Approximately half of American adults have periodontal disease—a chronic inflammatory disease affecting gum tissue and supporting teeth. Longstanding untreated periodontal infections are linked to overall health issues. Especially in older adults, these infections and other oral health problems can lead to poor general health and pain. Pain and inability to eat, in turn, can cause nutritional problems and weight loss. Research also suggests links between poor oral health and pneumonia, cardiovascular disease, diabetes, and even low-birth-weight in infants. An autoimmune disorder, such as lichen planus, may cause oral signs and symptoms; someone with AIDS may have leukoplakia (white patches on the tongue and inner cheeks). What’s more, poor health secondary to chronic oral infection may increase cardiovascular and stroke risk. Experts believe inflammation is a key factor in the oral-systemic health connection. Healthy People 2020, a national agenda for improving the Americans’ health, identified oral health as a leading health indicator.

Traditionally, nurses have largely omitted oral assessment, leaving it to dental professionals. For many people, the community health nurse is the first point of contact for health care. The nurse’s initial visit is an opportunity to assess the patient’s oral health. During this visit, ask the patient to look at his or her own mouth and gums in a mirror, discuss preventive interventions, and provide education on the importance of oral health and its connection to overall health. Subsequent nursing visits give the nurse a chance to repeat essential information. Repetition of information is a key learning principle, in this case reinforcing the importance of oral health care.

Materials and methods

Bring a mirror, penlight, toothbrush, toothpaste, dental floss, disposable gloves, and patient education material to each visit. To encourage oral care, ask the patient if he or she has a mirror at home to view the inside of the mouth. Inform the patient that the mouth in the mirror reflects overall health. If the patient doesn’t have a mirror, consider providing a small mirror and keychain penlight so he or she can view the oral cavity.

Obtaining the patient history
Ask the patient the following questions:

• Do you have tooth or gum?
• Do you have problems swallowing?
• Can you eat without pain or discomfort?
• Is any part of your oral cavity numb?
• Do you have ear pain?
• Have you changed your eating habits due to pain?
• Have you lost weight recently?

Inform the patient that tooth or gum pain isn’t normal and that problems swallowing or chewing may stem from an oral disease.

Performing the oral exam

Start by inspecting the face and check for skin irregularities (such as swelling or a painless lump). Palpate the occipital, submandibular, and supraclavicular lymph nodes and assess alignment of the transmandibular joint (TMJ). Note abnormal findings.

Intraoral exam. After donning disposable gloves, examine the patient’s oral cavity with a penlight. Note bad breath, which could indicate a disease; for instance, a fruity odor suggests diabetes. Be aware that patients with diabetes may have trouble maintaining a normal blood glucose level if they also have periodontal disease. In this case, provide education, document the condition, and refer the patient to an appropriate healthcare professional.

Assess the color of the oral mucosa and examine the lips, labial and buccal mucosa, gingiva, tongue, floor of the mouth, and palate. Do you see signs of trauma in these areas? Stay alert for changes in texture, color, swelling, or other surface abnormalities. What color is the oral-cavity tissue? Is it pink (normal), reddened (suggesting inflammation), or white with an indentation (indicating an ulcer)? Observe for tooth decay, and screen for signs and symptoms of oral cancer. (See the box below.) Be sure to document all findings.

Patient self-exam. Instruct the patient perform a self-exam by looking into the mirror, opening the mouth, and looking inside with a penlight. Ask what he or she sees. Explain that anything other than pink, healthy tissue isn’t normal. Reddened or white tissue, ulcers, and areas that aren’t smooth are abnormal and should be reported to a dental professional. Show the patient photos of oral disorders from oral health brochures to help him or her identify normal and abnormalities. Leave the brochures so the patient can refer to them later and compare with his or her own oral condition.

Patient teaching

Teach patients early and often to reinforce the link between oral health and systemic health problems. Inform them that failure to care adequately for their teeth and gums can cause medical conditions far more serious than gum disease or tooth loss. Point out that certain systemic medical conditions have early oral manifestations. Explain, for example, that someone who has diabetes and periodontal disease may suffer loss of jaw structure and poor healing. Periodontal diseases are ongoing gum infections ranging from superficial inflammation of the gingiva to gradual destruction of the jaw and other supporting structures. Periodontitis is a common chronic inflammatory disease causing destruction of supporting structures. Diabetes increases risk for periodontitis and periodontitis. Also explain the link between oral cancer and tobacco and alcohol use.

To help patients avoid dental problems, provide the following instructions:

• Schedule a routine dental visit for each family member at least once a year.
• Brush teeth twice daily with a fluoride toothpaste for at least 2 minutes.
• Use dental floss and antiseptic mouthwash after brushing.
• If dry mouth occurs, increase fluid intake and use moisture drops.
• For denture care, use a denture cleanser and denture toothbrush and soak dentures overnight.
• Check teeth, gums, and mouth in the mirror with a small light.
• Contact a dentist as soon as possible if you note red, ulcerated areas or experience tooth or mouth pain.

Encourage the patient to watch instructive oral health videos on such topics as how to brush teeth and floss and how to care for children’s teeth. Instruct patients on proper use of oral hygiene aids and equipment.

Referrals

Provide an appropriate referral if the patient’s history or physical exam findings suggest a problem. Referrals to a dentist or a “safety-net” dental clinic are essential. Dental treatment to ease pain and optimize overall health may include smoothing a rough area on a tooth or denture, antibiotic therapy, abscess drainage, and tooth extraction. Dental X-rays help evaluate bone support of the jaw. Also document follow-up referrals made for patients, and read referral reports and treatment notes from dental health professionals.

Breaking the chain

Your critical thinking and decision-making skills can benefit patients by helping to prevent or detect oral inflammation and breaking the chain linking oral health problems to other health conditions. During your visit, you can promote the oral health not just of the patient but of family members who are present.

On subsequent visits, ask the patient questions about follow-up treatment and oral health practices. As necessary, provide new referrals. Keep in mind that promoting and improving oral health is a process. Check for new research findings frequently, including newly discovered links between oral and overall health and interventions.

The role of community health nurses in promoting oral health is likely to expand as new evidence-based interventions continue to improve patient outcomes. Through your knowledge of the oral-systemic health connection and by making oral health assessment a priority, you can help uncover or prevent a systemic health problem linked to periodontal disease. When you prioritize oral-health assessment, you can detect systemic disorders early or prevent them from developing.

Susan Parsons is an associate professor of nursing at Wichita State University in Wichita, Kansas. She wishes to acknowledge Kathy Trilli, RDH, ECP ll, MSEd, of Wichita State’s department of Dental Hygiene for her assistance on collaborative oral health education.

Selected references
American Dental Hygienists’ Association. Standards for Clinical Dental Hygiene Practice. 2008. www.adha.org/resources-docs/7261_Standards_Clinical_Practice.pdf. Accessed August 31, 2014.

Dounis G, Ditmeyer M, Vanbeuge S, et al. Introprofessional faculty development integration of oral health into the geriatric diabetes curriculum from theory to practice. J Multidiscip Health. 2013;7:1-9.

Evidence-based dentistry. American Dental Association. http://ada.org/276.aspx.
Accessed August 31, 2014.

Healthy People 2020. Oral health. Page last updated Sunday, August 31, 2014. http://healthypeople.gov/2020/LHI/oralHealth.aspx. Accessed August 31, 2014.

Johnstone G. Oral health and the general health Implications. www.yourdentistryguide.com/oral-and-general-health/. Accessed August 31, 2014.

Oral health. National Institute of Dental and Craniofacial Research. 2008. www.nidcr.nih.gov/oralhealth/. Accessed August 31, 2014.

Parsons S. Collaborative oral health education for caregivers in an assisted-living facility. J Nurs Educ Prac. 2013; 3(3):44-51.

Preshaw PM, Alba AL, Herrera D, et al. Periodontitis and diabetes: a two-way relationship. Diabetologia. 2012:55(1):21-31.