Oral health- something to worry about in Neuro rehabilitation

Aarhus University
Department of Clinical Medicine
Aarhus University
 Talk of the Day!!
Oral health- something to worry about in Neuro
rehabilitation settings ?
• Do we really have a problem?
• How to identify? – Screening/ Indexing
• How big/ severe is the problem? - Screening
• How to solve the problem? - Treatment plan
• Are there any firm treatment plans? - Mixed
Mohit Kothari BDS, PhD
Hammel Neurocenter
• Can acute care setting be translated into rehabilitation arena
or it requires some modification?
Aarhus University
 Key components of oral health
Aarhus University
 Left unnoticed in the oral cavity
• Teeth
• Tongue
• Gingiva (bleeding and redness)
• Mucosal lining
• The dorsal posterior aspect of the tongue
is major source of microorganisms as
cleaning is not undertaken as a routine
• Interproximal area of teeth
• Lips (dry/cracked)
• Saliva- consistency, production (hyper/hypo)
• Swallowing habits
Aarhus University
 Standard oral care protocol
Aarhus University
 Recommended in our set-up
• Standard foam tooth paste
• Tooth brush
 Pediatric (soft-bristled baby tooth brush)
 Electric tooth brush (Research shows the best
• Foam sticks
• Adult/ and seldom pediatric manual tooth brush
• Saline as a rinse
• Lubricant
 Fluoridated non-foaming tooth paste (readily
• Dental Floss
• Oral moisturizers
Aarhus University
 Recommended in our set-up
Suction devices (tip)
Bite Blocks
Tongue Scrapers (backward to forward)
Aarhus University
 Introduction (What has been proven so far?)
• Incidence of neurological patients- ageing
• Combination of motor, sensory, perceptual and
cognitive deficit- Impacts ADL
• Three dimensions of oral self care: Function,
education and training, and compliance
Aarhus University
Aarhus University
 Introduction (What has been known so far?)
 But on the other end…
• Dental plaque and oral pathogen loads: possible
starter/ worsens systemic health problems or viceversa
• Various clinical guidelines and assessments
Each country has oral health guidelines
Oral Assessment Guide (OAG)
Bed side Oral Examination (BOE)
• Commonest condition associated with systemic
disease: Periodontitis
Aarhus University
 Why Oral Health care not a priority ?
• Common barrier to effective oral care
Perception oral care doesn’t provide
significant benefits
Inadequate nursing staff
Few trainings and unfocused care policies
Even expressed strong dislike for oral care
At least 15 articles in Critical Nursing Care, Gerodontology etc.
• Research protocols
Clinical measurements (1-12)
Microbiological examination
Immunological aspect
Socio-behavioral aspect
Aarhus University
Need for a planned, easy to follow, tailor-made protocol
for the staff in rehabilitation settings
• Protocol should be:
Easy to follow
Cost effective
Simple bedside oral examination protocol
Without an extra burden to present clinical staff
• Aim: Comprehensive oral health assessment
in neuro rehabilitation setting
Aarhus University
Aarhus University
 Materials and Methods
 Possible assessment tool (Measurements)
• 12 ABI patients from semi-intensive care unit (one
• Social History
• Self administered structured questionnaire
• Full mouth clinical examination protocol
• Entire examination took: 60 minutes
 Gender/ Age/Marital
Status/Education/Alcohol/Smoke/ Medical History
• Behavioral aspects
 Dental visit/ Only when had some trouble
 Tooth brushing frequency
• EFA and its oral health sub score
• Onset of Disease (Time since injury)
Aarhus University
 Dental Armamentarium
• Mouth Mirror
• Arch Explorer
• UNC-15 probe
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 Clinical measurements
• Plaque and calculus indexing
• Pocket depth indexing
• Bleeding on probing
• Clinical attachment loss
• Decayed, missing, filled tooth indexing
Aarhus University
Aarhus University
 Bedside Oral Examination (BOE)
• Modified from the oral assessment guide (OAG)
• Scores: 8 to 24
 8-10: Excellent oral health
 11-14: Moderate impaired oral health
 15-24: Significantly impaired oral health
Aarhus University
Aarhus University
 Microbiological examination
 Results
• Saliva
• No significant effect of smoking or alcohol
consumption on oral health
• Trachesotomy secretions
• Brushing frequency related to severity and extent
• Swab from posterioir 1/3 of tongue
• Dentist appointment related to periodontal severity
• All patients were diagnosed with chronic generalized
periodontitis (P<0.001)
Aarhus University
 Results
• Correlation between BOE and severity of
periodontitis (P<0.01)
• Patient age group was significantly related to poor
oral health
Aarhus University
 Discussion
• Assessment of oral health: Beyond traditional
clinical markers
• Need to perform comprehensive oral health
assessment including all possible measures
 Higher BOE score (P=0.01)
• All evaluated ABI had chronic generalized
periodontitis: enhanced oral health care
 Extent and severity of periodontitis was higher
• Association between periodontitis and systemic
disease (Cerebro vascular, endocarditis, stroke)
Aarhus University
 Discussion
• BOE provides a narrative and visual reference, useful
tool to reinforce and sustain the assessment practice
• Older population shows relation between oral
health and systemic disease as well as QOL
Aarhus University
 Conclusion
Most of the recent literature demands to perform a
structured and validation study involving all available
tools for comprehensive oral health assessment in a
larger patient based population
• Access to professional oral health care is not limited
to “Rx per se” but also to the motivation and
instructions to the patients
Aarhus University
Aarhus University
 Future Plans
 Acknowledgement
• Standardized Assessment criteria of clinical oral
health status, behavioral and microbiological
outcomes are required to confirm oral health
Professor Jørgen Felbæk Nielsen, MD, PhD, Dr Med.
Hammel Neurorehabilitation and University Research Clinic, Hammel, Denmark
Mette Skjærbæk Svane, Occupational Therapist
Early Intensive Care Unit, Hammel Neurorehabilitation and University Research
Clinic, Hammel, Denmark
Rubens Spin-Neto, BDS, PhD
Section of Oral Radiology, School of Dentistry, Aarhus University, Denmark
(Mouth and Oral Hygiene Indexing and Treatment plan)
0 week/ 2 week
• Mouth and Oral Hygiene Indexing
• Treatment plan
Aarhus University
Thank you