It is with great excitement that the Registered Nurses' Association of Ontario (RNAO) presents this guideline, Oral Health: Nursing Assessment and Interventions to the health care community. Evidence-based practice supports the excellence in service that nurses are committed to delivering in our day-to-day practice. RNAO is delighted to provide this key resource to you. RNAO offers its heartfelt thanks to the many individuals and institutions that are making our vision for Nursing Best Practice Guidelines (BPGs) a reality: the Government of Ontario for recognizing our ability to lead the program and providing multi-year funding: Irmajean Bajnok, Director, RNAO International Affairs and Best Practice Guidelines (IABPG) Programs, for her expertise and leadership in advancing the production of the BPGs; each and every Team Leader involved, and for this BPG in particular -Toba Miller -for her superb stewardship, commitment and, above all, exquisite expertise. Also thanks to Heather McConnell, Associate Director, IABPG Program, who provided the coordination and worked intensely to see this BPG move from concept to reality. A special thanks to the BPG Panel -we respect and value your expertise and volunteer work. To all, we could not have done this without you! The nursing community, with its commitment and passion for excellence in nursing care, is providing the knowledge and countless hours essential to the development, implementation, evaluation and revision of each guideline. Employers have responded enthusiastically by nominating best practice champions, implementating and evaluating the guidelines and working towards a culture of evidence-based practice. Successful uptake of these guidelines requires a concerted effort from nurse clinicians and their health care colleagues from other disciplines, from nurse educators in academic and practice settings and from employers. After lodging these guidelines into their minds and hearts, knowledgeable and skillful nurses and nursing students need healthy and supportive work environments to help bring these guidelines to practice actions. We ask that you share this guideline with members of the interdisciplinary team as there is much to learn from one another. Together, we can ensure that the public receives the best possible care every time they come in contact with us. Let's make them the real winners in this important effort! Doris Grinspun, RN, MScN, PhD(c), O. ONT.Nursing Best Practice Guideline Disclaimer These guidelines are not binding on nurses or the organizations that employ them. The use of these guidelines should be flexible based on individual needs and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses' Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work.With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced and published in its entirety, without modification, in any form, including in electronic form, for educational or non-commercial purposes. Should any adaptation of the material be required for any reason, RNAO written permission must be obtained. Appropriate credit or citation must appear on all copied materials as follows: Registered Nurses' Association of Ontario. (2008) Oral Health: Nursing Assessment and Interventions. Toronto, Canada. Registered Nurses' Association of Ontario.# How to Use This Document
This nursing best practice guideline is a comprehensive document providing resources necessary for the support of evidence-based nursing practice. The document should be reviewed and then applied to both specific needs of the organization or practice setting/environment, and to meet the needs and wishes of the client. This guideline should not be applied in a "cookbook" fashion, but used as a tool to assist in decision-making for individualized client care, and in ensuring that appropriate structures and supports are in place to provide the best possible care.
Nurses, other health care professionals and administrators who are leading and facilitating practice changes will find this document valuable for the development of policies, procedures, protocols, educational programs, assessment and documentation tools. It is recommended that this guideline be used as a resource tool. Nurses providing direct client care will benefit from reviewing the recommendations, the evidence in support of the recommendations, and the process that was used to develop the guidelines.
It is highly recommended that practice settings/environments adapt these guidelines in formats that would be user-friendly for daily use. This guideline has some suggested formats for such local adaptation and tailoring.
Organizations wishing to use the guideline may decide to do so in a number of ways:
 Assess current nursing and health care practices using the recommendations in the guideline.  Identify recommendations that will address identified needs or gaps in services.  Systematically develop a plan to implement the recommendations using associated tools and resources.
The Registered Nurses' Association of Ontario (RNAO) is interested in hearing how you have implemented this guideline. Please contact us to share your story. Implementation resources will be made available through the RNAO website to assist individuals and organizations to implement best practice guidelines.

# Table of Contents

# Oral Health: Nursing Assessment and Interventions
Practice Recommendations 1.
Nurses should be aware of their personal oral hygiene beliefs and practices, as these may influence the care they provide to their clients.
As part of their client admission assessment, nurses obtain an oral health history that includes oral hygiene beliefs, practices and current state of oral health.
Nurses use a standardized, valid and reliable oral assessment tool to perform their initial and ongoing oral assessment.
Oral health status information is regularly reviewed with all members of the health care team to monitor client progress and facilitate the development of an individualized plan of care.
Nurses provide, supervise, remind or cue oral care for clients at least twice daily, on a routine basis. This includes clients who:  have diminished health status;
 have a decreased level of consciousness; and  who have teeth (dentate) or do not have teeth (edentate).
Nurses provide or supervise the provision of oral care for clients at risk for aspiration.
Nurses provide ongoing education to the client and/or family members regarding oral care.
Nurses are knowledgeable of oral hygiene products and their applications as they pertain to their specific client populations.
Nurses are aware of treatments and medications that impact on the oral health of clients.
- Nurses use appropriate techniques when providing oral care to clients.
- Nurses advocate for referral for those clients who require consultation with an oral health professional (e.g. dental hygienist, denturist, dentist).
- Nurses ensure that all oral health-related history, assessment and care be documented.

# Educational Recommendations
- Nurses require appropriate oral health knowledge and skills acquired through entry-level nursing education programs, workplace orientation programs and ongoing professional development opportunities. 16. Health care organizations develop partnerships and increase capacity among providers to deliver collaborative practice models that improve the oral health care they provide to their clients.
- Health care organizations implement continuing education opportunities for nurses and support them to complete oral hygiene education and training that is applicable to their health care setting.
- Health care organizations develop oral hygiene care standards that are based on the best available evidence and ensure they are implemented and monitored as part of the organization's commitment to providing quality oral health care and services.
- Organizations should encourage and offer support, including time and resources, for nurses to participate in oral hygiene research to assist in better understanding the issues related to oral hygiene care provision in various health care settings.
Oral hygiene care is monitored and evaluated as part of the organization's quality management program, utilizing a variety of quantitative and qualitative approaches.
- Organizations develop a plan for implementation of best practice guideline recommendations that include:  An assessment of organizational readiness and barriers/facilitators.  Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process.  Ongoing opportunities for discussion and education to reinforce the importance of best practices.  Dedication of a qualified individual to provide the support needed for the education and implementation process.  Ongoing opportunities for discussion and education to reinforce the importance of best practices.  Opportunities for reflection on personal and organizational experience in implementing guidelines.

# Interpretation of Evidence

# Level of Evidence
Ia Evidence obtained from meta-analysis of randomized controlled trials.
Ib Evidence obtained from at least one randomized controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomization.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization.
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.

# Responsibility for Guideline Development
The Registered Nurses' Association of Ontario (RNAO), with funding from the Government of Ontario, has embarked on a multi-year project of nursing best practice guideline development, pilot implementation, evaluation, dissemination and support of uptake. One of the areas of emphasis is on nursing interventions related to oral health assessment and management in those populations with special needs. This guideline was developed by a panel of nurses and other health professionals convened by the RNAO, conducting its work independent of any bias or influence from the Ontario Government.

# Purpose and Scope
Best practice guidelines are systematically developed statements to assist practitioners' and clients' decisions about appropriate health care (Field & Lohr, 1990). This best practice guideline aims to assist nurses working in diverse practice settings provide evidence-based oral health care to adults with special needs. Within the scope of this guideline, those with special needs may include older adults, those who are medically compromised, intellectually challenged, physically challenged, and/or have severe and persistent mental illness. Many may be frail or dependent upon caregivers to help with their activities of daily living. These adults may live in the community or may be in institutions. It should be noted that children have special assessment needs related to developmental stages that are beyond the scope of this guideline.
The guideline will focus on specific vulnerable populations over the age of 18 years (those who need assistance to meet their oral hygiene needs) and will address:
 assessment of oral health (incorporating screening);  assessment of current oral hygiene practices; and  interventions (incorporating care plan development).

# The goal of this document is to provide nurses with recommendations, based on the best available evidence, to support the provision of oral hygiene care to adults with special needs.
The clinical questions to be addressed by the guideline include:
 What are the risk factors associated with poor oral hygiene?  What are the current attitudes and beliefs of nurses providing oral hygiene care?  What are the optimal oral hygiene interventions for oral health in vulnerable populations? This guideline contains recommendations for Registered Nurses (RNs) and Registered Practical Nurses (RPNs) on best nursing practices in the area of vulnerable adults requiring assistance with their oral hygiene care. It is intended for nurses who are not necessarily experts in this area of practice who work in a variety of practice settings across the continuum of care. It is acknowledged that the individual competencies of nurses varies between nurses and across categories of nursing professionals, and are based on knowledge, skills, attitudes, critical analysis and decision-making that are enhanced over time by experience and education. It is expected that individual nurses will perform only those aspects of oral hygiene interventions for which they have received appropriate education and experience, and that they will seek appropriate consultation in instances where the client's care needs surpass their ability to act independently.
It is acknowledged that effective health care depends on a coordinated interdisciplinary approach incorporating ongoing communication between health professionals and clients /families.

# Development Process
In July of 2006, a panel of nurses, oral health professionals (including registered dental hygienists and a dentist) and speech-language pathologists with expertise in the management of oral hygiene care from a range of practice settings was convened under the auspices of the RNAO. The panel discussed the purpose of their work, and came to consensus on the scope of the best practice guideline. Subsequently, a search of the literature for clinical practice guidelines, systematic reviews, relevant research studies and other types of evidence was conducted. See Appendix A for details of the search strategy and outcomes.
Several international guidelines have reviewed the evidence related to oral hygiene, and it was determined that a critical appraisal of these existing guidelines would serve to inform the development of this guideline. A total of three clinical practice guidelines on the topic of oral hygiene were identified that met the following initial inclusion criteria:  published in English;  developed in 2002 or later;  strictly on the topic of oral hygiene;  evidence-based; and  the guideline is available and accessible for retrieval.
Members of the development panel critically appraised these three guidelines using the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE Collaboration, 2001). As all met the requirements of the AGREE review, a decision was made to work with all three of these guidelines to inform the guideline development process. These were:

# Oral Health: Nursing Assessment and Interventions
The panel members divided into subgroups to undergo specific activities using the short-listed guidelines, evidence summaries, studies and other literature for the purpose of drafting recommendations for nursing assessment and interventions. This process resulted in the development of practice, education, and organization and policy recommendations. The panel members as a whole reviewed the first draft of recommendations, discussed gaps, reviewed the evidence and came to consensus on a final set of recommendations.
A draft was submitted to a set of external stakeholders for review and feedback; an acknowledgement of these reviewers is provided at the front of this document. Stakeholders represented various health care professional groups, clients and families, as well as professional associations. External stakeholders were provided with specific questions for comment, and the opportunity to give overall feedback and general impressions. In addition, client and family focus groups in long-term care and mental health were conducted to gather feedback and input to inform the guideline development process.
The feedback from stakeholders was compiled and reviewed by the development panel; discussion and consensus resulted in revisions to the draft document prior to publication. An acknowledgement of the focus group members and stakeholder reviewers is provided at the front of this document.
Stakeholder: An individual, group or organization with a vested interest in the decisions and actions of organizations who may attempt to influence decisions and actions (Baker et al., 1999).
Stakeholders include all individuals or groups who will be directly or indirectly affected by the change or solution to the problem.

# Systematic Review:
An application of a rigorous scientific approach to the preparation of a review article (National Health and Medical Research Centre, 1998). Systematic reviews establish where the effects of health care are consistent and research results can be applied across populations, settings and differences in treatment (e.g. dose), and where effects may vary significantly. The use of explicit, systematic methods in reviews limits bias (systematic errors) and reduces chance effects, thus providing more reliable results upon which to draw conclusions and make decisions (Alderson, Green & Higgins, 2004).

# Background Context

# Significance of Oral Hygiene on Health
It is an expectation by both clients and families that when entering a health care provider's office, hospital, long-term facility or receiving care within the home, that the individual's health care needs will be met; however, there is evidence that oral health care is not addressed to the same level as other care needs (Frenkel, Harvey & Needs, 2002).
Research has consistently indicated that oral health has a significant impact on quality of life (Almomani, Brown & Williams, 2006;Chalmers, Carter & Spencer, 2002;Petersen, Bourgeois, Ogawa, Estupinan-Day & Ndiaye, 2005;Sheiham, 2005;Watt, 2005). Good oral health enables individuals to communicate effectively, to eat and enjoy a variety of foods (Watt, 2005). Additionally, poor oral health affects the ability to sleep well, especially in the presence of pain, and impacts on a person's perception of self -both their self-esteem and self-confidence.
Petersen of the World Health Organization, (2005), states "oral diseases such as dental caries, periodontal disease, tooth loss, oral mucosal lesions and oropharyngeal cancers human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) -related oral disease and orodental trauma are major public health problems worldwide" (p.661). The relationship between oral health problems and specific medical conditions is being substantiated by evidence from clinical, epidemiological and laboratory studies. "Oral organisms have been linked to infections of the endocardium, meninges, mediastinum, vertebrae, hepatobilary system and prosthetic joints" (Shay, 2002(Shay, p. 1215). In addition, oral pain can have an economic impact on society through time away from work, lost productivity and increased health care expenditures (Watt, 2005).

# Medical/Dental Interface
The emerging association between periodontal disease and systemic disease is a new area of research with important implications for overall client health. The literature reports a link between oral health and systemic disease. Salomon & Xiaozhe (2003) states that conditions such as cardiovascular disease, diabetes, respiratory diseases and adverse pregnancy outcomes can be linked to oral health status. In a systematic review, Chalmers (2003) reports, "dentate status, tooth loss and tempromandibular disorders are associated with hearing loss. An increased number of missing teeth have been associated with coronary heart disease. Periodontal diseases have been associated with cardiovascular diseases, atherosclerosis, sub-clinical lower artery disease, stroke/cerebrovascular disease, metabolic/lipid disorders and obesity" (p.4). Periodontal disease is emerging as a significant risk factor in the metabolic syndrome (heart disease, diabetes, and stroke) (Chalmers, 2003).
Periodontal diseases (periodontitis and gingivitis) are multifactoral diseases with bacterial infiltration as an essential component. Bacterial infection of the supporting structures of the teeth elicits an inflammatory response. This chronic infection and inflammation of the gums establishes a systemic burden via the blood stream of bacterial pathogens, bacterial antigens, endotoxins and inflammatory cytokines. Elevated inflammatory cytokines, in particular C-reactive protein (CRP), destabilizes atherosclerotic plaques and contributes to a prothrombic state. Dr Steven Offenbacker, member of the American Academy of Periodontology states that "periodontal disease needs to be considered as a major contributor to increased levels of CRP by the medical community" adding "previous studies reported that inflammatory effects from periodontal disease could cause bacterial byproducts to enter the bloodstream and trigger the liver to make proteins such as CRP that inflame arteries. The effects may cause blood clots that contribute to clogged arteries leading to heart attacks and strokes" (American Academy of Periodontology, 2004).
In a recent treatment intervention study, Taylor et al. (2006) demonstrated that with full mouth tooth extraction which eliminated periodontitis, lower systemic inflammatory and thrombotic markers of cardiovascular risk were achieved. Shay (2002) describes "the total area of inflamed epithelial lining of periodontal pockets in individuals with full dentition may exceed a surface area of 25 cm 2 " (p.1221) (this can be visualized as approximately half the size of a credit card). This open tissue is at considerable risk for the complications of infection. Over the past two decades the prevalence of diabetes has increased 30 to 40%, and there is a bidirectional association between glycemic control and periodontal disease. Grossi et al. (1997) report that the effective treatment of periodontal infection and reduction of periodontal inflammation is associated with reduction in levels of glycated (glycolated) hemoglobin. It is therefore recommended that control of periodontal infections should be an important part of the overall management of those with diabetes mellitus (Grossi et al., 1997). The association between oral health and diabetic control was further documented through research conducted by Engebretson et al. (2004) who found that poor glycemic control was associated with elevated levels of gingival crevicular fluid (GCF) interleukin-1 beta (1L-1 beta). Increased blood sugar levels cause inflammation in the gum tissue that may lead to increased destruction, independent of bacterial load. Current research indicates that poor oral health is a prominent factor in a number of other illnesses.

# Vulnerable Populations
The greatest burden of oral disease is to disadvantaged and poor population groups, both in developing, and developed countries (Petersen et al., 2005). Loeppeky and Sigal (2007) have identified people with special needs who are in most need of meticulous oral hygiene: "physical, developmental, mental, sensory, behavioural, cognitive or emotional impairment or a condition that requires medical management, health care interventions or use of specialized services or programs" (p.915).

# Residents of Long-Term Care Homes and/or Persons with Dementia
Canada's population is aging quickly and according to new population projections the elderly (60-years-ofage and older) will outnumber those under eighteen in 10 years. According to Health Canada's report Canada's Aging Population (2002), the proportion of elderly in the overall population has gone from one in 20 in 1921in to one in eight in 2001in. As "baby boomers" age (born between 1946in and 1965, the elderly population is expected to reach 6.7 million in 2021, and 9.2 million in 2041 (nearly one in four Canadians).
In fact, the growth of the elderly population will account for close to half of the growth of the overall Canadian population in the next four decades.
The generation prior to the baby boomers predominantly lost most of their teeth, and the use of dentures was very common. Baby boomers and subsequent generations have had the benefit of access to preventative and restorative dental care throughout their lives, and people are retaining their teeth longer. This next cohort of elderly is better educated, are more aware of the importance of maintaining oral health, and expects comprehensive services from health care providers. explains "this concept of compression of morbidity requires aggressive application of preventive health measures. If oral health can be maintained across a person's lifespan, this will contribute to improved quality of life and successful aging" (p.295). However, this population will be entering into a time in their life that is often associated with impaired self-care. The combination of impaired self-care and greater tooth retention will increase their risk for dental and periodontal diseases.
"Aspiration of oropharyngeal (including periodontal) pathogens is the dominant cause of nursing homeacquired pneumonia; factors reflecting poor oral health strongly correlate with increased risk of developing aspiration pneumonia" (Shay, 2002(Shay, p.1215. Nursing home-acquired pneumonia is the leading cause of death from infection in long-term care home residents, and is the second most common cause for hospitalization (Oh, Weintraub & Dhanani, 2004;Shay, 2002). Not brushing the teeth or not receiving adequate oral hygiene care significantly increases oral bacteria in the saliva that residents swallow and may aspirate. Reduced salivary flow, a common side effect of many medications, increases the concentration of bacteria in the saliva, and if the saliva is aspirated, or more likely mixed with food or fluids, up to 100 million bacteria per ml could enter the lungs. A resident with dysphagia is more likely to aspirate in quantities that may far exceed 1 ml (Langmore et al., 1998). " Poor oral hygiene, plaque accretion and compromised host defense that accompany periodontal breakdown also provide conditions favourable for proliferation and subsequent aspiration of orally incubated pulmonary pathogens" (Shay, 2002(Shay, p.1219. Inflammation of the gums is caused by bacterial plaque.
In older people, inflammation forms faster in response to plaque and responds more slowly when plaque is removed (Shay, 2002), hence the importance of regular plaque control through oral hygiene measures.
Along with the increasing elderly population, the number of persons suffering from dementia continues to rise in Canada. Alzheimer's Disease is the most common form of dementia, and accounts for 64% of all dementias. Alzheimer's is a progressive, degenerative disease of the brain that causes thinking and memory to become seriously impaired. Dementia is a syndrome consisting of a number of symptoms that include loss of memory, judgment and reasoning, and changes in mood, behaviour and communication abilities.
In Dementia is a significant impairment and poses a particular challenge for caregivers due to behavioural changes and decreased levels of cooperation. In her research with the dementia population, Chalmers (2003), found that "participants with dementia had significantly higher experiences of oral diseases and conditions at baseline and at one year compared with patients without dementia" (p.16). Additionally, her findings indicated that plaque scores after one year were significantly higher for clients in care settings.

# Oral Health: Nursing Assessment and Interventions

# Persons with Mental Illness
Persons with psychiatric illnesses, including those with schizophrenia, schizoaffective disorder, depression and bipolar disorder may have their oral health compromised, not only by the illness, but also from the medications used to treat the illness. These medications can cause a range of oral complications and side effects, with tooth decay, periodontal diseases and xerostomia being encountered most frequently (Almomani et al. 2006). Side effects of psychotropic medications may include tardive dyskinesia, which impedes mobility of the limbs, and therefore, the ability to effectively brush the teeth.
Several factors contribute to the poor oral health of the person with mental illness:
 The negative symptoms of schizophrenia, which may include apathy and avolition, decrease a person's interest in attending to oral hygiene (Almomani et al. 2006;Jolly, 1991).
 Cognitive deficits associated with schizophrenia and schizoaffective disorder can interfere with attention, memory, concentration and problem-solving skills.
 Some medications used in the treatment of both schizophrenia and depression have an anticholinergic effect resulting in xerostomia. This hypo-salivation can result in rapid tooth decay and periodontal disease.
 Many people with psychiatric illness have limited finances which adversely impacts on their nutritional status and the ability to access treatment in the community (Almomani et al. 2006).
 Those with bipolar disorder exhibit one of the highest rates of associated substance abuse among all the major psychiatric illness (Clark, 2003).
In addition to the physical effects of prescription medications, substance abuse including alcohol, cocaine, heroin and marijuana also can lead to gingivitis or tooth loss (Bailes, 1998). Further, "Meth Mouth" a condition from the use of crystal methamphetamines results in a very rapid decay rate. Klassen (2006) confirms that the level of decay that would normally take years to occur instead happens over a period of months.
Major depression is characterized by mood disturbances that can affect a person's interest or pleasure in daily activities of life. Depression is often accompanied by self-care deficits including oral hygiene practices. In bipolar illness, mood fluctuates between periods of depression and elation, both exhibiting lack of proper attention to oral hygiene Almomani et al. (2006) cites a study by Barnes et al. (1988), which reported that a prime need for people with psychiatric disorders included "prophylaxis, calculus removal and periodontal therapy" (p.274). It is further reported (Hede, 1995cited in Almomani et al., 2006 that only 55% of people with psychiatric disorders engaged in regular tooth brushing. A study by Velasco and Bullon (1999) found the need for oral hygiene instruction among the hospitalized dentate psychiatric population was determined to be 91.5% and for prophylactic dental care was 77.3%. This client population often suffers from poor self-esteem and is stigmatized within the community; poor oral hygiene stigmatizes this population further.

# Challenged Individuals A) Physically and Mentally Challenged Individuals
The Surgeon's General's report on oral health indicates that individuals with mental retardation or with other developmental disabilities, including Down's Syndrome and Cerebral Palsy, have significantly higher rates of poor oral hygiene and an increased need for periodontal treatment than the general population (Glassman & Miller, 2003). It has been proposed that an exaggerated immune-inflammatory response occurs in people with Down's Syndrome (Chicon, Crawford & Grimm, 1998).

# B) Stroke Survivor
Hospitalized survivors of acute stroke experience numerous sources of stress that can adversely affect oral health (Heart and Stroke Foundation, 2006). These stressors include medications that cause dry mouth, decreased alertness, cognitive and perceptual changes, neglect, depression, paralysis resulting in immobility, dysphagia, apraxia, visual changes, mouth breathing and dehydration (Heart and Stroke Foundation, 2006). Dysphagia is strongly associated with aspiration pneumonia, a pulmonary infection caused by the entry of foreign substances and/or bacteria into the lungs. Some stroke survivors do not regain consciousness, which may complicate the provision of care.

# C) Individuals with Limited Dexterity
The ability to provide ones' own oral care may be impacted by variety of causes including, but not limited to, arthritic conditions, neurological diseases and amputations. Special consideration of these individuals will be required in the provision of oral care, and can be determined during the assessment of the individual. Planning for care should include an interdisciplinary approach.

# Intensive (Critical) Care
The patient in the intensive care unit (ICU) poses unique challenges for the nurse. An increased cause of morbidity and mortality among patients in the ICU is nosocomial infections and ventilator-acquired pneumonia (VAP). In Canada, nosocomial pneumonia may be the second most common type of infection acquired in hospital (Lux, 2007). Gingival and dental antiseptic decontamination significantly decreases the oropharyngeal colonization by aerobic pathogens in ventilated patients (Founrier et al, 2005). Findings that colonization of dental plaque could play a significant role in the occurrence of respiratory nosocomial infections in ICU ventilated patients have been supported by other studies (Fourrier et al, 2005).
Often, the patient is admitted to care with good oral health, and it becomes the responsibility of the ICU nurse to maintain that oral status while addressing the challenge of providing care under extremely difficult circumstances. Providing care to an unconscious patient, one who is on a ventilator or one who cannot swallow requires special attention to prevent aspiration pneumonia. Preventing oral disease in those who may require a long convalescence or who may become permanently compromised is a challenge for nursing care.

# Oral Health: Nursing Assessment and Interventions
Nursing Best Practice Guideline

# Clients Receiving Chemotherapy or Radiotherapy
Mucositis is a painful complication of chemotherapy and/or radiotherapy, and good oral hygiene protocols are important. Mucositis requires effective oral hygiene and a multi-disciplinary approach to management. Infection of the gums prior to chemo or radiotherapy is a potential compounding factor and therefore, when vulnerable populations are scheduled to have chemotherapy or radiotherapy, it is imperative that prior to this treatment they have good oral health. Neutropenic patients with mucositis have an increased risk for potentially life-threatening infections, as well as for prolonged hospital stays. Standard care of oral mucositis is based on effective oral hygiene, appropriate analgesia, infection management and parenteral nutrition when needed; few other approaches have been shown to be effective (Peterson & Cariello, 2004).

# Barriers to Achieving Optimal Oral Health
The majority of caregivers, regardless of their category, have not been educated on how to care for the oral hygiene of residents in long-term care (Chung, Mojon & Budtz-Jorgensen, 2000). Sumi et al. (2001) investigated oral care practices among caregivers in Japanese nursing homes and found that 99% of staff desired the development and dissemination of simple oral care equipment, while 97% wanted training in oral care. Chalmers (2003) asserts that realistic, creative and practical strategies need to be developed and promoted for caregivers in long-term care. It has also been reported in the literature that oral hygiene promotion involves any combination of education, organizational, economic and environmental supports for behaviour conducive to oral health (Croxson, 1993as cited in Choo 1999.

# Therapeutic dehydration
Staff attitudes concerning oral health care are a significant barrier to optimal care. In a study by Wardh et al., 2000(as cited in Sumi et al. 2001, it was found that oral care was considered to be the most undesirable task among caregivers. Why is oral hygiene care such an unpleasant task? Some evidence supports the belief that the oral cavity is a very private body part and health care providers are reluctant to perform care for this reason. Perhaps it is because nurses feel ill-equipped to provide such care due to a lack of education in this area, or perhaps oral hygiene is not being given the importance it deserves, especially when competing with the numerous care needs of clients (Chung et al. 2000;Paulsson, Soderfelt, Nederfors, Frindlund, 2002). Several studies have shown that health care providers are not receiving adequate oral health education, support from management or interdisciplinary integration to implement a comprehensive oral health care strategy. (Wardh et al., 2000) In addition to lack of education and staff attitudes, there are several myths associated with the elderly in relation to oral health. These include:
1) the elderly are set in their ways and are not likely to change their practices or beliefs about oral hygiene;
2) the elderly do not benefit from activities aimed at promoting health;
3) the elderly are not co-operative and are difficult to work with; 4) changes in practices have only a small impact on longevity and physical health and well-being; and 5) the costs out weigh the benefits (Chalmers, 2003).
In addition to economic reasons or other physical health concerns, many older persons ignore oral pain because they may believe that tooth loss is an inevitable part of the aging process" (Randolph, Ostir & Marleides, 2001).
Tooth loss and oral pain are not an inevitable product of aging, nor is decreased salivary flow and the problems associated with it. "Flow from the parotid, submandibular and minor salivary glands remains largely unaffected in healthy persons, regardless of age (Shay, 2002(Shay, p. 1216).

# Interdisciplinary Approach
A wide range of disciplines can be called upon to assist in the provision of care in various care settings. This interdisciplinary team can include the nurse, physician, occupational therapists and speech language pathologists in addition to dental hygienists, denturists and dentists. It is also recognized that unregulated health care providers, families and clients do provide care and should be included in this team approach.
Research has shown that an interdisciplinary approach to oral health care improves knowledge, awareness and moves oral health practices closer to best practice (Fallon, et al, 2006). Dental hygienists' services are relatively inexpensive and easily delivered within organizations. It was estimated that the cost in one hospital to prevent nosocomial pneumonia was less than 10% of the cost associated with treating a single case (Lux, 2007). Chalmers and Pearson (2005) concur with previous studies, stating that a multi-faceted approach to implementation, one that draws on a range of different sources of knowledge and implementation strategies to bring about change, is more effective than a single intervention approach.
The president of the Canadian Dental Association, Dr. Wayne Halstrom, (2007), stated that preventing oral disease among vulnerable groups is socially desirable and will make economic sense for Canada's publicly funded health care system. He urged the medical and dental professionals to work together to encourage the evolving Canadian health care system to "put the mouth back in the body" (p.145).
To create an oral health strategy, education and skill development are necessary. The clinical research evaluating the effectiveness of education in oral health care has demonstrated a positive change in attitude and behaviour. In Sweden, oral health assessments of 170 residents' plaque levels and oral mucosal conditions were significantly improved after implementation of an oral health screening protocol teamed with care provider oral health education program (Chalmers, Carter & Spencer, 2004). Another trial reported improved oral mucosal health and reduced candidal colonization to dentures and oral mucosa in institutionalized older adults who received a comprehensive care provider and professional oral hygiene care protocol.
Education must enhance knowledge levels, change behaviours and shift attitudes. The current system of oral care education for nurses and unregulated care providers are inadequate to meet client's needs.
Caregivers reported that the topic of oral health care is inadequately covered, nor given sufficiently high priority in educational programs (Sumi et al, 2001). Nurses have identified a need for additional foundational and ongoing education and specifically, more practical education regarding oral hygiene and the provision of care (Jones, Newton & Bower, 2004;Paulsson et al, 2002). There is also a recognized need for increased collaboration with the dental service for standards of oral care, including documentation. Evidence on the use of assessment tools by care givers to evaluate long-term care residents oral health demonstrated that successful assessment of residents by nursing staff requires appropriate training by a dental professional. Inadequate education and oral health knowledge in nursing practice must be addressed in order to change behaviour.
Through a greater understanding of the oral cavity and current knowledge from the dental community, caregivers will appreciate the need for oral care and see it as a priority. Oral hygiene education needs to be reinforced through ongoing learning activities to ensure sustained behaviour change and to keep abreast of the developments within the field. This also ensures that new health care providers joining the organization are brought into the culture of the workplace. Axelson et al, 1991 as cited in Paulson, Neterfors and Frindlund (1999) found that the nursing personnel's view of oral care depended on the knowledge, commitment and enthusiasm on the part of administration.
Health care professionals' anxiety about their own oral hygiene and health may adversely impact the care and advice they provide to clients (Preston, Punekar & Gosney, 2000). Preston et al. (2000) reports that deficiencies in care giver knowledge appear to be associated with their own anxiety about visiting a dentist.
Canada is a multicultural community that employs caregivers from diverse ethnic and cultural backgrounds. Along with cultural differences, education varies from country to country and therefore oral hygiene advice may reflect cultural norms, rather than be evidence-based Skill development is an important aspect in the provision of oral care. The oral cavity is not always easy to access. Sumi et al. (2001) noted that oral hygiene is often performed in a narrow field of view or in an uncomfortable position, which indicates the urgency of standardizing and systematizing oral care to relieve the strain on caregivers. Along with performing skills effectively with the least strain to the provider, consideration must also be given to infection control measures. Skill development must also address proper techniques with acceptable products to prevent harm to clients.

# External Factors
Tooth loss is linked to socio-demographic and behavioural characteristics (Randolph et al., 2001). Women, older persons and those with a lower socio-economic status present with more tooth loss, either complete or partial. Also linked to tooth loss and/or gingivitis is smoking, substance abuse including alcohol, marijuana and cocaine (Bailes, 1998;Randolph et al, 2001).
The relationship between tobacco and general health is well documented, but the relationship between tobacco and oral health must also be considered. Smoking has significant effects on the oral cavity, including oral cancers and pre-cancers, increased severity and extent of periodontal diseases, and poor wound healing (FDI/WHO, 2005). Up to one half of all adult cases of periodontitis are linked directly to tobacco use and when health care providers advocate for smoking cessation programs, they are advocating for better oral health. 1 2
Organizations must show their commitment to quality oral hygiene care by implementing oral hygiene care standards that can be achieved at local, provincial and national levels. Oral care standardization with well-defined protocols will help ensure sustainability. There is a need for protocols that maintain simplicity, care that can be completed efficiently, safety for both client and caregiver, and universality (effective when provided by different caregivers).
The Canadian Oral Health Strategy (Federal, Provincial & Territorial Dental Directors, 2005) is a blueprint to improving oral health and guiding oral health initiatives, yet it does not set standards. This strategy looks at establishing a baseline of current oral health, setting targets, developing strategies to improve and maintain oral health and developing a system of measurement and monitoring so that individual provinces, regions and organizations can compare themselves.
As a powerful force within the health care system, nurses are encouraged to act in a health promotion capacity to advocate for reforms that will provide access for all persons to good oral health care. Diseases of the oral cavity not only compromise the functions of the oral cavity, but also compromise the function of many other body systems.
The RNAO recognizes the importance of this area of health promotion, and through this guideline delivers evidence to support the practices of nurses delivering oral hygiene care. The diverse members of this guideline development panel strongly believe that the availability of appropriate equipment, educational opportunities and skills training in oral hygiene delivery will empower nurses to advocate on behalf of their clients, and to provide optimal oral health care.

# Practice Recommendations
The following recommendations, based on the best available evidence, support the provision of oral hygiene care to adults with special needs. Refer to Appendix C for an Algorithm that summarizes the Practice Recommendations.
Focus group feedback was incorporated into this document as "Comments from our clients" within the discussion of evidence, as appropriate.

# Recommendation 1
Nurses should be aware of their personal oral hygiene beliefs and practices, as these may influence the care they provide to their clients.

# Level III

# Discussion of Evidence
In order to begin the process of quality oral care, self-awareness is crucial (Croxson, 1993). Attitudes towards oral health are influenced by personal experiences (Frenkel et al, 2002). Therefore, a nurse's personal oral hygiene beliefs and practices can affect the oral health care and advice given to their clients (Wardh et al, 2000).

# Recommendation 2
As part of their client admission assessment, nurses obtain an oral health history that includes oral hygiene beliefs, practices and current state of oral health.

# Level IV

# Discussion of Evidence
The choice of an approach to assist with an oral health history is client and setting-specific. To ensure that the oral health needs of the client are met and maintained, the first step is to complete a thorough assessment upon admission (Chalmers & Pearson, 2005;Pearson, 2004). Oral assessment should take place on the first meeting with the client as evidence suggests that pre-intervention assessment can reduce both the incidence and severity of oral complications (Miller & Kearney, 2001), especially in the oncology client.
Challenges may arise as this assessment relies on the client's ability to communicate and co-operate with assessment (Chalmers & Pearson, 2005;Pearson, 2004).
This oral health history should identify oral hygiene beliefs and practices so that a plan for care can be developed which will mimic or augment that person's routine. The care provider must determine if the client is able to tend to oral hygiene independently and if not, to what extent interventions are needed. These interventions may include "reminding, assisting, providing or palliative" care (Johnson & Chalmers, 2002).

# Comments from our clients
When asked whether they believed questions about oral hygiene are an important part of their health history:
"...Yes, I think with depression I don't really take care of myself the way that I should, and I really don't think about brushing my teeth."
"...Of course, because teeth tell a lot about you. If you have clean teeth, people look at you one way, and if you have dirty teeth they look at you different. When you have bad breath, no one likes to talk to you."
"...I have a sensitive tooth and if you give me something sweet it kills me. I remember one time being sick and the nurse gave me medicine that was syrup and that killed. I spit the medicine out."
"...it wouldn't bother me but they need to tell me why they are asking."
"..in all the times I've been to the hospital, no one has ever asked me about my teeth."

# Recommendation 3
Nurses use a standardized, valid and reliable oral assessment tool to perform their initial and ongoing oral assessment.

# Level IV

# Discussion of Evidence
Oral hygiene should be looked upon as an integral component of total care to a client (Sumi et al, 2001). A client's oral status should be assessed on a regular basis, and in a routine and methodical manner. Oral health assessments and screening can be conducted by educated nurses and caregivers, as appropriate, to monitor oral health, to evaluate oral hygiene care interventions, to initiate dental visits when required and to assist with individual oral hygiene care planning (Pearson & Chalmers, 2004).
Utilizing an established oral assessment tool objectively and reproducibly classifies and measures the oral cavity in clients. Ideally, the tool chosen should be objective, validated and reproducible across all clinical situations (Rubenstein et al, 2004). The scale should have inter-rater reliability, should be easy to perform, should be simple to understand and easily adaptable for use in multiple clinical settings. Numerous assessment tools are available (Atchison & Dolan, 1990;Bauer, 2001;Burke & Wilson, 1995;Calabrese, Friedman, Rose & Jones, 1999;Fitch, Munro, Glass, Pellegrini, 1999;Jenkins, 1989;MacEntee & Wyatt, 1999;Roberts, 2000;Thai, Schuman & Davidson, 1997); however, very few of these tools have been validated through repeated randomized clinical trials. Many oral assessment tools have been developed primarily for research purposes or for assessment of particular client populations. When selecting a screening/assessment tool the type of facility, the client population and staff mix should be considered.
Instruments to be used should be setting and client-specific.

# Nursing Best Practice Guideline

# Document Findings
The nursing oral health assessment should identify those clients at risk for development of oral problems such as stomatitis, mucositis and periodontal diseases. Nursing oral health assessments should be completed on all clients as part of a routine, systematic assessment (e.g. oral health assessments should be completed on admission, during routine monitoring and documented on the client's health record).
Examples of oral health assessment tools include:
 Oral Assessment Guide (OAG)  - Validated in oncology patients in multiple clinical trials, HIV patients, elderly rehab patients, psychiatric patients and rehab patients.
 Revised Oral Assessment Guide (ROAG) (Andersson, Halberg & Renvert, 2002) - Used in three small studies of geriatric rehab patients.
 Brief Oral Health Status Examination (BOHSE) (Kayser-Jones, 1995)
- Validated in long-term care and residential care settings; can be used with cognitively impaired clients.
 Oral Health Assessment Tool (OHAT) modified from Kayser-Jones, 1995 - Validated in Austrailian long-term care facilities in a single trial.
 THROAT  - Developed and tested for use in elderly hospitalized patients in a single trial.
 Mucosal Plaque Index (MPS)  - Measures mucosal and plaque indices (valid for when to refer to a dental hygienist).
 National Cancer Institute (NCI) Scale (WHO, 1997)
- NCI more commonly used in clinical trials.
- Focuses on the assessment of mucositis.
 World Health Organization (WHO) Grading Scale (WHO, 1997)
- WHO has been validated in clinical trials, and is a commonly used tool in oncology practice.
- Focuses on the assessment of treatment induced mucositis.
Refer to Appendix E for additional information regarding the tools listed above.
Oral Health: Nursing Assessment and Interventions

# Comments from our clients
When asked if it was important to them to have a nurse look inside their mouth to determine the state of health:
"...As long as I was told why they were looking into my mouth I guess it would be okay. When I have a sore throat the doctor looks into my mouth, so if there was a good reason...."
"...I think now that I know how important it is I would feel better if she did it...."
"...does that mean that everyone would get asked the same questions? Then it would be better...."

# Recommendation 4
Oral health status information is regularly reviewed with all members of the health care team to monitor client progress and facilitate the development of an individualized plan of care.

# Level IV

# Discussion of Evidence
It is important that health care is provided with a focus on the principles of client-centred care (RNAO, 2006), and that care is individualized to meet the person's individual goals and needs (Freer, 2000;Jones, Brown & Volicer, 2000). One very useful tool to guide the delivery of care to a client is the individual plan of care. The care plan identifies client needs and sets out the level of services and care needed to meet those objectives (Fallon et al., 2006). The care plan addresses all needs of the client including, but not limited to, communication, nutrition, hygiene, mobility and social interaction. The care plan identifies: problems determined during the initial assessment; client-centred goals as they relate to the identified problems including achievable outcomes; and interventions or strategies aimed at achieving the desired goals. When regularly reviewed and updated, the care plan can provide accurate, relevant and consistent communication between all care providers (Fallon et al, 2006;Freer, 2000). Refer to Appendix F for examples of oral hygiene care plans.

# Comments from our clients
When asked if they had ever been referred to a dental hygienist, dentist or denturist by a nurse, or if they had oral health concerns that were not being addressed:
"...No. It would be nice though, because I don't go to a dentist because I don't have enough money."
"...I can't afford to go to a dentist so maybe the nurse could look in my mouth instead."
"...I smoke so I have stains on my teeth. That looks awful, but I don't know how to get them off."
"...I brush my teeth when I have the energy, but I don't know if I'm doing it right..."
Refer to Appendix N regarding resources for financial supports in reference to "Comments from our Clients".

# Discussion of Evidence
Dental plaque is the primary contributor to bacteria growth that contributes to such conditions such as gingivitis, dental caries, periodontal conditions, xerostomia or halitosis. Most oral infections in patients originate from their own oral flora (The Royal Free Hampstead NHS Trust, 2000). The literature also supports that oral complications may be due to various illnesses (The Royal Free Hampstead NHS Trust, 2000). To decrease dental plaque build up on the surface of the teeth or mucosa, regular oral hygiene care is required. It becomes an important role of nurses to promote or provide effective oral care to those clients with special needs (Jolly, 1991).
Oral care is a fundamental nursing activity and an important aspect of client care. Nurses play an important role in providing effective oral care and promotion of oral hygiene (Satku, 2004). Brushing teeth twice daily is considered a social norm; however, this recommendation is in direct relationship to controlling the accumulation of plaque biofilm and halitosis (Darby & Walsh 2003). Pneumonia, fevers and death from pneumonia "significantly decreased" in dentate as well as edentulous clients who received oral care (Yoneyama et al., 2002). A soft bristle toothbrush is the most effective tool for plaque removal, even for edentulous clients who need to have their oral mucosa and tongue gently brushed (Jones et al., 2004).
Unconscious or intubated clients should receive oral care every two to four hours, and as required (Schleder, 2003). Intubated clients should also be assessed to determine the need for removal of oropharyngeal secretions frequently, as well as prior to repositioning the tube or deflation of the endotracheal cuff (Schleder, 2003).
Halitosis (bad breath) is a common problem, predominantly affecting adults. Most cases of halitosis result from microbial putrefaction within the oral cavity, and sulphide compounds have been indicated as the main cause of the odour (Rosenberg et al., 1991). The most effective management of halitosis in most cases is simple, regular oral cleaning with a toothbrush (Scully, Porter & Greenman, 1994). It is generally recommended that tooth brushing occur in the morning after a period of sleep and again at night prior to going to bed (Darby & Walsh, 2003). Frequency of tooth brushing is dependent on the unpredictable rate of plaque biofilm accumulation and contributing factors such as smoking, dietary intake, systemic disease, compromised immune systems or an individual's dexterity (Darby & Walsh, 2003). To clean bacterial deposits from around the gums, a "dip and brush" method should be used, dipping a small headed, soft toothbrush in an antimicrobial rinse, usually chlorhexidine (personal communication, Lynda McKeown, April 3, 2008).
Whenever possible, clients should perform their own oral care. In situations where clients have decreased level of consciousness or have special needs, caregivers should incorporate oral hygiene procedures into the care (Jolly, 2001). An RCT conducted by Almomani, et al. (2006) found that the oral health of people with serious mental illness can be improved with a combination of education and instruction, along with a reminder (cuing) system.
Taking into consideration the client's medical history, oral care should continue to be provided even when gingival bleeding is evident. If the bleeding is uncontrolled and persistent, a referral to a dental care professional should be made (Fourrier et al, 2005)

# Comments from our clients
When asked if it would be useful to have someone remind them to brush their teeth, or to supervise while they brush their teeth:
"...Yes, stickies  on the door or on the mirror would be good."
"....when I'm sick I don't even think of taking care of myself or of brushing my teeth."
"...sometimes my arm is so heavy that I have to hold it up to brush my teeth, so I say, why bother?" "...there's nothing wrong with reminders."
"....it would be embarrassing to have someone doing it for you."

# Recommendation 6
Nurses provide or supervise the provision of oral care for clients at risk for aspiration.

# Level III

# Discussion of Evidence
Aspiration is defined as the inhalation of oropharyngeal or gastric contents into the larynx and lower respiratory tract, while aspiration pneumonia is a result of the inhalation of oropharyngeal secretions that are colonized by pathogenic bacteria (Marik, 2001). Aspiration pneumonia is one of the main causes of morbidity and mortality among intubated and ventilated patients, as well as the elderly who are in nursing homes or who are hospitalized (Sumi et al., 2001). Within 48 hours of admission to hospital, the composition of oral flora changes in critically ill patients (Munro, Grap, Jablonski & Boyle, 2004). Normal flora (which is concentrated in dental plaque) resides in the oropharynx. Antibiotics or other mechanisms change normal flora. Bacterial binding sites are susceptible to colonization by gram-negative bacteria. Once the oropharynx is colonized with gram-negative bacteria, these organisms can be aspirated.
Those clients experiencing: dysphagia (difficulty swallowing, including stroke related dysphagia); being bedridden in a prone position; reduced respiratory status (intubated on a ventilator); prolonged bolus holding; poor head/trunk control; dependence for feeding; poor oral hygiene; high levels of tooth decay; dependence for oral care; past history of aspiration and inability to manage their own secretions (i.e. excessive drooling) are all at an increased risk for aspiration (Chalmers et al., 2002). Forty-one percent of subjects who developed aspiration pneumonia were dependent for feeding and oral care (Langmore et al., 1998). Providing oral care (by ensuring the oral cavity is clear of debris and organisms) before meals reduces the risk of developing aspiration pneumonia (Yoneyama et al., 2002). Poor oral care can result in oropharyngeal colonization (Marik, 2001). Suction should be used when providing oral care to clients that have low levels of consciousness, for those that are NPO (no food or drink by mouth) and for those clients who cannot tolerate thin fluids. There is limited scientific evidence as to the efficacy of suction toothbrushes; however, clinical experience supports their use. Research in this area is ongoing, Refer to Appendix G for oral hygiene products appropriate for those at risk for aspiration.

# Nursing Best Practice Guideline

# Recommendation 7
Nurses provide ongoing education to the client and/or family members regarding oral care.

# Discussion of Evidence
Education of the client is an important first step in achieving adherence with oral hygiene practices as it involves the client in his/her own care, promotes a positive self-image and fosters independence. Nurses are well positioned within the health care team to support opportunities for interdisciplinary client education and to advocate for access to a range of health professionals. Involving the family assures that appropriate supervision and cuing occurs for the client (Jolly, 1991).
Oral care may be overlooked in those who are not at their optimal level of well-being. Emphasis on oral care generally decreases with the increasing dependency of clients (Johnson & Chalmers, 2002). It becomes important to disseminate knowledge related to the interrelationship of oral health to general health among clients and health care professionals. It also is important to ensure behaviour management strategies for specific client populations are in place to successfully implement and sustain optimal oral health among clients with special needs (Pearson & Chalmers, 2004). Rubenstein et al. (2004) recommend the use of oral care protocols that include client education in an attempt to reduce the severity of mucositis from chemotherapy or radiation therapy. In this context, client education refers to comprehensive, theory-based, educational approaches that prepare individuals for medical procedures, including what to expect in terms of adverse effects, and how to cope (psychoeducational strategies).
Cichon et al. (1998) conducted a clinical intervention study that explored the effect of oral hygiene care (provided by a dental hygienist) and education on oral health in those with Down's Syndrome. They found that this approach was effective in improving the gingival condition, reducing probing depth and affected the subgingival environment and its microflora in this client population.
Research conducted by Hede (1995) with 240 dentate psychiatric clients indicated that oral health education directed specifically towards those persons with schizophrenia and personality disorders should be an integral part of Activities of Daily Living training. Velasco & Bullon (1999) concluded through their research with 565 psychiatric patients in Spain that 91.5% required oral hygiene instruction. Almomani et al. (2006) reported the results from a randomized controlled trial that suggests that the oral health/hygiene of people with psychiatric disabilities can be improved with education, instructions and reminders.

# Comments from our clients
When asked if they believed it is important that the client and family receive ongoing education in the hospital and the community:
"...yes, both should have the education because they're there to help when you're sick."
"...the more information given the better."
"...the family should know. I can't really explain it to them. It's better for them to hear it all first hand from the source."
"...nurses are the appropriate people to teach us about how to brush our teeth. Most of us can't afford to go to a dentist or get our teeth cleaned. We see nurses most often."

# Recommendation 8
Nurses are knowledgeable of oral hygiene products and their applications as they pertain to their specific client populations.

# Level IV

# Discussion of Evidence
All clients' tooth/dentures, tongue and oral mucosal surfaces are to be cared for using the appropriate oral care products. A toothbrush is the most common product used in preventing periodontal disease (Assadoorian, 2006); however, nurses should be aware of the many other products that exist to address oral care needs such as moisture loss from lips and mucosa, dry mouth (xerostomia), dysphagia and, intubation. The enhancement of nurse's knowledge related to oral hygiene products and their use is an opportunity for interdisciplinary collaboration. Refer to Recommendation 14 regarding the content of education programs to support evidence-based oral care.
Appendix G provides an overview of selected oral hygiene products.

# Comments from our clients
When asked if nurses should know what products to use, how to use them and to teach the client about these products:
"...it would be helpful to have someone to ask about things we hear about."
"...I don't know enough about the different products, like what toothpaste is best for me."
"....I can't afford to go to the dentist so I need somewhere to get information because I don't know all this stuff."
"...the nurse is the right person to ask because she has the expertise and not everyone goes to the dentist."
"...it is important to know what to use so that you don't hurt your mouth."
"...if the nurse asks, then it prompts me to ask."

# Recommendation 9
Nurses are aware of treatments and medications that impact on the oral health of clients.

# Level IV

# Discussion of Evidence
The nurse must be aware of the potential oral side effects of the medications that the client is taking. Adverse drug reactions disclosed in drug monographs often include oral side effects. The most common medication adverse effect is on the saliva, such as the subjective complaint of dry mouth (xerostomia) and the alteration of salivary flow (hyposalivation). Other oral side effects include abnormal homeostasis, soft tissue lesions, reactions, taste changes, altered host resistance, gingival enlargement, burning oral sensations, increased caries due to high sugar content in the medications, involuntary oral movements and alveolar bone alterations. These signs and symptoms may appear concurrently, and the risk of oral adverse effects increase with polypharmacy (Shinkai, Hatch, Schnidt & Sartori, 2006).
Clients using certain types of inhalation devices often develop oral candidiasis. Clients receiving medication for chronic diseases may be at greater risk for developing tooth decay when they are using sweetened medications. Sugar is frequently a part of liquid medications, cough drops, vitamins, antacid tablets and antifungal agents. Some medications may result in altered taste -leaving a bitter or metallic taste in the mouth -including cardiovascular agents, central nervous system stimulants, nonsteroidal and anti-inflammatory drugs, respiratory inhalants and smoking cessation products (American Dental Association, 2005). Medication adverse effects can also impact on oral health in an indirect way (e.g. there is a significant risk of the serious condition tardive dyskinesia developing as a side effect of common antipsychotics). The physical challenges of living with tardive dyskinesia may impact on an individual's ability to perform oral hygiene care independently.
Mucositis is a painful complication of chemotherapy and radiotherapy, and good oral hygiene protocols are important in reducing the severity of this adverse effect of these treatments (Rubenstein et al., 2004).
Effective oral hygiene and a multi-disciplinary approach to management are essential to quality cancer care. Nurses have a role in advocating for oral health assessment prior to the initiation of chemotherapy or radiation therapy, when appropriate, in order to improve client outcomes. Nurses working in this specialty area of practice may wish to consult with guidelines specifically on this topic (e.g. Rubenstein et al., 2004).
Refer to Appendix H for a list of medications that impact on oral hygiene and oral health.

# Comments from our clients
When asked if they had ever experienced side effects from medications that made it difficult to maintain oral hygiene:
"...when I was on clozapine I would drool a lot. It bothered me but no one told me about it."
"...meds make me have a very dry mouth. If it's dry it gets sore..."
"...Sometimes I feel like stopping meds because having a dry mouth is a pain in the ass... you have cotton mouth and then your lips stick to your teeth and you can't speak right... you get so selfconscious."
"...and she  could tell you what to expect so you don't get frustrated and want to quit taking your meds..."

# Recommendation 10
Nurses use appropriate techniques when providing oral care to clients.

# Level IV

# Discussion of Evidence
Assessment of the mouth prior to the provision of oral care is essential; the use of direct light (such as that provided by a flashlight) to assess the oral cavity allows for greater visualization. Numerous tooth-brushing techniques exist with no one method being clearly superior to another (Assadoorian, 2006). Brushing the teeth systematically and thoroughly, using a technique that is suitable for the individual client, is important.
Appropriate care for dentures is needed as they too accumulate plaque and harbor harmful bacteria that can cause disease (Sumi, Nakamora & Michiwaki, 2002) Appropriate technique includes behaviour management strategies for specific client populations, such as those with cognitive impairment, which will help to support the successful implementation and sustainability of optimal oral health among those with special needs (Pearson & Chalmers, 2004). For comprehensive resources related to caring for clients with delirium, depression or dementia, refer to the RNAO guidelines Screening for Delirium, Dementia and Depression in Older Adults (2003) and Caregiving Strategies for Older Adults with Delirium, Dementia and Depression (2004).
Using an ergonomic approach in terms of client and nurse positioning during the provision of oral care is an important consideration for effectiveness of the care provided and the safety of the client and nurse.
Proper positioning of the client in bed or chair can prevent injury to the client (example, prevention of aspiration) and the nurse (muscle strain).
The educational resource Oral Care for Residents with Dementia (DVD) provides an overview of approaches for providing oral care to those with dementia, emphasizing safe and effective ergonomics. Refer to Appendix L for additional information and resources.

# Examples of Technique and Body Positioning in the Provision of Oral Care:
Client in bed: Client standing: "two toothbrush" technique "hand-over-hand" technique

# Oral Health: Nursing Assessment and Interventions
Refer to Appendix I (Denture Care), Appendix J (Tooth Brushing Techniques) and Appendix K (Approaches to Care) for additional details regarding techniques to support the provision of oral care.

# Safety First!
 The health care organization's infection control policies and procedures must be followed.
 Apply evidence-based measures, professional judgment and risk reduction principles in the provision of care. (College of Nurses of Ontario, 2005)
 Safe care provision includes ergonomics, infection control and appropriate equipment.

# Recommendation 11
Nurses advocate for referral for those clients who require consultation with an oral health professional (e.g. dental hygienist, denturist, dentist).

# Level IV

# Discussion of Evidence
The nurse, during the initial assessment and during regular oral care, will continually observe for changes in the oral cavity that would necessitate a referral to an oral health professional. It is important to recognize that a team approach including a dentist, dental hygienist, dental assistant and other trained staff will help in the provision of care to individuals with disabling physical, mental, sensory and cognitive abilities (Jolly, 2001). In their research with psychiatric clients, Velasco and Bullon (1999) found that this client population had "extensive dental disease" (pg. 16), adding that persons with advanced mental illness are often anxious and uncooperative. Preventive measures are best performed by "dentists and dental hygienists properly trained to provide oral treatment for psychiatric clients in collaboration with the psychiatric staff" (pg. 16). For definitions regarding scope of practice for oral health professionals, please refer to Appendix B.
Before surgery, clients should have an assessment and any dental work done to decrease the chance of infection (ADA, 2007). Research now shows that there is a potential link between oral disease and other health problems such as diabetes, heart disease and stroke (CDA, 2007).
Nurses should also note that tobacco users are at an increased risk of developing oral cancer and lesions, and should consult with a dentist or dental hygienist regularly (CDA, 2007). Tobacco is a major cause of tooth loss in adults through gum disease (ADA, 2007). Clients who abuse drugs and/or alcohol are at increased risk of fracturing teeth, and are at risk of dental problems due to neglect (ADA 2007).
Long time use of methamphetamine (MA) has been associated with severe MA induced caries (JCDA, Vol. #71, 2005). The client should provide a list of all medications to the dental professional, as these may affect oral health status.
Refer to Recommendation 16 for a discussion of evidence to support partnerships to facilitate access to care, and to Appendix M for resources related to financial assistance.  Kaiser-Jones et al., 1995

# Recommendation 12
Nurses ensure that all oral health-related history, assessment and care be documented.

# Level IV

# Discussion of Evidence
Communication is vital in the delivery of the care that clients are provided, and thorough documentation is a key communication strategy between members of the multi-disciplinary team. Clear, concise documentation is an integral part of safe and effective nursing practice (College of Nurses of Ontario, 2005) and allows for members of the health care team to provide safe, effective care and treatment. Further, this documentation also forms a permanent and reliable record of the client's health and information. The College of Nurses of Ontario has developed practice standards requiring nurses to document and to maintain records including the minimal expectations regarding what components are to be included in the health record. Clear, comprehensive and accurate documentation is a record of the judgment and critical thinking used in professional practice and provides an account of nursing's unique contribution to health care (CNO, 2005).
Within the scope of this guideline, documentation will include recording in the client's health record all information reflective of equipment and supplies being used. The initial health history documentation should include, but not be limited to, the following:
 oral health history;  oral health assessment; and  oral health practices.

# Oral health history documentation includes:
 identification of oral health beliefs and practices;  identification of the client's oral health routine; and  whether the client has their own teeth or dentures (full or partial)
Oral health assessment documentation includes:
 physical assessment of the oral cavity;  the ability of the client to tend to oral hygiene independently; and  identification of interventions required for the client to meet their oral hygiene needs (e.g. reminding, assisting, cuing or the provision of total care).

# Oral health practices documentation includes:
 type of equipment used for oral care; and  frequency of oral care.
Refer to Appendix E for oral health assessment tools and Appendix F for sample care plans.

# Education Recommendations

# Recommendation 13
Nurses require appropriate oral health knowledge and skills acquired through entry-level nursing education programs, workplace orientation programs and ongoing professional development opportunities.

# Level IV

# Discussion of Evidence
Caregivers reported that the topic of oral care is inadequately covered and not given sufficiently high educational priority (Longhurst, 1998;Sumi et al., 2001). When questioned, more than half of ICU nurses reported that they required initial or further training in oral care (Jones et al., 2004). In addition to facility orientation and entry-level nursing programs, oral health and hygiene education needs to be repeated through ongoing learning activities to achieve a lasting effect (Paulsson, Soderfeldt, Fridlund & Nederfors, 2001).
Oral hygiene care education, even when delivered at a modest cost, can enhance nurses' and other health care providers' knowledge, attitudes and practice (Frenkel, Harvey & Newcombe, 2001). Even one education session of only four hours has been shown to have a positive influence on nurses' conceptions and knowledge of oral health (Paulsson, 2001). Education that develops knowledge and skill in oral hygiene care will assist nurses in being more aware of their oral hygiene practices and beliefs, as these may have an impact on the care they provide to clients (see Recommendation 1).
For additional discussion regarding organizational support for oral health education, please refer to Organization and Policy Recommendation 17.

# Recommendation 14
Nurses who provide oral hygiene care to their clients, either directly or indirectly, must participate in, and complete, appropriate oral hygiene education and training.

# Level IV
Oral hygiene education should address the following content areas, at minimum:

# Discussion of Evidence
Opportunities for ongoing education to support knowledge transfer, uptake and sustainability are a key implementation strategy. Educational content should focus on the factors that influence quality oral hygiene. Education should include enhancement of knowledge, skills and attitudes. Skill development is a fundamental outcome in order to achieve appropriate oral care. Sumi et al., (2001) noted that visualizing the oral cavity in a narrow field of view or using an uncomfortable posture does not promote appropriate oral hygiene. Learning to perform proper techniques is essential for good oral hygiene care. Refer to the Practice Recommendations for discussion regarding the skills required to support optimal oral hygiene care, and to Organization and Policy Recommendation 17 for a discussion regarding organizational support for oral health education.
Facilitating changes to caregivers' behaviours and shifting of attitudes are also important. Cultural traditions and beliefs can influence not only the advice caregivers provide, but also oral hygiene practices. Many health care professionals and unregulated health care providers have their own anxieties about dental care. Their anxiety about their own oral hygiene and health may adversely impact the advice they provide to clients (Preston, et al.). Not valuing the importance of oral care and/or viewing oral care as unpleasant, are associated with the provision of poor quality oral care (Furr, Binkley, McCurren & Carrico, 2004;Wardh et al, 2000). Refer to Recommendation 1 for a discussion related to personal beliefs and practices related to oral care.
Refer to Appendix L for professional dental association websites and other resources.

# Organization and Policy Recommendations
Policy and Programming

# Recommendation 15
Health care organizations develop oral health care policies and programs that recognize that the components of oral health assessment, oral hygiene care and treatment are integral to quality client care.

# Level IV

# Discussion of Evidence
Oral health programs are most successful when adapted to both the client population and health care setting.  2000), the Surgeon General called for action to "reconnect the mouth to the rest of the body in health policies and programs".
Implementing the role of an oral hygiene champion, resource nurse or specially trained health care provider as part of a comprehensive oral hygiene program to promote improvements in oral hygiene care (e.g. conducting oral health assessments on admission; determining oral care plans with client-centered interventions; monitoring for their effectiveness) is a powerful approach in maintaining a high level of oral care and promoting effective communication between nursing and oral health care professionals (Wardh, Halberg, Berggren, Andersson & Sorensen, 2003). Organizations are encouraged to have specially trained nurses and health care providers who become responsible and accountable for oral hygiene care provision (Pearson & Chalmers, 2004).

# Coordination of Oral Health Care with Oral Health Care Professionals and Services

# Recommendation 16
Health care organizations develop partnerships and increase capacity among providers to deliver collaborative practice models that improve the oral health care they provide to their clients.

# Level IV

# Discussion of Evidence
In Canada, oral health care accounts for 7% of all health care expenditures. This is the second highest diagnostic category of expenditure in the nation, second only to cardiovascular disease (Seniors Oral Health Callaboration 2005). Unfortunately, many feel that oral health has low priority and is a conflicting priority within health care organizations. The World Health Organization Oral Health Report (2003) supports cost-effective interventions and strengthening intersectoral collaboration that is sustainable and reduces inequities. For many reasons, access to oral health care can be difficult. This results in clients being unable to access necessary care and they are left untreated, continuing in pain or discomfort, and at risk for associated health complications, impairment of function and reduced quality of life.
Solutions can be found through shared approaches that support the effective use of expertise and efficient use of resources to maximize the oral health care benefits to the client. Multidisciplinary approaches to improving oral health care can improve knowledge and awareness and move oral care practices in facilities closer to best practice (Fallon, 2006). Studies suggest that oral health care providers in addition to dentists (e.g. dental hygienists, denturists) need to be part of the solution. Research also shows that treatment should be combined with prevention strategies such as good oral hygiene and having a full dental team available that would allow for the most comprehensive services offered and avoid situations requiring crisis management (Pearson & Chalmers, 2004;SOHC, 2005).

# Education and Training

# Recommendation 17
Health care organizations implement continuing education opportunities for nurses, and support them to complete oral hygiene education and training that is applicable to their health care setting.

# Level III

# Discussion of Evidence
For some health care clients, the nurse may be the first health professional to identify oral hygiene care concerns or an oral health issue requiring further attention. The inadequacy of health care provider training and their continuing workplace training in oral hygiene care is well documented in the literature (Fallon, 2006;Frenkel, 2001;Frenkel, 2002;Nichol, 2005;Pearson & Chalmers, 2004;Wardh, 2003). It is important that oral health continuing education and training is provided to nurses and other health care providers so that oral health assessment and screening becomes part of nursing and personal care. It is important for nurses to understand the effects of oral health on overall health (SOHC, 2006).
Oral health is integral and essential to general health and is a determinant factor for quality of life (WHO, 2003). Several studies have shown that nurses whose organizations have implemented oral hygiene care education and hands-on training can successfully assess and screen oral hygiene health status, identify the need for referral to oral health professionals, better develop and implement client-centred oral care plans, and have produced significant improvement in clients' oral health. Annual updates of health education are necessary in order to maintain the beneficial effects of oral health care education. Organizations need to facilitate nurses attending, and also completing, continuing education opportunities that have multiple modules or courses.
Refer to Recommendation 14 for details regarding the components of a comprehensive educational program.

# Recommendation 18
Health care organizations develop oral hygiene care standards that are based on the best available evidence and ensure they are implemented and monitored as part of the organization's commitment to providing quality oral health care and services.

# Level III

# Discussion of Evidence
Many call for standards for oral care. In Ontario, the Ministry of Health and Long-Term Care recently revised the coordination of dental care services standards within the Long-Term Care Homes Program Manual. The Manual presents the Government's standards for long-term care homes' care, programs, services and expectations criteria (Ontario Ministry of Health 2006). However, the revised dental care standards are minimal and mandate that the home must have a mouth care policy that includes assessment, referral, education, consent, interventions and coordination with dental services from a dental professional for annual dental assessment and treatment plus emergency treatment components.
Organizations show commitment and accountability to quality oral hygiene care by implementing oral hygiene care standards. The lack of oral hygiene care standards can be viewed as a barrier to achieving and maintaining optimum oral health of people utilizing health care services, especially when they are unable to meet their own oral hygiene care needs. The implementation of standards can be accomplished on a local, provincial or national level.
The College of Nurses of Ontario (CNO) establishes practice standards and guidelines that assist nurses in providing safe, effective and ethical care. Nurses in Ontario are legally obliged to practice in accordance with these standards (CNO, 2004). Nurses consider oral health care an important and obvious, but often neglected, part of nursing practice (Paulsson, 1999). However, the CNO does not currently have a standard or guideline specific to the oral hygiene care practice for nurses. It has been suggested that lobbying efforts ought to focus on having oral health criteria integrated into the national health services accreditation program (SOHC, 2005). Accreditation Canada guides health care organizations to reach standards of excellence. Organizations that participate in the accreditation programs benefit from a thorough assessment that leads to an action plan for improving every aspect of the health care and services they deliver (Canadian Council on Health Services Accreditation 2006). In evaluating the quality of oral hygiene care and service they provide organizations would be able to accurately measure their clinical and operational performance, assess their strengths and areas for improvement, and compare themselves to other similar health care organizations (i.e. benchmarking).
The Canadian Oral Health Strategy ( 2005) is a blueprint to improving oral health and guiding oral health initiatives. It does not set standards but it is looking at establishing a baseline of current oral health, setting targets, developing strategies to improve and maintain oral health and developing a system of measurement and monitoring so that individual provinces, regions and organizations could compare themselves. The Seniors Oral Health Collaboration in Nova Scotia (2005), although specific to seniors, similarly recommends the development, implementation, monitoring and evaluation of standards for oral health care.
The World Health Organization has been continuously working to improve the oral health of people worldwide (WHO, 2003). Oral health is integral and essential to general health and is a determinant factor for quality of life. They acknowledge that opportunities exist within health care settings for health care providers to expand oral health care promotion, prevention and practices. Translating the oral health care knowledge and experiences into action is seen as necessary, urgent and complex and therefore should be on the agenda of policy makers. The WHO's Policy Framework for the WHO Oral Health Programme is primarily designed to encourage health policy-makers to set standards for oral health on key parameters (WHO, 2003).
Depending on the health care setting, standards may include the following elements:

# Recommendation 19
Organizations should encourage and offer support, including time and resources, for nurses to participate in oral hygiene research to better assist in better understanding the issues related to oral hygiene care provision in various health care settings.

# Level IV

# Discussion of Evidence
According to the Surgeon General's Report on Oral Health of America (2000) "...oral health and general health should not be interpreted as separate entities", yet the health of the mouth and oral cavity has long been seen as something separate from the rest of the human body. Recent studies regarding the association of dental plaque, oral microbial flora and periodontal disease on systemic health (Lavigne, 2004) have generated considerable interest in further interdisciplinary research and the expansion of oral disease prevention and health promotion knowledge and practice through community programmes and in health care settings (World Health Organization 2006).
The Canadian Oral Health Strategy (2005) report of the federal, provincial and territorial dental directors called for more support for oral health research from governments, health organizations and individuals, lending further support for the need for interdisciplinary research. In addition, the Canadian Dental Hygienists Association supports an interdisciplinary approach to research related to oral hygiene in their research agenda (CDHA, 2003). Given that oral health has the potential to be influenced by nursing interventions, nurses have an integral role to play in any interdisciplinary research (Lee et al., 2001;Munro, Grap, Jablonski & Boyle, 2006).

# Evaluation -Outcomes

# Recommendation 20
Oral hygiene care is monitored and evaluated as part of the organization's quality management program, utilizing a variety of quantitative and qualitative approaches.

# Level IV

# Discussion of Evidence
The purpose of evaluation is to provide information on the effectiveness of a program or intervention so as to optimize the outcomes, efficiency and quality of health care (Fink, 2005). Long-term maintenance and improvement in the oral health status of clients is the intended outcome of good oral hygiene care, and outcome measures act as indicators in assessing the effects of the intervention at short, intermediate and/or long-term stages (Petersen & Kwan, 2004).
Qualitative evaluations collect data through in-person interviews, direct observations and review of written documents. These evaluations aim to provide personalized information on the dynamics of a program and participants' perceptions of the program's outcomes and impact. Qualitative methods are used to complement other quantitative methods of gathering data (Fink, 2005).
The use of valid and reliable oral health assessment tools such as the brief oral health status examination -BOHSE  or the Oral Health Assessment Tool OHAT  -for oral health screening will support the quantitative component of the evaluation process. It will enable the collection of baseline data and support consistent data comparisons during the evaluation phases. Refer to Appendix E for a range of validated tools.
There is ample support in the literature regarding the effectiveness of monitoring and regular audits. In a study from the United Kingdom, the use of oral care feedback mechanisms resulted in improved removal of plaque and increased staff motivation (Schafer, Nicholson, Gerritson, Wright, Gillian & Hall, 2003). In another study, the authors concluded that routine audits of oral hygiene care documentation will ensure that oral care is both consistent and in line with best practice (Kinley & Brennan, 2004). Please refer to page 50 of the guideline for some suggested monitoring and evaluation indicators.

# Recommendation 21
Organizations develop a plan for implementation of best practice guideline recommendations that include:

# Discussion of Evidence
Organizations must ensure that all health care professionals involved in providing oral hygiene care work in an environment that allows them to practice according to the guidelines, and that they have access to appropriate assessment tools and equipment. Commitment to supporting the nurse's role in oral hygiene care requires a healthy work environment. Guideline implementation may be supported by:
 a critical mass of nurses educated and supported in guideline implementation;  care delivery systems and adequate staffing that support the nurses' ability to implement these guidelines; and
 a sustained commitment to evidence-based practice in caring for those needing assistance with maintaining oral hygiene. For effective teamwork to take place, all team members need to feel valued within the team.
A critical initial step in the implementation of guidelines must be the formal adoption of the guidelines. Organizations need to consider how to formally incorporate the recommendations to be adopted into their policy and procedure structure (Graham, Harrison, Brouwers, Davies, & Dunn, 2002). An example of such a formal adoption would be the establishment of a policy and procedure regarding the frequency of oral health assessments. This initial step paves the way for general acceptance and integration of the guideline into such systems as the quality management process.
A commitment to monitoring the impact of the implementation of the Oral Health: Nursing Assessment and Interventions best practice guideline is a key step that must not be omitted if there is to be an evaluation of the impact of the efforts associated with implementation. It is suggested that each recommendation to be adopted be described in measurable terms, and that the health care team be involved in the evaluation and quality monitoring processes. A suggested list of evaluation indicators can be found on page 50.
New initiatives, such as the implementation of a best practice guideline, require strong leadership from nurses who are able to transform the evidence-based recommendations into useful tools that will assist in directing practice. In this regard, RNAO (through a panel of nurses, researchers and administrators) has developed the Toolkit: Implementation of Clinical Practice Guidelines (2002) based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of the RNAO best practice guideline Oral Health: Nursing Assessment and Interventions. Appendix N provides a description of the Toolkit.

# Research Gaps and Future Implications
The development panel, in reviewing the evidence for the development of this guideline, has identified several gaps in the research literature related to oral hygiene care provided by nurses.
Organizations and nurses should participate in oral hygiene research that assists in better understanding oral hygiene care provision and issues in various health care settings. Recommendations for areas of oral health research include:
 frail older adults with/without dementia in community and long-term care homes and their oral health care needs;
 access to oral health care services;  assessment and provision of oral health care by nurses;  cost analysis for the impact of oral care; and  the effectiveness of suction toothbrushes.
The above list, although in no way exhaustive, is an attempt to identify and prioritize the research gaps in this area. Some of the recommendations in this guideline are based on evidence gained from qualitative or quantitative research, while others are based on consensus or expert opinion. Further substantive research is required in some areas to validate the expert opinion and impact knowledge that will lead to improved practice and outcomes related to oral hygiene.

# Evaluation and Monitoring of Guideline
Organizations implementing the recommendations in this nursing best practice guideline are advised to consider how the implementation and its impact will be monitored and evaluated. The following

# Implementation Strategies
The RNAO and the guideline development panel have compiled a list of implementation strategies to assist health care organizations or health care disciplines that are interested in implementing this guideline. A summary of these strategies follows:
 Have at least one dedicated person such as an advanced practice nurse or a clinical resource nurse who will provide support, clinical expertise and leadership. The individual should also have good interpersonal, facilitation and project management skills.
 Conduct an organizational needs assessment related to oral hygiene to identify current knowledge base and further educational requirements.
 Initial needs assessment may include an analysis approach, survey and questionnaire, group format approaches (e.g. focus groups), and critical incidents.
 Establish a steering committee comprised of key stakeholders and interdisciplinary members committed to lead the change initiative. Identify short-and long-term goals. Keep a work plan to track activities, responsibilities and timelines.
 Create a vision to help direct the change effort and develop strategies for achieving and sustaining the vision.  (Davies & Edwards, 2004).
 Provide organizational support such as having the structures in place to facilitate the implementation. For example, hiring replacement staff so participants in education sessions will not be distracted by concerns about work and having an organizational philosophy that reflects the value of best practices through policies and procedures. Develop new assessment and documentation tools (Davies & Edwards, 2004).
Oral Health: Nursing Assessment and Interventions  Identify and support designated best practice champions on each unit to promote and support implementation. Celebrate milestones and achievements, acknowledging work well done (Davies & Edwards, 2004).
 Organizations implementing this guideline should adopt a range of self-learning, group learning, mentorship and reinforcement strategies that will, over time, build the knowledge and confidence of nurses in implementing this guideline.
 Beyond skilled nurses, the infrastructure required to implement this guideline includes access to specialized equipment and treatment materials. Orientation of the staff to the use of specific products and technologies must be provided and regular refresher training planned.
 Teamwork, collaborative assessment and treatment planning with the client, family and interdisciplinary team are beneficial in implementing guidelines successfully. Referral should be made as necessary to services or resources in the community or within the organization.
In addition to the strategies mentioned above, the RNAO has developed resources that are available on the website. A toolkit for implementing guidelines can be helpful if used appropriately. A brief description about this toolkit can be found in Appendix N. A full version of the document in pdf format is also available at the RNAO website, www.rnao.org/bestpractices.  Assess ways to get oral hygiene care completed.
 Assess ways to get oral hygiene care completed.  Assess the client's abilities for rinsing/spitting/swallowing etc.  Assess the need for the use of toothpastes versus mouthrinses.
 Assess the cause of the offensive language.  Assess the feasibility of completing oral hygiene care at that time.  Assess ways to get oral hygiene care completed.
 Assess the cause of the aggression.  Assess ways to get oral hygiene care completed.
 Assess ways to get oral hygiene care completed  Assess ways to get oral hygiene care completed  Attempt oral hygiene care at a time when the client is more cooperative.  Use other techniques such as rescuing, distraction, etc.  Enlist the assistance of another caregiver.  List successful strategies in the client's oral hygiene care plan.  Enlist the assistance of another caregiver.  Use other techniques such as rescuing, distraction, etc.  List successful strategies in the client's oral hygiene care plan.
 Enlist the assistance of another caregiver.
 Use other techniques such as rescuing, distraction, etc.
 List successful strategies in the client's oral hygiene care plan.
 Consider strategies related to dry mouth, hypersalivation and swallowing problems, and list successful strategies in the client's oral hygiene care plan.  Enlist the assistance of another caregiver.  Use a suction toothbrush.
 Ignore the offensive language and attempt oral hygiene care if no other signs of aggression.  Use other techniques, such as rescuing, distraction, etc.  Enlist the assistance of another caregiver.  Try oral hygiene care at another time of day when client is less aggressive or in a different environment that is more suitable.  List successful strategies in the client's oral hygiene care plan.
 Try oral hygiene care at another time of day when client is less aggressive or in a different environment that is more suitable.  Use other techniques such as rescuing, distraction, etc.  Enlist the assistance of another caregiver.  List successful strategies in the client's oral hygiene care plan.
 Try oral hygiene care at another time of day when client is more alert.  Use other techniques such as rescuing, distraction, etc.  List successful strategies in the client's oral hygiene care plan.
 Enlist the assistance of another caregiver.
 Do oral hygiene care as best as is possible from different positions.  Investigate the success of the use of different dental products such as toothbrushing, mouthrinses, spray bottles, suction toothbrushes, etc.  Use other techniques such as rescuing, distraction, etc.  List successful strategies in the client's oral hygiene care plan.

# Problem Strategy Note
Client's head moves around constantly Client forgets to do oral hygiene care
Client can do some oral hygiene but not all of the tasks  Assess ways to get oral hygiene care completed.
 Assess the best way to remind the client to do oral hygiene care.
 Assess the client's abilities to do their oral hygiene care and if they need reminding or assistance during the different stages of the task  Enlist the assistance of another caregiver.
 Use other techniques such as rescuing, distraction, etc.  Do oral hygiene care as best as is possible from different positions.  Investigate the success of the use of different dental products such as toothbrushing, mouthrinses, spray bottles, etc.  If required, discuss holding the client's head gently during oral hygiene care with them and other parties involved.  List successful strategies in the client's oral hygiene care plan.
 Use task-breakdown to break all the steps of the oral hygiene care task down into small steps.  Use other techniques such as rescuing, distraction, etc.  Write reminder notes for the client, if helpful.  Ensure that the need for reminding about oral hygiene care is listed in the client's oral hygiene care plan.
 Use task-breakdown to break all the steps of the oral hygiene care task down into small steps.  Use other techniques such as rescuing, distraction, etc.  Write reminder notes for the client, if helpful.  Ensure that the parts of the oral hygiene care task that the client can do themselves are listed in their oral hygiene care plan.
Problem Strategy Note

# Process for Update and Review of Guideline
The RNAO proposes to update this best practice guideline as follows:
- Each nursing best practice guideline will be reviewed by a team of specialists (Review Team) in the topic area every three years following the last set of revisions.
During the three-year period between development and revision, RNAO program staff will regularly monitor for new systematic reviews and randomized controlled trials and other relevant literature in the field.
Based on the results of the monitor, program staff will recommend an earlier revision period.
Appropriate consultation with a team of members comprising original panel members and other specialists in the field will help inform the decision to review and revise the guidelines earlier than the three-year milestone.
Three months prior to the three year review milestone, the program staff will commence the planning of the review process by: a. Inviting specialists in the field to participate in the Review Team. The Review Team will be comprised of members from the original panel as well as other recommended specialists.
b. Compiling feedback received, questions encountered during the dissemination phase as well as other comments and experiences of implementation sites.
c. Compiling new clinical practice guidelines in the field, systematic reviews, meta-analysis papers, technical reviews, randomized controlled trial research and other relevant literature.
e. Developing detailed work plan with target dates and deliverables.
The revised guideline will undergo dissemination based on established structures and processes.

# Oral Health: Nursing Assessment and Interventions

# Appendix A: Search Strategy for Existing Evidence
The search strategy utilized during the development of this guideline focused on two key areas. One was the identification of clinical practice guidelines published on the topic of oral hygiene care, and the second was to identify systematic reviews and primary studies published in this area from 1995 to 2006.

# STEP 1 -DATABASE Search
A database search for existing evidence related to oral hygiene management was conducted by a university health sciences library.

# STEP 3 -Search Engine Web Search
In addition, a website search for existing practice guidelines on oral hygiene was conducted via the search engine "Google", using key search terms. One individual conducted this search, noting the results of the search, the websites reviewed, date and a summary of the results. The search results were further reviewed by a second individual who identified guidelines and literature not previously retrieved.

# STEP 4 -Hand Search/Panel Contributions
Panel members were asked to review personal archives to identify guidelines not previously found through the above search strategy.

# SEARCH RESULTS
The search strategy described above resulted in the retrieval of 1163 abstracts on the topic of oral hygiene. These abstracts were then screened by a research assistant in order to identify duplications and assess for inclusion/exclusion criteria. A total of 26 abstracts were identified for article retrieval, quality appraisal and data extraction.
In addition, three clinical practice guidelines were identified that met the screening criteria and were critically appraised using the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE Collaboration, 2001).

# Appendix B: Glossary of Clinical Terms
Angular Chelitis: Cracked, eroded and encrusted surfaces at the commissural folds that frequently appear in conjunction with mucosal inflammation caused by Candida albicans infection; may cause moderate pain (Darby & Walsh, 2003).
The entry of food or liquid into the airway below that muscles that produce sound, that is, the vocal cords (Heart and Stroke Foundation of Ontario, 2006).
Assessment: Collecting and analyzing subjective and objective data about a client's risk or problem, and arriving at a judgement about the client's care needs (Darby & Walsh, 2003).
Dental Hygienist: Dental hygienists are registered health professionals who specialize in preventing oral health problems and diseases (Canadian Dental Hygienists' Association website, 2002). They provide teaching to clients, family and other health professionals regarding oral hygiene care. They conduct basic exams of the teeth and gums, and may take x-rays, make dental impressions or clean, polish and apply fluoride to the teeth (CDA website, 2007).
In dental terminology, this describes an individual having some or all of their natural teeth.
Dentist: Dentists are registered health professionals who diagnose and treat diseases, injuries and malformations of the teeth and mouth. They perform surgical procedures such as implants, tissue grafts and extractions. They also provide client education on how to care for their teeth and prevent oral disease (Retrived May, 2007 from ).
Refers to an individual who is lacking or without teeth.
Erythemia: A red area of variable shape and size reflecting tissue inflammation, thinness and irregularity (Darby & Walsh, 2003).
Gingivitis: Inflammation of the gingival tissue with no gingival recession; characterized by inflammation and redness of the gingival tissue and bleeding upon brushing (Darby & Walsh, 2003).
Hyposalivation or Hypoptyalism: Decreased secretion of saliva (Jablonski, Munro, Grap & Elswick, 2005).
Interproximal Cleaning: Cleaning between the teeth (e.g. flossing).
Mucositis: Direct cytotoxic action of chemotherapeutic agents on the oral mucosa resulting in atrophy or thinning of the oral mucosa, erythema, and ulceration (Darby & Walsh, 2003).
Periodontitis: Inflammatory disease of the periodontium that results from the progression of gingivitis; caused by specific mircroorganisms; characterized by progressive destruction of the supporting soft tissue and bone, leading to tooth mobility and loss (Darby & Walsh, 2003).
The presumptive identification of unrecognized disease or defect by the application of tests, examinations or other procedures that can be applied rapidly (Shah, 1998).

# Special Needs Dentistry: Geriatric and Special Need Dentistry
 dentistry which deals with the special knowledge, attitudes and technical skills required for the provision of oral health care for older adults and adults who are medically compromised, intellectually disabled, physically disabled and/or have chronic mental illness.
 These adults may live in the community or may be institutionalized (e.g. hospitals, nursing homes)
 Many are frail or dependent upon caregivers to help with their activities of daily living and instrumental activities of daily living.
Stomatitis: Any inflammatory disease of the oral mucosa, which may involve the buccal and labial mucosa, palate, tongue, floor of the mouth and the gingival (Jablonski, 2005).
Tardive Dyskinesia: Tardive dyskinesia is a disorder that causes involuntary movements (Medline Plus, 2008).
The medical term for a dry mouth due to a lack of salvia, also know as hyposalivation.

# STAFF EDUCATION REQUIRED
The type of oral care should be tailored to the clients' specific needs and risk factors

# YES NO

# DOES CLIENT REQUIRE ORAL CARE TO BE PROVIDED, SUPERVISED, REMINDED OR CUED?

# Appendix D: Oral Hygiene History -Sample Questions
Please Note: These are suggested questions to assist in taking an oral hygiene history. It is not a validated tool for the assessment of the person's oral health history.

# Admission Oral Hygiene History Sample Questions
Which statement best describes your beliefs regarding your teeth:
a) I expect that with proper care my teeth will last me a lifetime. b) No big deal if I lose my teeth, most people do when they get older. c) If I lose my teeth I can always get dentures.
Where on a scale would you place your oral health?

# Appendix E: Oral Health Assessment Tools
The following tools are examples of oral health assessment tools, recognizing that these instruments are setting and client specific. The interpretation of the assessment results vary from tool to tool (based on unique scoring systems, etc.); however, the results should guide decisions regarding the development of an individualized care plan and evidence-based interventions.
Nursing Best Practice Guideline

# Appendix F: Sample Care Plans
The following are examples of care plans that were developed to facilitate communication regarding the plan of care for individuals receiving oral health care.

# Appendix G: Brief Reference -Oral Hygiene Products
Remember! Ensure all products are labeled with the client's name.
The following table is not intended to be all-inclusive, but rather provides examples for a range of practice settings of products currently utilized in the provision of oral hygiene care in a range of practice settings.
Best Practice Guideline Toothbrushes Oral Rinses Manual Powered Suction Regular Chlorhexidine

# Appendix H: Medications That May Impact on Oral Health
Management of oral side effects from medications is an important aspect of nursing care. Oral side effects may cause client discomfort and interfere with the ability to chew, swallow and digest food. Some oral side effects put the client at risk for oral trauma, and others may lead to infection, pain and potential tooth loss.
Medication induced xerostomia results from a combination of reduced salivary flow rate and a change in the nature and quality of residual saliva. Residual saliva is more viscous, which causes food and plaque adherence to tooth surfaces, appliances, dentures and oral tissues. The pH of the mouth becomes more acidic, which puts the client at increased risk for dental caries (Darby & Walsh, 2003).

# EXAMPLES OF MEDICATIONS CAUSING DRY MOUTH
The following list consists of generic (and brand names) of various medications that may cause dry mouth (xerostomia) as a side effect. Adapted from: www.laclede.com
- phentermine (Adipex-P, Fastin, Ionamin, Zantryl)
- phendimetrazine (Anorex SR, Adipost, Bontril PDM)
- loperamide (Imoddium AD)
- diphenoxylate with atropine (Lomotil)
- diphenhydramine (Benedryl)
- loratadine (Claritin)
- terfenadine (Seldane)
- aptopril (Capoten)
- prazosin (Minipress)
- reserpine (Serpasil)

# Antiinflammatory Analgesic
- ibuprofen (Motrin)
- naproxen (Naprosyn)
- piroxicam (Feldene).
- dyphenhydramine (Dramamine)
- meclizine (Antivert)
- chlorothiazide (Diuril)
- furosemide (Lasix)

# Muscle Relaxant
- cyclobenzaprine (Flexeril)
- orphenadrine (Norflex, Disipal)
In addition to xerostomia, the following is a list of common oral adverse effects of medications:  (2002). Oral health matters for denture wearers. www.cdho.org.
 Brush the denture(s), using a denture brush, regularly after each meal, or at least before bed to remove loose food debris, plaque and some stains. Rinsing dentures under water after meals will also remove loose food debris.
 Do not use scouring powders or other abrasive cleaners as they scratch the denture making it more susceptible to collecting debris, plaque and stain.
 Brush both the denture(s) and gums carefully. A soft toothbrush should be used for the gums.
Be sure to clean and massage the gums.
 Use a separate brush for cleaning any natural teeth.  If using a toothbrush is painful, try using a finger wrapped in a clean, damp cloth.  Take dentures out every night, and soak them overnight. Soaking dentures loosens plaque and tartar.
Removing the dentures for several hours helps to prevent gingival irritation and possible candidiasis infections.
 Soak dentures in warm water with a denture cleanser, or in a mix of warm water and vinegar 1:1 solution - (CDA, 2007). Soak dentures in warm water without vinegar if there are metal clasps on the dentures.
 After overnight soaking, rinse and brush the denture(s) as described above prior to wearing them for the day.

# Denture Removal Technique

# Photos reprinted with the permission of the Halton Region Health Department
Oral Health: Nursing Assessment and Interventions

# Appendix J: Tooth Brushing Techniques
There are a multitude of tooth brushing techniques that have been developed, but no one method has been shown to be superior (Asadoorian, 2006). The technique that is described below is an example of a tooth brushing method that may be used:
Illustrations and instructions (for the Bass or sulcular method of brushing) adapted from:  Published with permission.
Nancy Bauer, RN, Hon. BA, Hon. Bus. Admin., E.T.

# Nursing Best Practice Guideline
Brushing outer and inner surfaces:
Place the toothbrush at the gum margin at an angel of 45.
Press the bristles against the teeth and gums softly. Move the toothbrush with small, vibratory to and from motions.
Brushing the front teeth:
For cleaning the inner surfaces of the front teeth, put the toothbrush in an upright position and place the bristles at the gum margin. Move the toothbrush in the directions from the gums to the Brushing outer surfaces:
Brushing inner surfaces:
Brushing the front teeth:

# Appendix K: Approaches to Care
The following approaches to care have been adapted for those working with older adults with cognitive impairment. Nurses working with those with behaviour and/or communication problems or dementia need to consider their approach to care in order to achieve successful oral hygiene outcomes.
Behaviour/Communication/Dementia Problems  Regular removal of calculus, debris and staining is essential.
 Regular sterilization of denture storage containers is required.
 All partial and full dentures should be named.
 Regular cleaning/sterilization of dentures.
 Treatment of fungal infection, if present.  Lubricating and protection of corners of mouth.  Attention to any denture-related problems.
 Removal of cause of irritation to allow the soft tissue to heal.
 Physical cleaning of dentures at least once daily, or more frequently in a bowl or sink filled with water (or a washcloth placed in the bottom of the sink).
Clean with denture cleaning paste and a denture brush.  Chemical denture cleaner tablets or pastes can be used in addition to cleaning with soap and water.
 Dentures may be soaked at night or during the day in a solution of diluted white vinegar and cold water (50:50). This applies to acrylic dentures only.  Dentures may need professional and chemical cleaning by a dental professional.
 Weekly, or more frequently, physical cleaning of the denture storage container and then soaking in a solution of diluted sodium hypochlorite (bleach) for 1 hour. Clean with soap and water before using.
 Permanent naming of dentures can be done by a dental professional by inserting the name into the denture.  Temporary naming of dentures can be done by caregivers -very lightly sand the pink acrylic denture surface on the cheek side (not the fitting side), write on initials or name with a permanent marker or dark pencil, cover with several layers of clear nail varnish and allow to thoroughly dry. Temporary commercial kits are available from medical/dental suppliers.
 Physical cleaning of dentures at least once daily, or more frequently. Removal of dentures at night whenever possible.  Treatment must be done in consultation with a dental professional -dentures may require sterilization in diluted sodium hypochlorite (bleach), and an antifungal medication may need to be prescribed and placed inside the denture's fitting surface.
 Treatment must be done in consultation with a dental professional -antifungal cream may need to be prescribed and applied to the corners of the mouth. Apply moisturizer to corners of mouth several times daily to protect the skin. Dentures may require treatment, especially if recurring angular cheilitis persist.
 Whenever possible, remove denture until ulcer is healed. Warm salt and water mouthrinses/spray bottle/saturated gauze can be applied several times daily to ulcer.  Use of numbing gels/ointments must be carefully monitored and is not generally advised.

# Appendix M: Sample Financial Assistance Programs and Other Resources for Dental Treatment
The following is a sample of programs that provide support for dental treatment in Ontario:

# Ministry of Community and Social Services (MCSS)

# Accredited dental hygiene programs in Ontario:
All dental hygiene programs provide dental hygiene services to the public at minimal cost, usually around $25, which includes examination, x-rays and cleaning. This list was compiled from the Ontario Dental Hygienists Association website, and was current as of December 2007.

# Appendix N: Description of Toolkit
Best practice guidelines can only be successfully implemented if there are: adequate planning, resources, organizational and administrative support as well as appropriate facilitation. In this light, RNAO, through a panel of nurses, researchers and administrators has developed the Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of any clinical practice guideline in a health care organization.
The Toolkit provides step-by-step directions to individuals and groups involved in planning, coordinating and facilitating the guideline implementation. Specifically, the Toolkit addresses the following key steps in implementing a guideline: