Oral health directly influences overall health and yet is often not consistently or rigorously addressed during health assessments and care encounters. This care deficiency is a national and international problem and is likely influenced by incorrect assumptions, limited resources, and, perhaps, biases on the part of care recipients, providers, and policy makers. Holistic providers have a role to play in improving oral care practices. Health care professionals need to ensure that clients and patients appreciate the impact of a healthy mouth on overall health, particularly when people are dependent on others for assistance with oral care practices.
Oral care provision as intimate and direct care requires intrusion that differs from assessments that many providers offer on a regular basis. Certainly there are varying degrees of intimacy associated with auscultating chests, examining skin lesions, changing appliances, cleansing practices, or providing foot care. However, there is something unsettling about asking a patient or family member to remove their dentures or plates for cleaning. Flossing someone else's teeth may feel unnatural and, likewise, people requiring assistance may feel uncomfortable requesting assistance with denture cleaning or tooth brushing. Cleaning someone's mouth, carefully examining teeth, and manipulating the tongue require close physical proximity, shared breathing space, and confidence in the skills required for the task. In response to these potentially awkward feelings or a general feeling of reluctance, important oral hygiene responsibilities may be missed.
A recent publication describes the reaction of staff to an assigned activity related to patient-centered care practices that involved brushing each other's teeth.1 Nurses expressed outrage, humiliation, and anger in response to the assignment. Many devised strategies and excuses to avoid the activity. The author and colleagues theorized that the nurses were comfortable with providing mouth care when they were in control of providing the intervention; however, when compelled to relinquish control and allow others to enter their mouths, some nurses were incensed and uncomfortable. In addition to learning about how patients/clients may feel when they are dependent on others for oral hygiene, the nurses also learned that the toothpaste provided by the agency was unpleasant tasting and that the toothbrush bristles were rigid and uncomfortable. It was interesting to find that these powerful lessons learned arose from a creative assignment that simply involved nurses giving the same care to each other that they presumably provide to dependent patients on a regular and frequent basis!
The history of oral hygiene is intriguing and supports the premise that people typically want to have clean mouths, if possible. Toothbrushes are recorded as early as approximately 3500 BC when frayed twig ends were used by Babylonians and Egyptians.2 In the 15th century, the Chinese modified the toothbrush to include pig neck bristles and a bone or bamboo handle.2 Later, Europeans used horsehair to create a softer toothbrush. In the early part of the 1900s, nylon was invented and triggered subsequent modernizations of the toothbrush. An alternative to manual tooth brushing is the electric toothbrush invented in 1939.2
Toothpastes preceded toothbrushes and were first used in 5000 BC.2 Recipes have varied over the centuries although the goals of oral hygiene and mouth care are fairly consistent, specifically, white teeth, fresh breath, and cleanliness. Select ingredients have included ox hooves' ash, burnt egg shells, pumice, crushed bones or oyster shells, or herbs.2 Modern oral hygiene products include mouth rinses, floss, and a variety of whitening and plaque-reducing products but the "nuts and bolts" continues to be based on toothbrushes and toothpastes.
Despite a history of mouth care that reflects the regard that most people have for their teeth, gums, and breath, lack of universal access to oral hygiene care and professional dental care is a serious international health concern. The World Health Organization reports that across the globe, 30% of people aged 65 to 74 years have no natural teeth while 60% to 90% of school-aged children and nearly all adults have dental caries.3 Additional oral health concerns include cancers, trauma, malnutrition, infections, and malformations. Self-esteem, confidence, and impaired nutritional intake are influenced by the state of oral health and problems with teeth and gums can contribute to missed work and school time. These data and their associated implications demand consideration as treated and untreated dental caries as well as tooth loss are key oral health indicators for the United States and the world.
The National Health and Nutrition Examination Survey 2005-2008 provides national data that describe the current state of oral health in the United States. Findings support the premise that there are important differences in the number of treated and untreated caries and the frequency of dental sealant applications that reflect disparities based on race, socioeconomic status, and culture.4 Untreated dental caries for adults older than 65 years occurred at a prevalence rate of 45%, while those at 200% of the federal poverty level experienced a prevalence rate of 15%.4 Findings revealed that 1 in 5 adults older than 65 years had untreated tooth decay.4
Healthy People 2020 (HP 2020) documents that research findings support the existence of a relationship between periodontal disease and several chronic illnesses.5 This finding is concerning given that the prevalence of a dental visit for persons 2 years of age and older has decreased since 2003 to a 2013 prevalence of 43%. The likelihood of having a dental visit over the past year was found to relate to education, socioeconomic status, race, and insurance coverage.5
Data support the premise that vulnerable populations receive inadequate dental care putting this population at greater risk for oral health compromise and associated illnesses. There are multiple HP 2020 oral health indicators and most address improved access to dental services for children, adolescents, and adults; reduced numbers of dental caries in permanent teeth, decreased numbers of untreated dental caries, fewer extracted permanent teeth as a result of decay or periodontal disease, earlier assessment of oral and pharyngeal cancers, and diminished periodontal disease.5 Providers need to maximize their opportunities to contribute to these HP 2020 objectives.
Health care professionals should consider ways to incorporate oral hygiene into their care practices. In addition to including oral assessment into examination practices and direct care routines, providers should adopt strategies designed to improve oral health literacy. The oral health literacy method is best described as the application of the more generic health literacy framework to the specific concern of oral health.6
Communicating with patients/clients about the importance of oral health and its positive and negative impacts on overall health status, beyond caries and tooth loss, is potentially powerful as it is likely that critical content points are not always known or understood. Consistent with recognized strategies for improving health literacy, professionals should avoid sophisticated terminology, for example, periodontal disease or dental caries, without offering basic explanations. Patients of all ages should be periodically asked to describe their typical oral health practices, and recommendations should be provided, as appropriate, to positively influence opportunities for improved oral health.6 Providers need to particularly address the oral health care needs of vulnerable populations, including those who are vulnerable to oral health compromise as a result of risky behaviors, including smoking, oral tobacco product usage, and excessive alcohol.
The lack of universal access to dental care services for people of all ages is a significant barrier to healthy mouth conditions. There are many circumstances that require the expertise of a dental professional or periodontal specialist. Providers may want to consider local dental resources and having this information available for patient access in the health care setting. Many dental schools offer services at reduced rates or on a sliding fee basis. Dental hygienist programs, often available at community colleges, frequently offer free cleanings and other preventive services. It may also be helpful to actively encourage clients to consider dental insurance when selecting a health care policy. Although insurance plans with dental coverage will be more costly than those without such features, they certainly are advantageous for oral health maintenance and for nonpreventive care services.
Oral health is an important concern that may not be a key component of typical health assessments. Many people lack dental insurance and this lack of payer support contributes to oral health challenges and deficiencies. Providers need to routinely integrate oral health assessment and education into care practice routines. Exploring local dental resources and providing information about such programs during health care visits may assist in reducing risks of illnesses that have well-established relationships to compromised oral health.
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