good oral hygiene is important for eating, talking and improved quality of life, and is part of basic patient care, but there are few observational studies in hospitalised older patients. The aim of this study is to investigate dental plaque load in older patients over time in hospital.

Methods

we examined the mouths of 93 patients with lower limb fracture prospectively at day 1, 7 and 14 after admission in a Newcastle upon Tyne Hospital. We assessed dental and denture plaque load, dry mouth symptoms and tooth number, along with demographic and frailty variables. We used univariate generalised linear modelling and mixed effects models to investigate associations between increased plaque and patient characteristics.

Results

in dentate patients, plaque score increased with time in hospital (P = 0.007, odds ratio (OR): 1.02; 95% confidence of interval (CI): 1.01–1.04). Frailty (P = 0.015, OR: 1.19; 95% CI: 1.04–1.37), dementia (P < 0.001, OR: 4.30; 95% CI: 2.03–9.12), residence in an institution (P < 0.001, OR: 4.61; 95% CI: 2.18–9.74), decreased mobility (P = 0.013, OR: 0.97; 95% CI: 0.96–0.99), but not Charlson comorbidity index (P = 0.102, OR: 1.08; 95% CI: 0.99–1.19), were associated with increased plaque scores at every time point.

Conclusions

oral hygiene deteriorated in dentate patients in hospital. Plaque scores were significantly higher in patients who were more likely to be dependent on others for their oral hygiene.

Introduction

Oral hygiene is important for eating, communicating and social reasons. Reported personal attention to oral hygiene declines in older people with increasing health needs and frailty [1] and in the last year of life [2]. Oral health may be low down the priority list for busy hospital staff (and patients). However, a proportion of community acquired pneumonias may be attributable to higher plaque scores [3], and improving oral hygiene may also improve swallowing function in those with dysphagia [4], and cough sensitivity in institutionalised patients [5]. Furthermore, a number of (non-randomised) intervention trials have reported reductions in rates of hospital acquired pneumonia after improving oral hygiene [6–8], with costs savings of $1.6 million reported over a 12-month period in one study [6].

A study of 22 nursing homes in the South of England showed that many patients who were dependent on others for oral hygiene did not receive assistance, and that both plaque levels and oral disease were high [9]. A cluster randomized controlled trial demonstrated that oral hygiene education to nursing staff did improve oral care, though it was acknowledged that oral care remained suboptimal [10].

Observational studies of oral hygiene in older hospital in-patients are surprisingly rare. This study investigated denture and dental plaque in a cohort of older orthopaedic patients with lower limb fracture (predominantly hip fracture) to establish baseline levels of dental and denture plaque. We hypothesised that plaque levels would remain constant over time in hospital, and tested this using linear mixed effects models.

Methods

Full methodology can be found in Appendix 1 of Supplementary data at http://www.ageing.oxfordjournals.org/.

Results

Findings from oral health examinations

The demography of the patients is described in Appendix 2, Supplementary material. Basic dental examinations were undertaken on 93 patients, mean age of 80.8 years. Overall, 50 patients possessed teeth, with a range of 0–28, (median = 4, 0–19). Of these, 24 also wore dentures. A total of 43 patients had no teeth and all but one wore dentures. In total, 67 patients wore dentures. One patient had neither teeth nor dentures. Subsequent examinations were undertaken at day 7 (n = 78) and day 14 (n = 61). Of dentate patients, plaque scores were available from n = 49, n = 44 and n = 33 at each timepoint, respectively.

Mean modified Quigley Hein indices in dentate patients at admission was 1.4 (range: 0–3.5). Linear mixed effect modelling demonstrated that in dentate patients, dental plaque increased significantly over time (P = 0.007, odds ratio (OR): 1.02; 95% confidence of interval (CI): 1.01–1.04). In those who wore dentures (n = 67), mean modified Quigley Hein scores of denture teeth at admission was 0.7, (range: 0–1.5). Denture plaque scores did not change significantly over time (P = 0.930).

Table 1 shows the results of univariate generalised linear models (GLMs) investigating the association between higher dental plaque score and patient variables. Elevated dental plaque score was associated with the same variables at each timepoint studied: residence in institution, poorer mobility (negative estimate for HABAM score), increased clinical frailty score and dementia. Models of denture plaque scores are not presented due to underdispersion (denture plaque scores did not vary enough to detect associations with patient variables).

Dichotomous xerostomia inventory score (n = 58) was not significantly associated with any variable tested (see Appendix 3, Supplementary data).

Discussion

In dentate persons, plaque scores increased significantly while in hospital, though the effect size was small. Increased dental plaque scores at were significantly associated with dependence on others for oral hygiene (residence in institution, dementia, increased frailty and decreased mobility). Denture plaque appeared stable over time suggesting that denture hygiene was maintained either by staff or patients in hospital.

Few hospital studies of plaque scores exist, and differences in plaque scoring methods make it difficult to compare our results directly with those in other studies. However, two other groups have also reported a deterioration of plaque scores during hospitalisation, in critical care patients (n = 50, n = 10 at 14 days) [11], and in hospital patients (n = 162, n = 16 at 14 days) [12], though in the former there was no difference between those who did and did not require assistance with oral care.

The findings of this study are unsurprising and consistent with previous studies of residential homes [13–15]. All hospital patients, and especially frail, dependent patients, deserve access to good oral hygiene as a basic care need. If the studies suggesting that improving oral hygiene decreases hospital acquired pneumonia do prove to be correct, then not attending to this becomes financially imprudent and potentially neglectful.

Though the quality and heterogeneity of oral hygiene intervention studies precludes recommending any particular strategy to improve oral health [16, 17], the majority of intervention studies report improvement in plaque scores after intervention [8, 18–20], though care may be more time-consuming [18]. In essence, doing something is better than doing nothing.

Several barriers to implementing better oral hygiene in hospitals are likely to exist; a qualitative study in residential care home staff in Australia identified lack of skills, lack of confidence especially when caring for natural teeth and increasing burden on daily workload as barriers to proving oral care [21]. Future studies should consider barriers to improving oral hygiene provision in hospitals and further examine the association between oral hygiene and pneumonia.

Conclusions

This study shows that dental plaque increases in hospital, and that dental plaque scores were higher in more dependent patients.

Funding

This study was funded by a Medical Research Council Clinical Research Training Fellowship.

References