WHY: The bidirectional effects of systemic diseases such as cardiovascular disease, cerebrovascular accident (CVA), human immunodeficiency virus (HIV), diabetes, and pneumonia on oral health in older adults is well recognized (National Academies (IOM), 2011).  Almost 49 million Medicare beneficiaries have no dental coverage (Willink, Schoen, & Davis 2016) and states may elect to provide dental coverage to adult Medicaid recipients however less than half provide comprehensive dental care (U.S. Department of Health and Human Services, 2012). By the time older adults enter nursing homes this unmet need for dental care may take back seat to the myriad demands imposed by comorbid conditions. Additionally, chronic diseases and the side effects of medications prescribed to treat them can further adversely affect oral health (Tavares, Lindefjeld Calabi, & San Martin, 2014). The National Academies of Sciences Engineering, Medicine: Health and Medicine Division (previously known as Institute of Medicine) report (2011) Improving Access to Oral Health Care for Vulnerable and Underserved Populations recognizes the barriers to oral care in the current health system and supports training nondental health professionals such as nurses to perform oral disease screening.

BEST TOOL: In a systematic review of oral health assessment by nurses and others in the care of cognitively impaired institutionalized residents, the Kayser-Jones Brief Oral Health Status Examination (BOHSE) was found to be the most comprehensive, validated and reliable screening tool (Chalmers & Pearson, 2005). The 10-item examiner-rated BOHSE catalogues oral health problems with a higher score identifying more problems. The BOHSE assessment begins with observation and palpation for enlarged cervical lymph nodes and includes a complete oral cavity evaluation. Using a pen light, tongue depressor, and gauze, the conditions of the oral cavity, surrounding tissues, and natural/artificial teeth are examined and categorically graded from 0 (normal) to 2 (significantly problematic).

TARGET POPULATION: The BOHSE was designed to evaluate the oral condition of nursing home residents, with and without cognitive impairment, by those providing nursing care. The BOHSE has been employed in a variety of populations including community-dwelling and hospitalized older adults, nursing home residents, and individuals with cognitive impairment (Chalmers, Spencer, Carter, King, & Wright, 2009; Chen, Chang, Chyun & McCorkle, 2005; Lin, Jones, Godwin, Godwin, Knebl, & Niessen, 1999; Yu, Lee, Hong, Lau, & Leung, 2008).  

VALIDITY AND RELIABILITY: Statistically significant test-retest reliability (r=.83-.79), inter-rater reliability (r=.68-.40), and content validity have been established by six field experts (Kayser-Jones, et al, 1995).

STRENGTHS AND LIMITATIONS: The BOHSE is a screening tool with demonstrated reliability and validity that should be used by nursing personnel in residential settings. Systematic use of this tool at scheduled times can facilitate oral health triaging of residents to allow for timely care provided by the dentist.

FOLLOW-UP: Although the cumulative score is helpful, individuals who score on items with an asterisk that are underlined should be referred for a dental evaluation and exam and follow-up immediately. In general, a semi-annual checkup is recommended by a dentist for oral health assessment. 

MORE ON THE TOPIC:

Chalmers, J.M., Spencer, A.J., Carter, K.D., King, P.L., & Wright, C. (2009). Caring for oral health in Australian residential care. Dental statistics and research series no. 48. Cat. no. DEN 193. Canberra: AIHW.

Chalmers, J.M., Pearson, A. (2005). A systematic review of oral health assessment by nurses and carers for residents with dementia in residential care facilities. Special Care Dentist, 25(5), 227-232. 

Chen, C. C-H., Chang, C.K., Chyun, D., & McCorkle, R. (2005). Dynamics of nutritional health in a community sample of American elders. Advances in Nursing Science, 28(4), 376-389.

Douglass, A.B., Maier, R., Deutchman, M., Douglass, J.M., Gonsalves, W., Silk, H., Tysinger, J.W., Wrightson, A.S. (2010). Smiles for Life: A National Oral Health Curriculum. 3rd Edition. Society of Teachers of Family Medicine. Course 8: Geriatric Oral Health.  www.smilesforlifeoralhealth.org.

Kayser-Jones, J., Bird, W.F., Paul, S.M., Long, L., & Schell, E.S. (1995). An instrument to assess the oral health status of nursing home residents. The Gerontologist, 35(6), 814-824. 

Lin, C.Y., Jones, D.B., Godwin, K., Godwin, R.K., Knebl, J.A., & Niessen, L. (1999). Oral health assessment by nursing staff of Alzheimer’s patient in a long-term care facility. Special Care in Dentistry, 19(2), 64-71.

Willink, A., Schoen, C., & Davis, K. (2016). Fewer older Americans have dental insurance. Johns Hopkins Bloomberg School of Public Health. Retrieved October 30, 2017 from https://www.jhsph.edu/news/news-releases/2016/fewer-older-americans-have-dental-insurance.html

Tavares, M., Lindefjeld Calabi, K.A., & San Martin, L. (2014) Systemic diseases and Oral health. Dental Clinics of North America, 58, 797-814

The National Academies of Sciences Engineering, Medicine: Health and Medicine Division (previously known as Institute of Medicine) (2011). Improving access to oral health care for vulnerable and underserved populations. Retrieved November 12, 2017 from http://www.nationalacademies.org/hmd/Reports/2011/Improving-Access-to-Oral-Health-Care-for-Vulnerable-and-Underserved-Populations.aspx.

U.S. Department of Health and Human Services. (2012). Does Medicaid cover dental care? Retrieved on October 30, 2017 from https://hhs.gov/answers/medicare-and-medicaid/does-medicaid-cover-dental-care/index.html

Yu, D.S., Lee, D.T., Hong, A.W., Lau, T.Y., & Yeung, E.M. (2008). Impact of oral health – related quality of life in Chinese hospitalized geriatric patients. Quality of Life Research, 17 (3), 397-405.