Oral Health Assessment by Lay Personnel for Older Adults

Summary

The goal of this protocol is to enable non-dental professionals to assess oral health status for research or health-screening purposes. Aspects assessed include lips, tongue, soft and hard tissues, natural and artificial teeth, oral cleanliness, plaque, swallowing, and impact of oral health on quality of life.

Abstract

Oral health is an often-undervalued contributor to overall health. The literature, however, underscores the myriad of systemic diseases influenced by oral health, including type II diabetes, heart disease, and atherosclerosis. Thus, assessments of oral health, called oral screenings, have a significant role in assessing risk of disease, managing disease, and even improving disease by oral care. Here we present a method to assess oral health quickly and consistently across time. The protocol is simple enough for non-oral health professionals such as students, family, and caregivers. Useful for any age of patient, the method is particularly key for older individuals who are often at risk of inflammation and chronic disease. Components of the method include existing oral health assessment scales and inventories, which are combined to produce a comprehensive assessment of oral health. Thus, oral characteristics assessed include intraoral and extraoral structures, soft and hard tissues, natural and artificial teeth, plaque, oral functions such as swallowing, and the impact this oral health status has on the patient's quality of life. Advantages of this method include its inclusion of measures and perceptions of both the observer and patient, and its ability to track changes in oral health over time. Results acquired are quantitative totals of questionnaire and oral screening items, which can be summed for an oral health status score. The scores of successive oral screenings can be used to track the progression of oral health across time and guide recommendations for both oral and overall health care.

Introduction

Oral health affects overall health. Oral movement serves to move food and debris immediately from the mouth, and together with the protective functions of saliva, they are the body's natural defense mechanism against oral infections and tooth decay¹. Lack of oral health leaves individuals highly prone to accumulation of oral pathogens, inflammation, and infection that can spread to the body. For example, patients with type II diabetes are at higher risk of developing periodontitis, an inflammatory gum disease. So too, patients with periodontitis are more likely to develop type II diabetes, as periodontal disease can affect glycemic control^2,3. Poor oral health is linked with many additional systemic, or body-wide diseases, including heart disease, stroke, and osteoporosis^4,5,6.

The need to screen patients for oral health status, then, is not only important for diagnosing oral disease, but also assessing systemic disease risk. This is particularly important in older individuals, who more often develop inflammatory chronic conditions⁶. Further, poor oral health begets social isolation, dehydration, and malnutrition. Patients with infirmities such as dementia, stroke, and Parkinson's disease (PD) often develop dysphagia, or have trouble swallowing⁷. In addition to causing unsightly drooling, this life-threatening condition can cause oral bacteria to be swallowed inadvertently into the lungs. Aspiration pneumonia is a common outcome and major cause of death in the elderly⁸.

Our objective is to provide an oral screening protocol that non-dental professionals can use for research or health purposes. We describe a compilation of existing oral screening tools that together are a comprehensive and expedient assessment of oral health. We chose these tools primarily to allow dental students to collect data in research studies and gain patient experience. Legal restrictions limit the techniques students (i.e., non-degreed, non-licensed trainees) can perform; this compilation is designed to be conducted by any pretrained or calibrated student. In addition, nurses, caregivers, and family members may also use these protocols in the oral health monitoring of senior adults. These tools include the General Oral Health Assessment Index (GOHAI)⁹, the swallowing subscale of the Radboud Oral Motor Inventory (ROMP)¹⁰, the Brief Oral Health Status Examination (BOHSE)¹¹, and the Simplified Oral Hygiene Index (OHI-S)¹². Oral characteristics assessed include intraoral and extraoral structures, soft and hard tissues, natural and artificial teeth, plaque, oral functions such as swallowing, and the impact this oral health status has on the patient's quality of life. Anyone can complete this oral screening legally and safely, even those without dental training or dental instruments. The brief nature of the oral screening allows caregivers and researchers to track changes in oral health easily across time.

In addition to the fact that almost anyone can learn to administer this oral screening, an advantage of this method is that it includes both screener and self-report components. Thus, concrete measures of oral health can be partnered with the functional and emotional perceptions of the patient.

Self-report components (patients' opinions of their oral health)

General Oral Health Assessment Index

The GOHAI is a self-reported measure of oral health quality of life status in older adults⁹. The survey has 12 questions that rate oral function, oral pain and discomfort, and psychosocial impacts (Table 1). Used to assess oral health in over 200 scientific publications, the GOHAI questionnaire has been shown to be sensitive to the provisions of dental care¹³ and to predict subjective well-being after 10 years¹⁴. Furthermore, a caregiver can complete the GOHAI if the patient is unable to communicate effectively¹⁵.

Several questionnaires exist to measure oral health-related quality of life; the most popular include the Oral Impacts on Daily Performances (OIDP)¹⁶, the Oral Health Impact Profile (OHIP)^17,18, and GOHAI. The OIDP measures eight daily performances in frequency and severity but is not specifically designed for elderly patients. The OHIP was originally designed as a 49-statement survey but was later shortened to 14 statements (OHIP-14)¹⁹. Several studies have compared the effectiveness of OHIP-14 and GOHAI. All conclude that both assessments are comparable, although a few studies show that elderly people with high oral health needs may identify better with GOHAI, and that GOHAI may be more sensitive to objective values of oral functioning^{20,21,22,23,24,25,26}. Therefore, we chose to use the GOHAI over the OHIP-14.

Swallowing subscale of the Radboud Oral Motor Inventory

Dysphagia (swallowing difficulty) commonly affects the elderly population due to muscle atrophy. It can affect up to 35% of elderly people over 75 years of age, and it greatly increases the risk for malnutrition and aspiration pneumonia²⁷. The percentage of affected patients increases to more than 50% if the patient has a neurological disorder (e.g., Parkinson's disease, Alzheimer's disease, multiple sclerosis, stroke, and others)²⁸. Most objective measures of dysphagia are too invasive for the elderly, or require the expertise of a professional (i.e., clinician or speech and language pathologist) as well as specialized equipment (i.e., endoscope or videofluoroscope). Therefore, using a validated self-assessment questionnaire is a good alternative when students are collecting data or caregivers must quickly assess dysphagia in a patient for referral to a specialist.

There are over two dozen self-evaluation questionnaires for dysphagia, each specific for a certain type of patient^29,30,31,32. The most comprehensive and popular is the Swallowing Quality-of-Life (SWAL-QOL) questionnaire³³, which is designed for many different types of patients, including patients with neurodegenerative disorders. However, this questionnaire is rather long, consisting of 44 questions.

A patient may be overwhelmed answering a battery of questionnaires and sitting for long sessions while examiners collect data, especially if the patient is suffering an age-related disorder. The ROMP was originally created to measure dysphagia, sialorrhea, and speech problems in patients with PD¹⁰. The swallowing portion of the ROMP consists of 7 questions with a 5-point Likert scale response option (Table 2). It can be administered in a short time and even in frail elderly. Therefore, this compilation includes the swallowing portion of the ROMP. For research purposes, investigators may evaluate other swallowing assessment surveys to ensure use of the best option for their research goals³².

Screener components (screener's rating of patients' oral health)

Brief Oral Health Status Examination and Simplified Oral Hygiene Index

Oral health has improved over the years, with more elderly keeping their teeth and thus needing oral care into their last decades^34,35. Certain sectors of this population, however, remain with poor oral health. Specifically, elderly people living in long-term care facilities and those suffering age-related diseases have prevalent oral problems including caries (i.e., cavities), gingivitis, plaque accumulation, denture problems, and mucosal lesions^36,37,38,39. Ideally, elderly have a dental visit at least twice a year and upon admittance to a long-term care facility, but most often this is not the case. The final two components of our oral health assessment employ observation of the oral cavity but without the need of dental expertise or professional dental instruments.

Few oral health assessments are designed for a lay or inexperienced person to evaluate oral health. The index for Activities of Daily Oral Hygiene (ADOH) is an assessment of physical ability to perform oral hygiene and evaluates an elderly individual complete flossing, brushing, topical fluoride application, and oral rinses⁴⁰. Whereas this tool is a good option to record the progressive loss of oral hygiene capacity by elderly people, it does not assess oral status and is involved and time consuming. The Oral Health Screening Tool for Nursing Personnel (OHSTNP) was recently published and validated⁴¹. This oral screening tool has 12 items, including many that are very similar to the BOHSE. The screening includes evaluation of basic nutrition and oral functioning during meal intake and swallowing. Yet, no other studies corroborate its validity. The Oral Health Assessment Tool (OHAT) is an 8-item tool, derived from the BOHSE, widely used to screen oral health in residents of long-term care, including those with dementia⁴². Therefore, we include the BOHSE (Table 3) as it is well-established, reliable, validated and can be used by lay personnel^11,42,43. To include measurement of plaque accumulation, we added the OHI-S (Table 4) with a modification to help nurses, caregivers, and health students calculate debris index easily without interfering with dental license restrictions^12,44.

Together, these four oral health assessments comprise a short and easy evaluation tool that can be used by nurses and caregivers to quickly assess oral health status in elderly individuals at home, long-term care or even the hospital before referring to a dental professional. This compilation is also useful to engage health students in research and patient interaction, particularly helping future dental professionals care for the growing elderly population.

Protocol

The Institutional Review Board (IRB) of The University of Texas Health Science Center at Houston has approved all methods described here.

1. General recommendations

1. If time allows, complete the questionnaires and the oral health assessment on subsequent days or with a break between them as this reduces patient fatigue and resistance.
2. Begin with the questionnaires to create rapport and trust between the screener and patient, which eases the transition to the oral screening, when the screener will be in close proximity to the patient's face and mouth.
3. Always allow the patient to rest between questions if they request. Elaboration on the questionnaire items is not necessary, so as needed, gently keep the conversation on topic.
4. For research purposes, randomize the order of the questionnaires and include information regarding the last time the patient had a meal or drink (other than water) and the last time the patient performed oral hygiene (i.e., brushing teeth, using oral rinse, etc.), as needed.
5. Use proper infection control techniques. Be mindful of the sequence of physical contact the oral screener has with the patient and surrounding objects. For example, do not use examination gloves (or bare hands) to touch the patient's mouth, pick up a pen to write the results on paper, and then return to the patient's mouth.
6. Recruit a second observer to serve as the scribe, writing the results of the oral screening on the paper questionnaires.
   NOTE: This allows the oral screening to proceed more quickly and also serves as an infection control, limiting the oral screener's physical contact exclusively to the patient.
7. Include all patients over 50 years of age.
   NOTE: As the assessment is intended for use to rate oral health for possible referral to a dentist, the method can be used on all patients, including those who have dentures, are edentulous, bed-ridden, mute, or cognitively impaired. In the latter cases, ask caregivers for responses to the self-report questions.

2. Training

1. Read the original research papers for the four oral health assessment tools included here. Pay particular attention to the Introduction and Discussion sections of the papers, as they describe why and for what populations each tool was created.
2. Watch the video associated with this publication to see the oral health screening in action.
3. Practice screening friends and family for oral health status using Table 1, Table 2, Table 3, Table 4, and the protocol described here. Repeat until an individual's oral screening can be repeated in under 30 min.

3. General Oral Health Assessment Index (GOHAI)⁹

1. Ask the patient to sit comfortably to answer questions. Tell the patient to consider the last 3 months when answering. If the patient is unable to answer the questions due to a disability, have a caregiver answer the questions and make a note of this.
2. Ask questions from Table 1 one at a time. Mark the patient's answers on a paper or digital copy of this GOHAI questionnaire. At the conclusion of the 12 questions, thank the patient and ask if he/she has any comments to add.
3. Score the GOHAI in one of two ways, either the additive or simple count methods.
   NOTE: Additive score: For the 3 questions worded in a positive way (questions 3, 5 and 7), reverse the codes (1 = never, 2 = seldom, 3 = sometimes, 4 = often, 5 = always to 1 = always, 2 = often, 3 = sometimes, 4 = seldom, 5 = never). Sum the response codes for the 12 answers. For this method, the GOHAI scores range from 12 to 60. The simple count GOHAI score is used to ensure that patients did not get confused using a 5-point scale. Score 0-points for "never" and "seldom" and 1-point for "sometimes" "often" and "always". Summed GOHAI scores with the simple count method range from 0 to 12. In both cases, higher scores represent poorer oral health-related quality of life.

4. Swallowing subscale of the Radboud Oral Motor Inventory (ROMP)¹⁰

1. Tell the patient to consider the last 3 months when answering the next 7 questions. If the patient is unable to answer the questions due to a disability, have a caregiver answer the questions and make a note of this.
2. Ask questions from Table 2 one at a time. Mark the patient's answers on a paper or digital copy of this swallowing subscale of the ROMP. Thank the patient and ask if he/she has any comments to add.
3. Sum the scores of each swallowing question for a total swallowing score.
   NOTE: ROMP swallowing scores range from 7 to 35; higher scores represent worsened swallowing ability. The simple count method can also be used with this questionnaire (see step 3.3 for more information).

5. Brief Oral Health Status Examination (BOHSE)¹¹

1. Have a paper copy of the BOHSE for the oral screening and mark scores on it during examination of each oral and dental area (Table 3). Recruit a second observer to serve as a scribe to speed the examination and prevent infections.
2. Ask the patient to sit comfortably and to expect observation of his/her neck, mouth, and teeth. Tell the patient he/she should not feel any discomfort and if they do, to communicate this by raising his/her hand.
3. Stand in front of the seated patient. Cup fingers and gently palpate the submandibular and submental lymph nodes just anterior to the angle of the jaw. Ask the patient if he/she is tender to the touch. Select the BOHSE score for lymph nodes (0−2) that applies.
   NOTE: Lymph nodes are small (~1 cm diameter) lumps beneath the skin but are not palpable if they are healthy. Infected lymph nodes are tender, soft, painful to the touch and are movable. Cancerous lymph nodes are hard, not painful and unmovable.
4. Tell the patient that next is observation of his/her lips. Observe the lips and corners of the mouth for their color, dryness and any other abnormalities (such as ulcers, bleeding, crusty scars, sores with rounded edges or discoloration at the edge of the lips that meet the facial skin). Ask the patient for how long he/she has had any abnormalities observed. Select the BOHSE score for lips (0−2) that applies.
5. Tell the patient that next is observation inside his/her mouth. Ask the patient to open his/her mouth and stick out his/her tongue. Observe the status of the tongue for color, dryness and any other abnormalities such as ulcers and bleeding.
6. Touch the tongue (with examination gloves) and assess for texture. Ask the patient for how long he/she has had any abnormalities observed. Select the BOHSE score for tongue (0−2) that applies.
   NOTE: If the patient cannot protrude the tongue for as long as needed, grasp the tongue with thumb and forefinger and gently hold the tongue outside the oral cavity.
7. Observe inside his/her mouth at the inside of the cheeks and the floor and roof of the mouth for their color, dryness and any other abnormalities such as ulcers and bleeding. Use a tongue depressor as needed to stretch open the cheeks and a penlight for better observation. Ask the patient for how long he/she has had any abnormalities observed. Select the BOHSE score for tissue inside cheek, floor and roof of mouth (0−2) that applies.
8. Examine the patient's gums, using a tongue depressor to gently press his/her gums and evaluate for firmness and coloration. Ask the patient if he/she has any loose teeth or soreness around his/her teeth. Select the BOHSE score for gums (0−2) that applies.
   NOTE: The gums should not have redness, bleeding, food debris or plaque at the triangle between the teeth.
9. Tell the patient that next is looking at his/her saliva and touching his/her tongue with a tongue depressor. Observe for oral tissue dryness and salivary flow (i.e., by saliva pooling in the floor of the mouth). Ask the patient if his/her mouth feels dry when eating or if he/she has difficulty swallowing food without drinking water. Select the BOHSE score for saliva (0−2) that applies.
10. Tell the patient next is inspection of the teeth. Count all of the natural (original) teeth and write the number at the bottom of the BOHSE table. Look for decayed, broken or chipped teeth while looking at the natural teeth. Select the BOHSE score for natural teeth (0−2) that applies.
    NOTE: Decayed teeth may have discoloration or breakdown of the tooth surface, widening of the fissures of the tooth, and there may be small holes in the white enamel or even brown or black visible discolored spots.
11. Look at the condition of any artificial teeth (i.e., dentures, implants, or crowns). Look for chips and wear. Ask the patient: if he/she has partial dentures or has had any tooth replacements or implants, if he/she has lost any artificial teeth or other oral appliances in the past, and how often and for what purposes the artificial teeth are worn. Select the BOHSE score for artificial teeth (0−2) that applies.
12. Count the pairs of teeth in the chewing position.
    NOTE: These are maxillary (upper) and mandibular (lower) teeth that contact when the jaw is closed, enabling bite. The pairs of teeth can be natural or artificial. For example, teeth 8 and 25 (Figure 1) are one pair; if one of them is missing, do not count as a pair.
13. Score overall oral cleanliness by observing the entire oral cavity and teeth for food particles (called food debris), and tartar (called calculus). Select BOHSE score for oral cleanliness that applies (0−2). Thank the patient for his/her willingness to participate and ask if he/she has any comments to add.
    NOTE: Dental calculus is a crusty deposit at the gum line of the tooth that can trap stains on the teeth and cause yellow discoloration.
14. Sum the scores of each BOHSE item for a total BOHSE score.
    NOTE: BOHSE scores range from 0 to 20; higher numbers represent poor oral health. Refer the patient to a dentist if any score for an item is a 2.

6. Simplified Oral Hygiene Index (OHI-S)¹²

1. Ask the patient to sit comfortably. Tell the patient that a dye will be applied to his/her teeth to be able to see plaque accumulation. Explain that the dye may stay in the mouth for a few hours if he/she doesn't brush his/her teeth, but it will slowly fade away.
2. Hold the plastic blister pack containing the plaque disclosing dye swab. Locate the cotton tip with the pink line around it. Remove the other half of the plaque disclosing dye swab from its plastic blister pack, leaving the end with the pink line in the plastic. Locate the cotton tip with the pink line around it. With the thumb and index finger of each hand grasping either side of the pink line, break the cotton tip from the shaft by giving the pink line a sharp snap with both hands. Confirm that the pink dye, stored in the hollow shaft of the swab, drains quickly to the other cotton tip.
   NOTE: The pink disclosing dye will discolor clothing, skin, and gums, so be careful to touch the swab tip only to teeth. The dye adheres to tooth plaque and may remain in the mouth for hours, unless brushed or wiped away.
3. Swab the six tooth surfaces depicted in red in Figure 1 with pink disclosing dye: the labial surfaces (outer side) of the upper right (tooth 8) and lower left (tooth 24) central incisors, the lingual surfaces (tongue-side) of the selected lower molars (teeth 19 and 30), and the buccal surfaces (cheek-side) of the selected upper molars (teeth 3 and 14). In the absence of the indicated upper or lower central incisor, substitute the central incisor (tooth 9 or 25, respectively) on the opposite side of the midline. Substitute upper (teeth 1, 2, 15, or 16) and lower molars (teeth 17, 18, 31, or 32) as needed. Gently rinse with water and score the debris index using the criteria in Figure 2 under the section "Debris Index Before Tooth Brushing".
4. Provide oral hygiene instructions if the debris index is high.
5. Calculate debris index by adding the debris scores for buccal, lingual and labial, and then divide the total by the number of examined surfaces.

Results

This compilation of oral health assessment tools was evaluated in different elderly populations. One patient with dementia (D-06) was selected to demonstrate how to interpret the results of an elderly person by a caregiver. All patients signed a consent form prior to enrollment and the studies have IRB approval.

Using the four assessment tools to evaluate a patient
Patient D-06 completed the GOHAI questionna...

Discussion

Here we demonstrate a widely accessible and comprehensive methodology to assess oral health. These tools include the GOHAI⁹, the swallowing subscale of the ROMP¹⁰, the BOHSE¹¹, and the OHI-S¹². Currently, oral health professionals such as dentists, dental therapists, dental hygienists, and dental assistants nearly exclusively evaluate oral health. They have the advantage of training, dental chairs, and instruments for advanced...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Hurriview Plaque Indicating Snap-n-Go Swabs	Henry Schein	916553
Non-latex examination gloves	VWR	76246-462	any vendor will do; optional if you use only tongue depressor to touch the mouth
Small flashlight or pen light (Energizer LED Pen Flashlight)	VWR	500033-336	any vendor will do; unnecessary, but helpful
Sterile, individually wrapped tongue depressor	VWR	500011-108	any vendor will do