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Survey of oral hygiene knowledge and practice among Mississippi nursing home staff

Dissertation
Author: Robin McMillin Howard
Abstract:
The population of nursing home or institutionalized elderly residents in Mississippi is growing as a result of the Baby Boomer influx. Unlike previous generations of nursing homes residents, these residents have retained at least part of their natural dentition because of advances in dental care. Studies on the oral care available for institutionalized elderly patients have shown that nursing staff in nursing homes have inadequate knowledge of dental hygiene procedures. This study examined nursing staff's attitudes toward oral care, their perceptions of the importance of oral care, and their knowledge of oral healthcare according to the recommendations for its practice. A survey instrument designed to provide demographic data and both objective knowledge and subjective attitudes was employed. This instrument was reviewed by dental health care professionals and approved by the Institutional Review Board before deployment in the field. Initially, comparisons between public-pay rural and urban nursing homes were planned to determine whether differences exist in nursing staff's practice, attitudes, and knowledge depending on the population. Mississippi is predominantly a rural state and has only a few urban centers. This did not preclude the identification of rural and urban nursing staff for inclusion in this research. However, no statistically significant differences in any of the categories examined in the survey instrument were found. Thus, Mississippi is a very homogeneous state with regard to many of the self-reported responses concerning the attitudes, practice, and knowledge of nursing staff with regard to dental hygiene. The nursing staff reported assisting 88% of their patients with oral brushing twice daily, as recommended by the American Dental Association (ADA). However, only 19% of this same population received assistance with flossing and 4% with oral swabbing, which does not meet the standard of care. Most respondents reported an appreciation for dental care and felt that they had the support of their administrators to take the time to provide basic oral care. However, most reported that they provided what would be considered less than optimal care for their patients, particularly the dentate population. It was not clear whether this oversight was a result of a lack of time, knowledge, or personal attitudes on the part of the staff. The survey revealed that the most significant gaps in the nursing staff's understanding of oral care were evident in their self-reported knowledge and objective evaluation of knowledge. Over 83% of the nursing staff felt that they had good to excellent knowledge of oral health. However, the staff correctly answered only 64% of the specific questions on basic dental care. Indeed, the highest correct response rate for individual topics was 87% for denture care. This identifies an important gap that must be addressed because more nursing home patients are likely to retain their natural dentition. It is also important to note that the nursing home staff in Mississippi have at least high school diplomas, and the majority have some training beyond this basic level. This indicates that these individuals are among the more skilled members of the workforce in a state with a high number of unskilled workers without a high school education. Even so, the knowledge of dental health is lacking. In part, this must be attributed to failures in the training programs themselves, which include both formal classes and service programs. There should be a renewed emphasis on the part of dental professionals on increasing their profile with nursing schools, certification programs, and nursing homes.

TABLE OF CONTENTS CHAPTER I: INTRODUCTION ; 1 Statement of the Problem 3 Purpose of the Study 4 Hypothesis 4 Definition of Terms 4 Significance of the Study 7 CHAPTER H: REVIEW OF THE LITERATURE 8 Related Risk Factors Associated with Dental Disease 11 Plaque 12 Periodontal Disease 12 Pneumonia 13 Nursing Staffs Oral Hygiene Education in Nursing Homes 14 Reasons for the Potential Lack of Dental Care in Nursing Homes 17 Financial Implications of Dental Hygiene Care in Nursing Homes 20 Barriers to Oral Care in Mississippi: Demographic Characteristics of Mississippi ...21 Barriers to Oral Health Care in Mississippi Nursing Homes: State Law and Access to Care 22 Current Practices in Oral Care in Nursing Homes: Overcoming Barriers to Care 24 Rasmussen's Skill-Based Performance Theory 26 CHAPTER HI: MATERIALS AND METHODS 34 Hypotheses 35 Research Design 36 Survey Population Selection 39 Data Analysis 40 CHAPTER TV: RESULTS 42 Staff Demographics 43 Results of Practice, Attitudes, and Knowledge Questions 47 Oral-Care Practice in Nursing Homes 48 Attitudes of Nursing Staff Toward Oral Care 50 Nursing Staff Duties and Priority of Oral Hygiene 52 Dental Knowledge of the Nursing Staff 52 Hypothesis Results 57 CHAPTER V: DISCUSSION 75 Demographics of Nursing Home Staff: Rural vs. Urban Settings 76 Rural vs. Urban Areas 76 Sample Size: Rural versus Urban Nursing Staff 76 Age Distribution of Nursing Staff Populations 77 v

Gender Distribution of Nursing Staff Populations 77 Ethnic Distribution of Nursing Staff Population 78 Educational Background: Rural versus Urban 78 Staffing Requirements for Nursing Homes 79 Job Titles of Nursing Staff 83 Dental Hygiene Practices for Nursing Home Residents 87 Staff Participation in Resident Oral Hygiene 87 Nursing Home Staff Compliance with ADA Recommendations 87 Attitudes of Nursing Staff Toward Oral Care 88 Personal Dental Visits Reported by Nursing Staff 88 Perception of Oral Hygiene Practices 91 Dental Knowledge of Nursing Home Staff 92 Objective Knowledge: Rural versus Urban Nursing Staff 93 Length of Time Employed as Nursing Staff. 95 In-service Training for Dental Care 95 CHAPTER VI: CONCLUSIONS 98 Recommendations 100 Limitations of the Project 101 Future Analysis and Directions 102 REFERENCES 104 APPENDICES 116 Appendix A: Survey 117 Appendix B: Reminder for Staff. 120 Appendix C: IRB Revisions ....122 Appendix D: Invitation to Participate in the Study ...123 Appendix E: Copy of Exemption Letter 124 Appendix F: Description of Study for Participates 126 vi

LIST OF TABLES Table 1. Number of Nursing Homes in Mississippi 29 Table 2. Distribution of Dentists in Mississippi 32 Table 3. Distribution of Dental Hygienists in Mississippi 33 Table 4. Age of Nursing Staff 60 Table 5. Gender of Nursing Staff. 61 Table 6. Race/Ethnicity of Nursing Staff. 62 Table 7. Shift Assignments of Nursing Staff 63 Table 8. Length of Time Employed in Nursing Home 64 Table 9. Educational Training of Nursing Staff. 65 Table 10. Job Titles of Nursing Home Staff 66 Table 11. Lecture Time for Oral-Care Training 67 Table 12. In-service Oral-Health Training 68 Table 13. Hands-on Training for Oral Care 69 Table 14. Nursing Staffs Frequency of Dental Visits 70 vu

LIST OF FIGURES Figure 1. Poverty in Mississippi (U.S. Census Bureau, 2009a) 29 Figure 2. Medicaid Nursing Home Distribution 30 Figure 3. Private-Pay Nursing Home Distribution 31 Figure 4. Dentists in Mississippi 32 Figure 5. Dental Hygienists in Mississippi 33 Figure 6. Age of Nursing Staff. 60 Figure 7. Gender of Nursing Staff. 61 Figure 8. Race/Ethnicity of Nursing Staff. 62 Figure 9. Shift Assignments of Nursing Staff. 63 Figure 10. Length of Time Employed in Nursing Home 64 Figure 11. Educational Training of Nursing Staff. 65 Figure 12. Job Titles of Nursing Home Staff. 66 Figure 13. Lecture Time for Oral-Care Training 67 Figure 14. In-service Oral-Health Training 68 Figure 15. Hands-on Training for Oral Care 69 Figure 16. Nursing Staffs Frequency of Dental Visits 70 Figure 17. Oral Care Provided by Nursing Staff. 71 Figure 18. Awareness of Standards of Oral Care 72 Figure 19. Recognition of Signs and Symptoms of Oral Cancer 73 Figure 20. Awareness of Signs and Symptoms of Periodontal Disease 74 Figure 21. Oral Side Effects From Medications 74 viii

LIST OF ABBREVIATIONS ADA American Dental Association CNA Certified nursing assistant DON Director of Nursing IV Intravenous LPN Licensed practical nurse RN Registered nurse IX

SURVEY OF ORAL HYGIENE KNOWLEDGE AND PRACTICE AMONG MISSISSIPPI NURSING HOME STAFF Robin McMillin Howard Ph.D. Clinical Health Sciences School of Graduate Studies in the Health Sciences University of Mississippi At the Medical Center Jackson, Mississippi 2010 The population of nursing home or institutionalized elderly residents in Mississippi is growing as a result of the Baby Boomer influx. Unlike previous generations of nursing homes residents, these residents have retained at least part of their natural dentition because of advances in dental care. Studies on the oral care available for institutionalized elderly patients have shown that nursing staff in nursing homes have inadequate knowledge of dental hygiene procedures. This study examined nursing staffs attitudes toward oral care, their perceptions of the importance of oral care, and their knowledge of oral healthcare according to the recommendations for its practice. A survey instrument designed to provide demographic data and both objective knowledge and subjective attitudes was employed. This instrument was reviewed by dental health care professionals and approved by the Institutional Review Board before deployment in the field. Initially, comparisons between public-pay rural and urban nursing homes were planned to determine whether differences exist in nursing staffs practice, attitudes, and knowledge depending on the population. Mississippi is predominantly a rural state and has only a few urban centers. This did not preclude the identification of rural and urban nursing staff for inclusion in this research. However, no statistically significant x

differences in any of the categories examined in the survey instrument were found. Thus, Mississippi is a very homogeneous state with regard to many of the self-reported responses concerning the attitudes, practice, and knowledge of nursing staff with regard to dental hygiene. The nursing staff reported assisting 88% of their patients with oral brushing twice daily, as recommended by the American Dental Association (ADA). However, only 19%) of this same population received assistance with flossing and 4% with oral swabbing, which does not meet the standard of care. Most respondents reported an appreciation for dental care and felt that they had the support of their administrators to take the time to provide basic oral care. However, most reported that they provided what would be considered less than optimal care for their patients, particularly the dentate population. It was not clear whether this oversight was a result of a lack of time, knowledge, or personal attitudes on the part of the staff. The survey revealed that the most significant gaps in the nursing staffs understanding of oral care were evident in their self-reported knowledge and objective evaluation of knowledge. Over 83% of the nursing staff felt that they had good to excellent knowledge of oral health. However, the staff correctly answered only 64% of the specific questions on basic dental care. Indeed, the highest correct response rate for individual topics was 87% for denture care. This identifies an important gap that must be addressed because more nursing home patients are likely to retain their natural dentition. It is also important to note that the nursing home staff in Mississippi have at least high school diplomas, and the majority have some training beyond this basic level. This xi

indicates that these individuals are among the more skilled members of the workforce in a state with a high number of unskilled workers without a high school education. Even so, the knowledge of dental health is lacking. In part, this must be attributed to failures in the training programs themselves, which include both formal classes and service programs. There should be a renewed emphasis on the part of dental professionals on increasing their profile with nursing schools, certification programs, and nursing homes. xn

CHAPTER I: INTRODUCTION

The population of nursing home or institutionalized elderly residents in the United States and Mississippi is growing (US Census Bureau, 2003; Garrett and Martini, 2007). The Baby Boomers, born between 1946 and 1964, are estimated to include 76 million people (U.S. Census Bureau, 2003). Unlike previous generations of nursing home residents, these residents have retained at least part of their natural dentition because of advances in dental care. Studies on the oral care available for institutionalized elderly patients have shown that nursing staff in nursing homes have inadequate knowledge of dental hygiene procedures. This study examined nursing staffs attitudes toward oral care, their perceptions of the importance of oral care, and their knowledge of oral healthcare practices. Public-pay rural and urban nursing homes were compared to determine whether differences exist in nursing staffs attitudes towards oral care and practice and their perceptions of the importance of oral care. As the American population ages, oral health problems may become more of a focal issue because of the retention of their natural dentition (teeth; Longhurst, 2002). DeBiase and Austin (2003) estimated that the number of individuals in the United States (US) who are 65 years and older will increase 126% by 2011. In 2030, one of every four citizens in the US will be over the age of 65 years (Whitman & Whitman, 2006). Also in 2030, demographic studies have suggested that the number of people over the age of 100 will increase 956% (National Institute on Aging, 1997). In 2005,12% of the Mississippi population was 65 years old (Mississippi State Department of Health, Facilities Licensure and Certification, 2007). Of the residents in Mississippi nursing homes in 2005, 17.2% were 65 to 74 years old, 35.2% were 75 to 84 years old, and 35.7% were older than 85 years (Mississippi State Department of Health, Facilities Licensure and Certification, 2

2007). There has been a steady decline in the number of older (> 65 years of age) with loss of all their teeth in the last six decades (Burt et al., 1999; US Public Health Service, 2000; Vargas et al, 2003). Furthermore, the Texas Health and Human Services Commission (2002) estimated that 73 % of nursing home residents currently retain their natural teeth and that the number of edentulous residents (without teeth) in nursing homes has decreased by 80% since 1980. The progress of dental care in the general population has led to unprecedented good dental health in the aging population; however, if nursing staff do not meet the oral healthcare needs of nursing home residents, multiple health issues could develop (Longhurst, 2002). The Baby Boomer generation (those born between 1946 and 1964) is the first generation to benefit as children from fluoridated water and toothpaste, annual dental checkups, and dental hygiene education in the classroom and through the media. Consequently, this generation is more likely than previous generations to retain their natural dentition (Strayer 1999; Wardh, Berggren, Andersson, & Sorensen, 2002). As a result of improved oral practices and the greater likelihood of residents' retaining their natural dentition, nursing home staff will face growing challenges with nursing home populations' oral care (Australian Institute of Health and Welfare [AIHW], 2001). Statement of the Problem Current research has shown that residents of nursing homes often lack appropriate dental hygiene care (Schwartz, 2003). Nursing homes and assisted living facilities often lack sufficient personnel, facilities, and financial support to meet this growing demand for appropriate dental hygiene (Wardh, Hallberg, Berggren, & Sorensen, 2003).

Consequently, residents in nursing homes receive inadequate oral care, which will only increase with the number of residents doubling by 2020 (Ellis, 1999). Purpose of the Study The most common unmet dental need among the nursing home population is prophylaxis (teeth cleaning; Schwartz, 2003), and this project studied the claim in Mississippi. The nursing staff self-reported how often they provided daily oral hygiene and their knowledge of oral care. Hypothesis Research Question 1: Do differences exist between public-pay urban nursing homes and public-pay rural nursing homes in meeting the American Dental Association's (ADA's) standards of daily care that nursing home staff provide? Research Question 2: Do differences exist in attitudes between the nursing staff in public- pay urban nursing homes and public-pay rural nursing homes? Research Question 3: Do differences exist in the knowledge of oral hygiene with regard to overall health issues between urban nursing home staff and rural nursing staff? Definition of Terms The following are common medical and dental definitions that can be found in more detail at MedicineNet.com. (2010). Definitions concerning the designation of demographics terms and nursing homes and their staff can be found at the U.S. Census Bureau or at NursingHomeAbuse.com. Edentulous: Toothless Dentition: Teeth 4

Prophylaxis: Xerostomia: Plaque: Gingiva: Periodontal disease: Halitosis: Dentifrice: Caries: Mucositis: Stomatitis: Skilled nursing home: Measures designed to preserve health and prevent the spread of disease: protective or preventive treatment (prophylaxis against viral diseases; a paste containing fluorine for dental prophylaxis) Abnormal dryness of the mouth due to insufficient secretions; also called dry mouth A sticky, usually colorless film on teeth that is formed by and harbors bacteria The tissue that surrounds the necks of teeth and covers the alveolar parts of the jaws; broadly, the alveolar portion of a jaw with its enveloping soft tissues Any disease (such as gingivitis or periodontitis) that affects the periodontium Fetid breath A powder, paste, or liquid for cleaning the teeth A progressive destruction of bone or tooth, especially tooth decay Inflammation of a mucous membrane Any of numerous inflammatory diseases of the mouth with various causes (such as mechanical trauma, allergy, vitamin deficiency, or infection) A health institution planned, organized, operated, and maintained to provide facilities and health services with

related social care to in-patients who require medical care and 24-hour nursing services for illness, injury, or disability. Each patient shall be under the care of a physician licensed to practice medicine in the State of Mississippi. The nursing services shall be organized and maintained to provide 24-hour nursing services under the direction of a registered professional nurse implied full- time. Urban Mississippi: More than 1,000 people per square mile Rural Mississippi: Fewer than 1,000 people per square mile Dental hygienist An Individual who has completed an accredited dental hygiene education program, passed the national dental hygiene board and is licensed by the State Board of Dental Examiners to provide, as an auxiliary to the dentist, preventive care services including but not limited to, scaling and polishing, provide treatment that helps to prevent oral disease, and educating patients in prevention of these and other dental problems. Licensed practical nurse: A nurse who has graduated from a formal practical nursing education program and is licensed by the appropriate state authority 6

Certified nursing assistant: A person who has successfully completed a training program or course with a curriculum prescribed by the Mississippi State Board of Nursing Registered nurse: A graduate nurse who has passed a state board examination and has been registered and licensed to practice nursing Nurse's aide: A person who assists nurses at a hospital or other medical facility in tasks that require little or no formal education Oral hygiene: Activities that promote good health of the mouth Significance of the Study This is the first study on oral hygiene in Mississippi nursing homes. It is an overview of nursing staffs attitudes toward, practices in, and knowledge of oral hygiene. Based on the results, recommendations have been made for appropriate changes in nursing home oral protocol, staff education, and statewide legislation. 7

CHAPTER II: REVIEW OF THE LITERATURE

The most often quoted authority on good dental hygiene is the American Dental Association. This professional organization recommends practices and products that have been determined to have the most impact on oral health. As noted on the American Dental Association website, (http://www.ada.org/3072.aspx; accessed July, 2010.) the ADA recommends the following routine care for natural teeth: "Brush your teeth twice a day with an ADA-accepted fluoride toothpaste. Replace your toothbrush every three or four months, or sooner if the bristles are frayed. A worn toothbrush won't do a good job of cleaning your teeth.'" "Clean between teeth daily with floss or an interdental cleaner. Tooth decay- causing bacteria still linger between teeth where toothbrush bristles can't reach. This helps remove the sticky film on teeth called plaque and food particles from between the teeth and under the gum line." "Eat a balanced diet and limit between-meal snacks." "Visit your dentist regularly for professional cleanings and oral exams." Oral health impacts the quality of life for nursing home residents (Academy of General Dentistry, 2002; Adachi, Ishihara, Abe, Okuda, Ishikawa, 2002; American Academy of Periodontology, 1998; ADA, 2003; Baldwin, 2004; Fedele, 2004; Gift, Cherry-Peppers, & Oldakowski, 1998; Hamasha, Hand, & Levy, 1998; Harrell, 2003; Jones, Brown, & Volicer, 2000; Jurasek, 2002; Katz, Shenkman, Stavropoulos, & Melzer, 2003; Klassen & Krasko, 2002; Lamster, 2004; Limeback, 1998; Marmy & Mart, 2003; Martin, 1994; Matear, 2000; Maupome, Gullion, White, Wyatt, & Williams, 2003;

Mercola, 2002; Moffat, 2004; Mulligan & Navazesh, 1992; Russell, 1999; Scannapieco, 1999; Shay, 2002; Sullivan, Martin, Flaxman & Hagan, 1993; Watando et al., 2002; Yoneyama, Yoshida, et al., 2002). Research has shown, however, that residents are not receiving the appropriate care they need to maintain good oral health (AIHW, 2001; Ellis, 1999; Frenkel, Harvey, & Newcombe, 2000; Schwartz, 2003). Analysis of the general nursing home population showed that 63.8% of the residents had unmet dental needs (Texas Health and Human Services, 2002). Furthermore, in a later study Schwartz found that the percentage of nursing home residents with unmet dental needs ranged between 80% and 96%. The top two unmet dental needs for nursing home residents are prophylaxis (teeth cleaning) and treatment of xerostomia (dry mouth); the most common is prophylaxis (Schwartz, 2003). For example, in a study in Washington State that focusedon the oral hygiene of nursing home residents (n = 1063), 72% of the residents with natural dentition lacked routine oral hygiene care (Kiyak, Grayston, & Crinean, 1993). Geriatric residents often report taking as many as nine medicines a day, which can alter the mouth flora in the mouth. Xerstomia increases the possibility for tooth decay. Without saliva, which provides antimicrobial agents and minerals, bacteria are more likely to develop. When streptococci increase, the enamel of the tooth is dissolved, which causes dental decay (Shay, 2002). Kiyak et al.. (1993) found that 10% of nursing home residents reported xerostomia as a problem. Problems with the oral cavity in the elderly population require special considerations and care. A study commissioned by the Texas state department of Health and Human services that assessed several criteria of nursing home care, including dental 10

care, gave nursing homes, on average, a D rating in the category of dental care (Texas Health and Human Services, 2002). Neglect, lack of access, and otherwise unmet needs of nursing home residents have been documented in the literature (Kiyak et al.. 1993). The literature review for this study focused on the relationship between dental health and overall health (specifically, the relationships between plaque, periodontal disease, and pneumonia), nursing staffs dental education, and financial or legal implications (Adachi et al, 2002; ADA, 2003; Baldwin, 2004; Fedele, 2004: Gift et al., 1998: Hamasha et al., 1998: Harrell, 2003; Jurasek, 2002: Katz et al., 2003; Lamster. 2004: Limeback, 1998: Marmy & Matt, 2003; Matear. 2000: Maupome et al.. 2003: Mercola, 2002: Moffat, 2004; Russell, 1999: Shay, 2002: Watando et al. 2002: Yoneyama, Yoshida, et al.. 2002). Included in this review is a secondary focus on barriers to oral hygiene education, overcoming these barriers, and, finally, barriers to oral health' care in Mississippi in particular. Related Risk Factors Associated with Dental Disease Research has shown that oral hygiene is directly linked to overall health (Hamasha et al.. 1998). As many as 120 systemic diseases have been shown to originate in the mouth area (Mandel, 2002: Texas Health and Human Services, 2002). Oral disease may result in nutritional compromise, cancer, xerostomia, pneumonia, bacteremia, emphysema, brain abscess, heart problems, diabetes, surgery complications, and mortality (Harrell, 2003; Shay. 2002). Neglect of oral care may cause several health complications, such as aspiration pneumonia, bacteremia, cardiac problems, diabetes, infection of prosthetic joints, and surgery complications (Lamster. 2004: Shay. 2002). Residents who have chemotherap}' or radiation are further predisposed to a different list 11

of dental concerns, primarily xerostomia, which results in unresolved oral infections, mucositis, severe pain, potential abscesses, oral bone loss, and tooth loss (National Institute of Dental and Craniofacial Research, 2004: US Department of Health and Human Services, 2000). Infected dental tissues cause decay, and periodontal disease can affect the neck, eyes, and brain, as well as cause problems with dentures (Lamster, 2004). Plaque The existence of dental plaque is perhaps the most prevalent sign of poor dental hygiene for overall health. The reduction of plaque has been linked to improvements in nutrition, general health, communication, and management of health problems. Dental plaque is the colonization of bacteria on the teeth, which causes corruption or decay of oral tissues. Plaque is a result of improper or the lack of proper oral hygiene. Bacteria organized around the gingiva or gum line characterize plaque, which is the primary cause of periodontal disease. Plaque is an especially important problem for senior residents. As a result of aging, the teeth roots are more likely to be exposed (because teeth lack protective enamel, which protects them from the diseases of plaque). Plaque will usually colonize on the exposed root of the tooth. Decay and periodontal disease are unavoidable results of untreated dental plaque. Both of these conditions can be controlled or altogether avoided by routine dental plaque removal (Kambhu & Levy, 1993). Periodontal Disease The second most common oral health problem is periodontal disease (Lamster, 2004; Lloyd, 2003), which is a result of the inflammation of oral tissues that is caused by dental plaque accumulation on and around the tooth. Over a period of time, plaque bacteria may cause the aheolar bone and other supporting structures to resorb, which will 12

cause the teeth to loosen. Bacterial infection in the mouth may be both painful and dangerous and can potentially lead to arthritis, decreased salivary flow, blurred vision, and severe halitosis (Yoneyama, Yoshida, et al., 2002). Periodontal pathogens that stem from plaque can be related to systemic disease such as cardiovascular disease (Matear, 2000; Shay, 2002). Pneumonia Bacteria from plaque and subsequent periodontal disease have been directly correlated with aspiration pneumonia (Adachi et al., 2002; Dasaraju & Liu, 1996). Aspiration pneumonia is an infection that is likely to occur when food or stomach contents are inhaled into the lungs (Peterson, 2004). According to Peterson, patients who need assistance eating because of either physical or mental ailments are more likely to develop aspiration pneumonia (Chiappelli et al., 2002; Peterson, 2004). Controlling dental plaque reduces the occurrence of both aspiration pneumonia and periodontal disease (Yoneyama et al., 2002). Mouthwash alone can reduce the incidence of this disease, but brushing and flossing are the most effective measures to prevent the bacteria from organizing and causing these illnesses (Kambhu & Levy, 1993). Research has shown that residents who do not receive professional prophylaxis on a regular basis are twice as likely to die from pneumonic infection as are those who receive professional prophylaxis (Addachi et al., 2002; ADA, 2003; Peterson, 2004; Russell, 1999). Furthermore, those who receive no oral care are nearly two-and-a-half times more likely to die from pneumonia than are those who receive oral care (Yoneyama, 2002). One of the most prevalent causes of death in a nursing home is aspiration pneumonia (ADA, 2003; High, 2004; Jurasek, 2002). Staphylococcus species and 13

Candida albicans are much more prevalent in nursing home residents who lack proper oral hygiene care (Adachi et al, 2002). Among elderly residents, bacteria grow in the oral cavity for several reasons, one of the most common of which is unclean dentures. Wearing a denture increases the incidence of denture stomatitis (infection of the tissue around the denture). A recent study showed that 95% of nursing home residents had unacceptable denture cleanliness (Frenkle, 2000). The most obvious way for oral bacteria to grow in the mouth is by not removing food particles, which is the cause of oral plaque. Limeback (1998) documented the relationship between oral plaque and death due to pneumonia. With proper oral care, oral bacteria can be reduced, which will diminish the rate of death from pneumonia (Matear, 2000). Nursing Staffs Oral Hygiene Education in Nursing Homes Studies have shown that little is being done to address nursing home residents' oral care needs (Wardh et al., 2002). Either they are not receiving oral hygiene care, or untrained nursing staff are performing oral hygiene care (Kambhu & Levy, 1993). MacEntee (2000) charged that appropriate oral care for nursing home residents is nonexistent. Unfortunately, nursing home residents often depend on the staff to provide oral care (Fiske, 2000; Gomitsky, Paradis, Landaverde, Malo, & Velly 2002). It has been estimated that approximately 84% of nursing home residents need help with oral hygiene care (Chung, Mojon, & Butz-Jorgensen, 2000). Generally, the findings show that nursing homes do not prioritize oral health care, which means that nursing home residents' oral- care needs are unmet (Jurasek, 2002; Terpenning & Shay, 2002). For example, Marmy and Matt (2003) found that trained aides believed that oral care is a low priority in nursing homes despite the serious need for proper oral health care for nursing home 14

residents. It is uncertain whether nursing home administration, nursing staff, and dental personnel recognize the lack of dental care in nursing homes as an overall health neglect. Chung et al.. (2000) reported that, out of the 169 staff members that they questioned, the majority (69%) admitted lacking appropriate knowledge on oral care. The staff admitted never having received oral care education. With adequate education on routine oral care, nursing home staff can play a significant role in the vitality and quality of life of nursing home residents (Marmy and Matt, 2003). Assessment, training, and accessibility are necessary to fill the need for oral health care in nursing homes (Brayton, 2001). Studies have shown that nursing home staff recognize the need for additional tiaining in oral health care (Chung et al., 2000; Fiske, 2000: Gift et al.., 1998; Gornitsky et al., 2002; Kambhu & Levy, 1993; Jurasek, 2002; MacEntee. 2000; Marmy and Matt, 2003; Terpenning & Shay. 2002; Wardh et al., 2002). Nursing staff understand that without appropriate training they may not be able to identify dental problems or use appropriate oral care techniques (Chung et al., 2000; Marmy & Matt, 2003). For example, Fiske and Lloyd (1992) found that 93% of the nursing staff requested more education on oral hygiene procedures for nursing home residents. Former Senator Breaux, as the chairman of the Senate Special Committee on Aging, reported that the recognition of co-morbidities associated with chronic disease will likely increase the number of appropriate oral health services offered to residents in nursing homes (Gift et al., 1998). The lack of oral care was recognized over 15 years ago, and research continues to discuss this lack with regard to nursing home residents (Fiske & Lloyd, 1992). 15

Andersson, Hallberg, and Ren vert (2002) reported that the attitudes of the staff in their study were positive toward dental care in general, but the staff agreed that they needed more training in dental care to perform oral hygiene exams and daily oral care. To do adequate oral care, nurses' aides could benefit from training courses and continued encouragement from supervisors to tend to residents' oral hygiene. Educating nursing staff about periodontal disease would help to maintain nursing home residents' natural dentition, a result of improved oral care. More education is especially important because the nursing home population are retaining their natural dentition. Research has indicated that nursing staff with a lack of dental hygiene education are likely to set oral healthcare as a low priority (Wardh et al., 2003). Increased interaction is required between dental teams and nursing home staff to provide routine oral hygiene procedures. Paulsson, Soderfeldt, Nederfors, and Fridlund (2002) noted that nursing staff believed that oral health care should be included as routine strategy in their care for residents. Research has suggested that interactive staff training or oral healthcare would benefit the nursing home resident (Kayser-Jones, Bird, Paul, Long, & Schell, 1995). Regular visits by dentists to nursing home residents are strongly encouraged, although they are still a low priority (Chung et al., 2000). A small number of the physicians that Chung et al., questioned were interested in working with dentists to offer oral care (Chung et al., 2000). To improve the health of the patient, staff must know about oral structures, including gums, natural teeth, dentures and partials, and oral hygiene (Fiske, 2000). In a watershed study, Wardh et al.. (2003) held training sessions for nursing staff to assess their interest in learning about and providing oral hygiene care to elderly 16

Full document contains 143 pages
Abstract: The population of nursing home or institutionalized elderly residents in Mississippi is growing as a result of the Baby Boomer influx. Unlike previous generations of nursing homes residents, these residents have retained at least part of their natural dentition because of advances in dental care. Studies on the oral care available for institutionalized elderly patients have shown that nursing staff in nursing homes have inadequate knowledge of dental hygiene procedures. This study examined nursing staff's attitudes toward oral care, their perceptions of the importance of oral care, and their knowledge of oral healthcare according to the recommendations for its practice. A survey instrument designed to provide demographic data and both objective knowledge and subjective attitudes was employed. This instrument was reviewed by dental health care professionals and approved by the Institutional Review Board before deployment in the field. Initially, comparisons between public-pay rural and urban nursing homes were planned to determine whether differences exist in nursing staff's practice, attitudes, and knowledge depending on the population. Mississippi is predominantly a rural state and has only a few urban centers. This did not preclude the identification of rural and urban nursing staff for inclusion in this research. However, no statistically significant differences in any of the categories examined in the survey instrument were found. Thus, Mississippi is a very homogeneous state with regard to many of the self-reported responses concerning the attitudes, practice, and knowledge of nursing staff with regard to dental hygiene. The nursing staff reported assisting 88% of their patients with oral brushing twice daily, as recommended by the American Dental Association (ADA). However, only 19% of this same population received assistance with flossing and 4% with oral swabbing, which does not meet the standard of care. Most respondents reported an appreciation for dental care and felt that they had the support of their administrators to take the time to provide basic oral care. However, most reported that they provided what would be considered less than optimal care for their patients, particularly the dentate population. It was not clear whether this oversight was a result of a lack of time, knowledge, or personal attitudes on the part of the staff. The survey revealed that the most significant gaps in the nursing staff's understanding of oral care were evident in their self-reported knowledge and objective evaluation of knowledge. Over 83% of the nursing staff felt that they had good to excellent knowledge of oral health. However, the staff correctly answered only 64% of the specific questions on basic dental care. Indeed, the highest correct response rate for individual topics was 87% for denture care. This identifies an important gap that must be addressed because more nursing home patients are likely to retain their natural dentition. It is also important to note that the nursing home staff in Mississippi have at least high school diplomas, and the majority have some training beyond this basic level. This indicates that these individuals are among the more skilled members of the workforce in a state with a high number of unskilled workers without a high school education. Even so, the knowledge of dental health is lacking. In part, this must be attributed to failures in the training programs themselves, which include both formal classes and service programs. There should be a renewed emphasis on the part of dental professionals on increasing their profile with nursing schools, certification programs, and nursing homes.