Oral Health Assessment by Lay Personnel for Older Adults

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.

Transcript

This protocol provides a comprehensive oral health screening that assesses the risk of oral disease and response to its management. Non-oral health professionals can perform this oral screening, which includes the measures and perceptions of both the observer and the patient. Oral health influences many systemic diseases, including type two diabetes, heart disease, and arthritis.

Tracking oral health changes over time informs health providers of oral and systemic disease risks. Rather than timidly inspecting the oral cavity, we recommend the practicing of the screening on friends and family until you're comfortable entering this personal space. Demonstrating the procedure with Dr.June Sadowsky will be Jordyn Stanek, a research technician from my laboratory.

To administer a GOHAI or a Swallowing Subscale of the ROMP, have the patient sit comfortably and ask the patient to consider the last three months. Ask the questions one at a time, marking the patient's answers on a paper or digital copy of the questionnaire. At the conclusion of the questionnaire, thank the patient and ask if they have any comments to add, then score the questionnaires by the additive or simple count methods.

Before completing a BOHSE, obtain a paper copy of the questionnaire for the oral screening and recruit an observer to serve as a scribe to speed the examination and to prevent infections that can be spread, for example, by touching pen and paper and then the patient's mouth. Ask the patient to sit comfortably and inform the patient to expect observation of the neck, mouth, and teeth. Tell the patient that the examination should be painless but to raise a hand if any discomfort is felt.

To perform the exam, face the patient and with cupped fingers, gently palpate the submandibular and submental lymph nodes, just anterior to the angle of the jaw. Ask the patient if these areas feel tender to the touch and select the appropriate BOHSE score. Inform the patient that the lips will be observed and examine the lips and corners of the mouth for their color, dryness, and any abnormalities.

Select the appropriate BOHSE score for the lips and inform the patient that the next observation will be within the patient's mouth. Ask the patient to open their mouth and stick out their tongue and observe the status of the tongue for color, dryness, and any other abnormalities. With a tongue depressor, touch the tongue to assess for texture and select the appropriate BOHSE score for the tongue.

Using a tongue depressor and a penlight as needed, observe the inside of the cheeks and the floor and roof of the mouth for their color, dryness, and any other abnormalities and select the appropriate BOHSE score. Next, use the tongue depressor to gently press the patient's gums to evaluate for firmness and coloration and ask the patient about the presence of any loose teeth or soreness around the teeth, then select the appropriate BOHSE score. Inform the patient that a tongue depressor will be pressed onto their tongue to check the saliva and observe for oral tissue dryness and salivary flow.

Ask the patient about feelings of dry mouth with eating or difficulty swallowing food without drinking water and select the appropriate BOHSE score. Ask the patient to show their teeth for the next inspection and count all of the natural teeth, noting any decayed, broken, or chipped teeth. Write this number at the bottom of the BOHSE table and select the appropriate BOHSE score.

Examine the condition of any artificial teeth in the patient's mouth for chips and wear. Pictured is an example of artificial teeth. Ask about partial dentures or tooth replacements or implants, any artificial tooth or other oral appliances lost in the past, and how often and for what purposes the artificial teeth are worn.

Select the appropriate BOHSE score and count the pairs of teeth in the chewing position. Observe the entire oral cavity and teeth for food particles and tartar to score the overall oral cleanliness. At the conclusion of the examination, thank the patient for their willingness to participate and ask for any comments, then sum the scores of each BOHSE item for a total BOHSE score.

To perform a debris index of the simplified OHI-S, with the patient seated comfortably, inform the patient that a dye will be applied to their teeth to be able to observe plaque accumulation and that the dye may stay in the mouth for a few hours. Hold the plastic blister pack containing the plaque-dissolving dye swab. Locate the cotton tip with the pink line around it.

Remove the other half of the plaque-disclosing dye swab from it's plastic blister pack, leaving the end with the pink line in the plastic. With the thumb and index finger of each hand grasping either side of the pink line, give the pink line a sharp snap with both hands to break the cotton tip from the shaft. Confirm that the pink dye stored in the hollow shaft of the swab drains quickly to the other cotton tip.

Using this schematic as a guide, swab the labial surfaces of the upper right and lower left central incisors, the lingual surfaces of the selected lower molars, and the buccal surfaces of the selected upper molars. Substitute the central incisor on the opposite of the midline in the absence of either of these anterior teeth. When all of the teeth have been swabbed, score the debris index using the criteria as indicated.

If the debris index was high, provide oral hygiene instructions. This representative patient scored a 20 on the GOHAI questionnaire, suggesting that the patient felt fairly comfortable, although the answers to questions one and two suggest some discomfort during mealtime. The patient scored a 12 on the ROMP Swallowing questionnaire, suggesting correct swallowing and no significant choking events.

However, the answers to questions three and four once more emphasized discomfort during meals. The total BOHSE score for the patient is four, suggesting fairly good oral health with no major issues. However, the redness around the gums, decayed teeth, and poor overall oral cleanliness suggest possible dental problems.

The total OHI-S score is 2.17. Taken together with the BOHSE gums, teeth, and oral cleanliness scores, these data suggest that this patient needs better oral hygiene and would benefit from a visit to the dentist. Patient's with severe cognitive impairment report a significantly worse oral health-related quality of life through their GOHAI scores.

Elderly participants with a high school degree or less tend to have worse oral health than those with a higher degree, as evidenced by their reported greater BOHSE and OHI-S scores. In addition, patients with Parkinson's disease show significantly worse ROMP Swallowing scores than healthy control subjects. These patients also exhibit an overall worse oral health as evaluated by BOHSE.

When using the swab with the pink dye, be precise and use a tongue blade to open the mouth. Though not a hazardous substance, the pink disclosing dye will stain clothes, lips, and gums for a few hours.

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Oral Health Assessment by Lay Personnel for Older Adults

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