Oral Disease in Dependent Adult Patients: Extent of the Problem and the Need for Staff Training

The data reported in this thesis provide a description of the extent of oral disease among three groups of adults with special needs, namely the elderly, those with advanced cancer and patients suffering from psychiatric illness. In all three groups, the prevalence of oral disease is high, but when the provision of oral care is examined, it is clear that there is widespread unmet treatment need. This results in reduced quality of life and creates the potential for development of systemic disease such as aspiration pneumonia. The responsibility of providing oral care for dependent patients usually falls to medical and nursing staff. The literature discussed in this thesis illustrates that there are many barriers to the provision of such care by health care workers other than dental personnel. Mouth care is typically given a low priority in relation to other nursing tasks and is often undertaken by the most junior staff. One of the underlying problems is a widespread lack of knowledge of oral disease and practical mouth care procedures among health care workers. Studies have identified that this probably stems from a lack of training at both undergraduate and postgraduate levels. The final chapter of this thesis describes the development of multi-media training materials, produced by dental personnel for other groups of carers, particularly medical and nursing staff, to provide essential information on detection and prevention of oral disease. External evaluation of these training aids has proved their potential value in this context. The conclusion to be drawn from all the material presented in this thesis is the need for a much greater level of interdisciplinary working, both in relation to staff training and in the provision of mouth care for dependent patients. It is only when such interactions take place that there will be a significant oral health gain for those unable to care for themselves

Efficacy of Saliva Orthana in the Management of Xerostomia in Hospice Patients

Oral disease has been reported as a common feature in patients with advanced malignancy, although this area has been poorly researched. The development of appropriate mouth care regimes, particularly for use by nursing staff, is therefore a priority. Dryness of the mouth, often secondary to the use of xerogenic medication or previous radiotherapy, affects up to 70% of terminally ill cancer patients, but there have been no formal studies of its treatment in this group. This thesis describes a placebo-controlled, double-blind clinical trial of a mucin-based salivary substitute spray, among 70 hospice patients (25 male and 45 female; age range 42 - 88 [mean 66] years) complaining of xerostomia. At baseline, demographic data and details of symptomatology were recorded, and the mouth fully examined for clinical abnormalities. Imprint cultures were collected from the tongue and, in denture wearers, from the palate and denture fitting surface. These were cultured for yeasts, coliforms and staphylococci. A swab was collected for culture of herpes simplex virus. Sixty eight patients (97%) complained of oral dryness during the day, 21 (30%) indicating that it was a severe problem and 35 (50%) that it was a moderately severe problem. Fifty nine patients (84%) also complained of oral dryness at night. Soreness of the mouth was reported by 22 patients (31%). Forty six patients (66%) had difficulty talking and 36 (51%) reported difficulty eating. Of the 56 denture wearers, 23 (41%) complained of denture problems. On examination, 63 (90%) of the patients had clinical evidence of xerostomia. Oral mucosal abnormalities were detected in 45 patients (65%), most commonly erythema (20%), coated tongue (20%), atrophic glossitis (17%), angular cheilitis (11%) and pseudomembranous candidosis (9%). Forty seven (67%) of the patients carried yeasts in the mouth, 18 (26%) were carriers of Staphylococcus aureus and 13 (19%) carried coliforms. Herpes simplex virus was isolated from five patients, of whom two had herpetic stomatitis. These significant oral complications and abnormalities of the oral microflora confirmed previous reports on oral health in cancer patients. The clinical trial examined effectiveness of the mucin-containing mouth spray. Saliva Orthana (Nycomed [UK]), against a mucin-free version of the same preparation in this group of 70 patients. Each preparation was used for 14 days and the participants were interviewed, examined and specimens collected as described above, at days 7 and 14. The trial was complicated by reports from some of the earlier-enrolled patients of a burning sensation of the oral mucosa. On investigation, all of those affected were using active spray, and the trial was halted at Patient 35. Although chemical analysis revealed no abnormalities in the first spray batch, when the trial re-commenced three months later a new batch of active and placebo sprays was used for the remaining 35 patients. For the first 35 patients, 8/16 on Saliva Orthana and 6/13 on placebo felt by Day 7 that the respective sprays had been beneficial in relation to dryness during the day. For dryness at night the corresponding figures were 6/16 for Saliva Orthana and 5/13 for placebo. None of these differences between preparations were statistically significantly different. Similarly, with the exception of'oral soreness', there were no significant differences between the active and placebo sprays for any of the other symptoms recorded. This pattern of results was repeated at Day 14. Significantly more patients on Saliva Orthana complained of soreness of the oral mucosa between days 1 and 7 (p=0.04). For the second 35 patients, relief of oral dryness during the day was reported by 9/15 on Saliva Orthana and 10/16 patients on placebo by Day 7, with a similar degree of improvement maintained to Day 14. The corresponding figures by Day 7 for relief of dryness at night were 8/15 for Saliva Orthana and 8/16 for placebo. There were no statistically significant differences between those on active and those on placebo spray for any of the oral symptoms recorded. Neither spray had any major impact on the oral micro flora. However, the majority of patients in both treatment groups wished to continue using a mouth spray at the end of their involvement in the trial. Whilst the data from this study provide no evidence for increased benefit of a mucin-containing spray over a mucin-free placebo among xerostomic hospice patients, it was clear that both sprays provided worthwhile symptomatic relief of oral dryness for many of the participants. Further studies are required to determine the optimum saliva substitute for use by patients with advanced cancer

Antifungal, Cytotoxic, and Immunomodulatory Properties of Tea Tree Oil and Its Derivative Components: Potential Role in Management of Oral Candidosis in Cancer Patients

Candida albicans forms oral biofilms that cause disease and are difficult to treat with conventional antifungal agents. Tea tree oil (TTO) is a natural compound with reported antimicrobial and immunomodulatory activities. The aims of the study were to evaluate the antifungal efficacy of TTO and key derivatives against C. albicans biofilms, to assess the toxicological effects of TTO on a clinically relevant oral cell line, and to investigate its impact on inflammation. TTO and its derivatives were examined against 100 clinical strains of C. albicans. Planktonic minimum inhibitory concentrations (MICs) were determined using the CLSI M-27A broth microdilution method. Sessile MICs were determined using an XTT reduction assay. Inhibition, time-kill, and mode of action studies were performed. OKF6-TERT2 epithelial cells were used for cytotoxicity and cytokine expression assays. Planktonic C. albicans isolates were susceptible to TTO, terpinen-4-ol (T-4-ol), and α-terpineol, with an MIC50 of 0.5, 0.25, and 0.25%, respectively. These three compounds also displayed potent activity against the 69 biofilm-forming strains, of which T-4-ol and α-terpineol displayed rapid kill kinetics. For all three compounds, 1 × MIC50 effectively inhibited biofilm growth when C. albicans were treated at 0, 1, and 2 h post adhesion. By scanning electron microscopy analysis and PI uptake, TTO and derivative components were shown to be cell membrane active. TTO and T-4-ol were cytotoxic at 1 × MIC50, whereas at 0.5 × MIC50 T-4-ol displayed no significant toxicity. Transcript and protein analysis showed a reduction of IL-8 when treated with TTO and T-4-ol. These data provide further in vitro evidence that TTO and its derivative components, specifically T-4-ol, exhibit strong antimicrobial properties against fungal biofilms. T-4-ol has safety advantages over the complete essential oil and may be suitable for prophylaxis and treatment of established oropharyngeal candidosis. A clinical trial of T-4-ol is worthy of consideration

Developing and evaluating the implementation of a complex intervention: using mixed methods to inform the design of a randomised controlled trial of an oral healthcare intervention after stroke

<p>Abstract</p> <p>Background</p> <p>Many interventions delivered within the stroke rehabilitation setting could be considered complex, though some are more complex than others. The degree of complexity might be based on the number of and interactions between levels, components and actions targeted within the intervention. The number of (and variation within) participant groups and the contexts in which it is delivered might also reflect the extent of complexity. Similarly, designing the evaluation of a complex intervention can be challenging. Considerations include the necessity for intervention standardisation, the multiplicity of outcome measures employed to capture the impact of a multifaceted intervention and the delivery of the intervention across different clinical settings operating within varying healthcare contexts. Our aim was to develop and evaluate the implementation of a complex, multidimensional oral health care (OHC) intervention for people in stroke rehabilitation settings which would inform the development of a randomised controlled trial.</p> <p>Methods</p> <p>After reviewing the evidence for the provision of OHC following stroke, multi-disciplinary experts informed the development of our intervention. Using both quantitative and qualitative methods we evaluated the implementation of the complex OHC intervention across patients, staff and service levels of care. We also adopted a pragmatic approach to patient recruitment, the completion of assessment tools and delivery of OHC, alongside an attention to the context in which it was delivered.</p> <p>Results</p> <p>We demonstrated the feasibility of implementing a complex OHC intervention across three levels of care. The complementary nature of the mixed methods approach to data gathering provided a complete picture of the implementation of the intervention and a detailed understanding of the variations within and interactions between the components of the intervention. Information on the feasibility of the outcome measures used to capture impact across a range of components was also collected, though some process orientated uncertainties including eligibility and recruitment rates remain to be further explored within a Phase II exploratory trial.</p> <p>Conclusions</p> <p>Complex interventions can be captured and described in a manner which facilitates evaluation in the form of exploratory and subsequently definitive clinical trials. If effective, the evidence captured relating to the intervention context will facilitate translation into clinical practice.</p

The francis report – implications for oral care of the elderly

Oral health is an essential, yet often neglected, aspect of care in the elderly population. A mouth free of pain and disease which is functional, comfortable and aesthetic improves quality of life. Following the shocking reports of patient neglect and abuse published in the Francis Report, the dental profession must acknowledge that there are longstanding deficiencies in the provision of oral healthcare for the elderly, whether residing in care homes, hospitals or at home with support. It must be a universal goal to improve the care provision for this population through developing a greater understanding and overcoming the multi-factorial barriers to care. This article will highlight the key features of the Francis Report and its significance in the context of oral healthcare provision for the elderly. Clinical Relevance: To provide insight into the oral healthcare needs of the growing elderly population and the necessity of dealing with the current limitations in service provision

Peripheral and gastrointestinal immune systems of healthy cattle raised outdoors at pasture or indoors on a concentrate-based ration

peer-reviewedBackground: Despite an increasing preference of consumers for beef produced from more extensive pasture-based production systems and potential human health benefits from the consumption of such beef, data regarding the health status of animals raised on pasture are limited. The objective of this study was to characterise specific aspects of the bovine peripheral and the gastrointestinal muscosal immune systems of cattle raised on an outdoor pasture system in comparison to animals raised on a conventional intensive indoor concentrate-based system. Results: A number of in vitro functional tests of immune cells suggested subtle differences between the animals on the outdoor versus indoor production systems. There was a decrease in the number of neutrophils and monocytes engaged in phagocytosis in outdoor cattle (P < 0.01 and P < 0.05, respectively) in comparison to those indoors. Following mitogen stimulation, a lower level of interferon-γ was produced in leukocytes from the outdoor animals (P < 0.05). There was evidence of a gastrointestinal nematode infection in the outdoor animals with elevated levels of serum pepsinogen (P < 0.001), a higher number of eosinophils (P < 0.05) and a higher level of interleukin-4 and stem cell factor mRNA expression (P < 0.05) in the outdoor animals in comparison to the indoor animals. Lower levels of copper and iodine were measured in the outdoor animals in comparison to indoor animals (P < 0.001). Conclusion: Despite distinctly contrasting production systems, only subtle differences were identified in the peripheral immune parameters measured between cattle raised at pasture in comparison to animals raised on a conventional intensive indoor concentrate-based production system

Susceptibility to Melaleuca alternifolia (tea tree) oil of yeasts isolated from the mouths of patients with advanced cancer

Susceptibility to Melaleuca alternifolia (tea tree) oil of yeasts isolated from the mouths of patients with advanced cancer Yeasts that are resistant to azole antifungal drugs are increasingly isolated from the mouths of cancer patients suffering from oral fungal infections. Tea tree oil is an agent possessing antimicrobial properties that may prove useful in the prevention and management of infections caused by these organisms. In this study, 301 yeasts isolated from the mouths of 199 patients suffering from advanced cancer were examined by an in vitro agar dilution assay for susceptibility to tea tree oil. All of the isolates tested were susceptible, including 41 that were known to be resistant to both fluconazole and itraconazote. Clinical studies of tea tree oil as an agent for the prevention and treatment of oral fungal infections in immunocompromised patients merit consideration. (c) 2005 Elsevier Ltd. All rights reserved

Clinical and cost effectiveness of enhanced oral healthcare in stroke care settings (SOCLE II): a pilot, stepped wedge, cluster randomized, controlled trial protocol

Stroke-associated pneumonia, a leading cause of hospital-acquired infection after stroke, affects a fifth of stroke survivors annually. Associated with increased risk of death and poorer rehabilitation outcomes, research suggests a possible relationship between stroke-associated pneumonia and patients' oral health. Aim: The aim of this study is to evaluate the feasibility of a randomized controlled trial of the clinical and cost effectiveness of enhanced oral healthcare vs. usual oral healthcare for people in stroke care settings. Design: Our pilot, multicentered, pragmatic, stepped wedge, cluster randomized controlled trial oral healthcare [Stroke Oral healthCare pLan Evaluation (SOCLE II)] will compare enhanced oral healthcare intervention and usual oral healthcare. Over 13 months, across 4 wards, we seek to recruit 400 patients (estimating an average of 23 beds per site and a 50% recruitment rate) and 60 nursing staff (estimating an average of 20 members of staff per site and a 75% recruitment rate). Initially, control data (usual oral healthcare) will be collected from all sites. In a randomized, stepped manner, wards will convert to deliver the enhanced oral healthcare intervention. Study outcome(s): Outcomes will be captured across dimensions of care (as recommended for evaluations of complex interventions) at baseline and weekly thereafter. Primary outcomes are pneumonia (patients), knowledge and attitudes (staff), and specialist dental referrals (service). Secondary outcomes include oral health quality of life, plaque, antibiotics, length of stay, death (patients), use of oral healthcare equipment and products, completed assessments, and documented oral healthcare plans (staff). Discussion: As one of the first stepped wedge, cluster randomized, controlled trials in stroke care mapping of the complex intervention, our choice of primary and secondary outcomes and choice of trial design are described