The American Parkinson&#39;s Disease Association funded this work.

The Institutional Review Board (IRB) of The University of Texas Health Science Center at Houston has approved all methods described here.
1. General recommendations
<ol>
	<li>If time allows, complete the questionnaires and the oral health assessment on subsequent days or with a break between them as this reduces patient fatigue and resistance.</li>
	<li>Begin with the questionnaires to create rapport and trust between the screener and patient, which eases the transition to the oral screening...

Here we demonstrate a widely accessible and comprehensive methodology to assess oral health. These tools include the GOHAI9, the swallowing subscale of the ROMP10, the BOHSE11, and the OHI-S12. Currently, oral health professionals such as dentists, dental therapists, dental hygienists, and dental assistants nearly exclusively evaluate oral health. They have the advantage of training, dental chairs, and instruments for advanced...

Oral health affects overall health. Oral movement serves to move food and debris immediately from the mouth, and together with the protective functions of saliva, they are the body&#39;s natural defense mechanism against oral infections and tooth decay1. Lack of oral health leaves individuals highly prone to accumulation of oral pathogens, inflammation, and infection that can spread to the body. For example, patients with type II diabetes are at higher risk of developing periodontitis, an inflammatory gum disease. So too, patients with periodontitis are more likely to develop type II diabetes, as periodontal disease can affect glycemic control2,3. Poor oral health is linked with many additional systemic, or body-wide diseases, including heart disease, stroke, and osteoporosis4,5,6.
The need to screen patients for oral health status, then, is not only important for diagnosing oral disease, but also assessing systemic disease risk. This is particularly important in older individuals, who more often develop inflammatory chronic conditions6. Further, poor oral health begets social isolation, dehydration, and malnutrition. Patients with infirmities such as dementia, stroke, and Parkinson&#39;s disease (PD) often develop dysphagia, or have trouble swallowing7. In addition to causing unsightly drooling, this life-threatening condition can cause oral bacteria to be swallowed inadvertently into the lungs. Aspiration pneumonia is a common outcome and major cause of death in the elderly8.
Our objective is to provide an oral screening protocol that non-dental professionals can use for research or health purposes. We describe a compilation of existing oral screening tools that together are a comprehensive and expedient assessment of oral health. We chose these tools primarily to allow dental students to collect data in research studies and gain patient experience. Legal restrictions limit the techniques students (i.e., non-degreed, non-licensed trainees) can perform; this compilation is designed to be conducted by any pretrained or calibrated student. In addition, nurses, caregivers, and family members may also use these protocols in the oral health monitoring of senior adults. These tools include the General Oral Health Assessment Index (GOHAI)9, the swallowing subscale of the Radboud Oral Motor Inventory (ROMP)10, the Brief Oral Health Status Examination (BOHSE)11, and the Simplified Oral Hygiene Index (OHI-S)12. Oral characteristics assessed include intraoral and extraoral structures, soft and hard tissues, natural and artificial teeth, plaque, oral functions such as swallowing, and the impact this oral health status has on the patient&#39;s quality of life. Anyone can complete this oral screening legally and safely, even those without dental training or dental instruments. The brief nature of the oral screening allows caregivers and researchers to track changes in oral health easily across time.
In addition to the fact that almost anyone can learn to administer this oral screening, an advantage of this method is that it includes both screener and self-report components. Thus, concrete measures of oral health can be partnered with the functional and emotional perceptions of the patient.
Self-report components (patients&#39; opinions of their oral health)
General Oral Health Assessment Index
The GOHAI is a self-reported measure of oral health quality of life status in older adults9. The survey has 12 questions that rate oral function, oral pain and discomfort, and psychosocial impacts (Table 1). Used to assess oral health in over 200 scientific publications, the GOHAI questionnaire has been shown to be sensitive to the provisions of dental care13 and to predict subjective well-being after 10 years14. Furthermore, a caregiver can complete the GOHAI if the patient is unable to communicate effectively15.
Several questionnaires exist to measure oral health-related quality of life; the most popular include the Oral Impacts on Daily Performances (OIDP)16, the Oral Health Impact Profile (OHIP)17,18, and GOHAI. The OIDP measures eight daily performances in frequency and severity but is not specifically designed for elderly patients. The OHIP was originally designed as a 49-statement survey but was later shortened to 14 statements (OHIP-14)19. Several studies have compared the effectiveness of OHIP-14 and GOHAI. All conclude that both assessments are comparable, although a few studies show that elderly people with high oral health needs may identify better with GOHAI, and that GOHAI may be more sensitive to objective values of oral functioning20,21,22,23,24,25,26. Therefore, we chose to use the GOHAI over the OHIP-14.
Swallowing subscale of the Radboud Oral Motor Inventory
Dysphagia (swallowing difficulty) commonly affects the elderly population due to muscle atrophy. It can affect up to 35% of elderly people over 75 years of age, and it greatly increases the risk for malnutrition and aspiration pneumonia27. The percentage of affected patients increases to more than 50% if the patient has a neurological disorder (e.g., Parkinson&#39;s disease, Alzheimer&#39;s disease, multiple sclerosis, stroke, and others)28. Most objective measures of dysphagia are too invasive for the elderly, or require the expertise of a professional (i.e., clinician or speech and language pathologist) as well as specialized equipment (i.e., endoscope or videofluoroscope). Therefore, using a validated self-assessment questionnaire is a good alternative when students are collecting data or caregivers must quickly assess dysphagia in a patient for referral to a specialist.
There are over two dozen self-evaluation questionnaires for dysphagia, each specific for a certain type of patient29,30,31,32. The most comprehensive and popular is the Swallowing Quality-of-Life (SWAL-QOL) questionnaire33, which is designed for many different types of patients, including patients with neurodegenerative disorders. However, this questionnaire is rather long, consisting of 44 questions.
A patient may be overwhelmed answering a battery of questionnaires and sitting for long sessions while examiners collect data, especially if the patient is suffering an age-related disorder. The ROMP was originally created to measure dysphagia, sialorrhea, and speech problems in patients with PD10. The swallowing portion of the ROMP consists of 7 questions with a 5-point Likert scale response option (Table 2). It can be administered in a short time and even in frail elderly. Therefore, this compilation includes the swallowing portion of the ROMP. For research purposes, investigators may evaluate other swallowing assessment surveys to ensure use of the best option for their research goals32.
Screener components (screener&#39;s rating of patients&#39; oral health)
Brief Oral Health Status Examination and Simplified Oral Hygiene Index
Oral health has improved over the years, with more elderly keeping their teeth and thus needing oral care into their last decades34,35. Certain sectors of this population, however, remain with poor oral health. Specifically, elderly people living in long-term care facilities and those suffering age-related diseases have prevalent oral problems including caries (i.e., cavities), gingivitis, plaque accumulation, denture problems, and mucosal lesions36,37,38,39. Ideally, elderly have a dental visit at least twice a year and upon admittance to a long-term care facility, but most often this is not the case. The final two components of our oral health assessment employ observation of the oral cavity but without the need of dental expertise or professional dental instruments.
Few oral health assessments are designed for a lay or inexperienced person to evaluate oral health. The index for Activities of Daily Oral Hygiene (ADOH) is an assessment of physical ability to perform oral hygiene and evaluates an elderly individual complete flossing, brushing, topical fluoride application, and oral rinses40. Whereas this tool is a good option to record the progressive loss of oral hygiene capacity by elderly people, it does not assess oral status and is involved and time consuming. The Oral Health Screening Tool for Nursing Personnel (OHSTNP) was recently published and validated41. This oral screening tool has 12 items, including many that are very similar to the BOHSE. The screening includes evaluation of basic nutrition and oral functioning during meal intake and swallowing. Yet, no other studies corroborate its validity. The Oral Health Assessment Tool (OHAT) is an 8-item tool, derived from the BOHSE, widely used to screen oral health in residents of long-term care, including those with dementia42. Therefore, we include the BOHSE (Table 3) as it is well-established, reliable, validated and can be used by lay personnel11,42,43. To include measurement of plaque accumulation, we added the OHI-S (Table 4) with a modification to help nurses, caregivers, and health students calculate debris index easily without interfering with dental license restrictions12,44.
Together, these four oral health assessments comprise a short and easy evaluation tool that can be used by nurses and caregivers to quickly assess oral health status in elderly individuals at home, long-term care or even the hospital before referring to a dental professional. This compilation is also useful to engage health students in research and patient interaction, particularly helping future dental professionals care for the growing elderly population.

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	<tbody>
		<tr>
			<td>Hurriview Plaque Indicating Snap-n-Go Swabs</td>
			<td>Henry Schein</td>
			<td>916553</td>
			<td></td>
		</tr>
		<tr>
			<td>Non-latex examination gloves</td>
			<td>VWR</td>
			<td>76246-462</td>
			<td>any vendor will do; optional if you use only tongue depressor to touch the mouth</td>
		</tr>
		<tr>
			<td>Small flashlight or pen light (Energizer LED Pen Flashlight)</td>
			<td>VWR</td>
			<td>500033-336</td>
			<td>any vendor will do; unnecessary, but helpful</td>
		</tr>
		<tr>
			<td>Sterile, individually wrapped tongue depressor</td>
			<td>VWR</td>
			<td>500011-108</td>
			<td>any vendor will do</td>
		</tr>
	</tbody>
</table>

oral health assessment by lay personnel for older adults

Oral health is an often-undervalued contributor to overall health. The literature, however, underscores the myriad of systemic diseases influenced by oral health, including type II diabetes, heart disease, and atherosclerosis. Thus, assessments of oral health, called oral screenings, have a significant role in assessing risk of disease, managing disease, and even improving disease by oral care. Here we present a method to assess oral health quickly and consistently across time. The protocol is simple enough for non-oral health professionals such as students, family, and caregivers. Useful for any age of patient, the method is particularly key for older individuals who are often at risk of inflammation and chronic disease. Components of the method include existing oral health assessment scales and inventories, which are combined to produce a comprehensive assessment of oral health. Thus, oral characteristics assessed include intraoral and extraoral structures, soft and hard tissues, natural and artificial teeth, plaque, oral functions such as swallowing, and the impact this oral health status has on the patient&#39;s quality of life. Advantages of this method include its inclusion of measures and perceptions of both the observer and patient, and its ability to track changes in oral health over time. Results acquired are quantitative totals of questionnaire and oral screening items, which can be summed for an oral health status score. The scores of successive oral screenings can be used to track the progression of oral health across time and guide recommendations for both oral and overall health care.

This compilation of oral health assessment tools was evaluated in different elderly populations. One patient with dementia (D-06) was selected to demonstrate how to interpret the results of an elderly person by a caregiver. All patients signed a consent form prior to enrollment and the studies have IRB approval.
Using the four assessment tools to evaluate a patient 
Patient D-06 completed the GOHAI question...

Watch this Scientific Journal Video about Oral Health Assessment by Lay Personnel for Older Adults at JoVE.com

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.

Oral health is an often-undervalued contributor to overall health. The literature, however, underscores the myriad of systemic diseases influenced by oral ...

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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12.3K Views.  The University of Texas Health Science Center at Houston School of Dentistry. 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 t...