EFFECTIVENESS OF MODIFIED ORAL CARE PROTOCOL OVER ROUTINE ORAL CARE
By
R.VIJAYALAKSHMI
A DISSERTATION SUBMITTED TO THE TAMILNADU DR.M.G.R.MEDICAL UNIVERSITY, CHENNAI, IN PARTIAL FULFILMENT OF THE
REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING
MARCH 2011
EFFECTIVENESS OF MODIFIED ORAL CARE PROTOCOL OVER ROUTINE ORAL CARE
Approved by the Dissertation Committee on : _____________________
Research Guide : _____________________
Dr. Latha Venkatesan, M.Sc (N)., M.Phil., Ph.D.,
Principal and Professor in Nursing, Apollo College of Nursing,
Chennai - 600 095.
Clinical Guide : ___________________
Prof. Lizy Sonia, M.Sc (N)., Vice Principal and Professor in Nursing,
Apollo College of Nursing, Chennai – 600 095.
Medical Guide : ____________________
Dr. Nithya Narayanan, D.L.O., D.N.B., (ENT)
Senior Consultant – ENT surgeon
Apollo Hospitals,
Chennai – 600 006.
A DISSERTATION SUBMITTED TO THE TAMILNADU DR.M.G.R.MEDICAL UNIVERSITY, CHENNAI, IN PARTIAL FULFILMENT OF THE
REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING
MARCH 2011
DECLARATION
I hereby declare that the present dissertation entitled “Effectiveness of Modified Oral Care Protocol over Routine Oral Care” is the outcome of the original research work undertaken and carried out by me under the guidance of Dr. Latha Venkatesan M.Sc (N)., M. Phil., Ph.D., Principal and Prof. Lizy Sonia M.Sc (N)., Vice Principal and head of the department of Medical Surgical Nursing, Apollo College of Nursing, Chennai. I also declare that the material of this has not formed in anyway the basis for the award of any degree or diploma in this University or any other Universities.
ACKNOWLEDGMENTS
Lord God Almighty is praised for uttering profusely his blessing and guidance on me throughout my endeavor and sustained me in my hour of need.
I proudly and honestly express my sincere gratitude to Dr. Latha Venkatesan M.Sc (N)., M.Phil., Ph.D., Principal, Apollo College of Nursing for her perfect direction, valuable guidance, innovative suggestions, constant motivation and extreme patience without whom we would not have completed the dissertation successfully.
I express my sincere gratitude to my guide Prof. Lizy Sonia M.Sc (N)., Professor and vice principal, Medical Surgical Nursing, Apollo College of Nursing for her constant encouragement, splendid guidance throughout my work.
I express my sincere thanks to Dr. Nithya Narayanan, D.L.O., D.N.B., (ENT), ENT Surgeon, Apollo Hospitals, Chennai for her valuable suggestions and guidance for the successful completion of this research work.
I express my sincere gratitude to Ms. Vijayalakshmi., M.Sc (N)., Professor and Course Coordinator, Apollo College of Nursing for her splendid guidance and perusal in this study.
I extend my earnest gratitude to Prof.Helen M. Perdita, M.Sc (N)., Child Health Nursing, Apollo College of Nursing, for her elegant direction, encouragement and timely help.
I am immensely grateful to Ms. Jaslina, M.Sc (N)., Asst.Professor, Ms.
Sasikala,M.Sc (N)., Asst. Professor, Ms. Kanchana. M.Sc (N).,Asst Professor, Apollo
College of Nursing, for their kind support ,perpetual guidance and brain storming ideas and willingness to help at all times for the successful completion of this research work.
I extend my earnest gratitude to Mr. Porchelvan, Biostatistician, M.Sc.
(Stat)., .Phil (Stat)., for his constructive effort in clarifying and guidance in statistical analysis.
My ovation to thanks to all the Participants in this study and greatly indebted for their patience, co- operation and giving their valuable acceptance to be a participants in this study. I deem it a privilege and pleasure to thank All the faculty members of Apollo college of nursing, Chennai, for their continuous support and consideration at various stages of the study. I am highly pleased to extend my thanks to the experts who helped in validating the tool.
A note of thanks to the Librarians at Apollo College of Nursing and the Tamilnadu Dr. M.G.R. Medical University, for their help in providing needed reference materials which we required. I extend my heartfelt thanks to Mr. Senthil Kumar for the valuable assistance in my computer works at time.
I take pride and pleasure in expressing my gratitude to My Parents, Husband and Son, Sister and Brother for their untiring support and encouragement throughout the study. Last but not the least; I extend my warm thanks to all who helped me in shaping this study, directly or indirectly.
SYNOPSIS
An experimental study was conducted to assess the effectiveness of modified oral care protocol over routine oral care on improvement of oral hygiene among patients with self care deficit in selected Hospitals, Chennai.
The objectives of the study were,
1. To find out the prevalence of oral care problems among self care deficit patients.
2. To compare the effectiveness of modified oral care protocol on improvement of oral hygiene among patients with self care deficit in the experimental group.
3. To find out the association between the selected demographic variables with modified oral care in the experimental group of self care deficit patients.
4. To find out the association between the selected clinical variables with modified oral care in the experimental group of self care deficit patients.
5. To assess the level of satisfaction after oral care in the experimental group of self care deficit patients.
The conceptual frame work of the study based on Orem’s Self Care Deficit Theory. The study variables were Modified Oral Care Protocol and oral hygiene. Null hypotheses were formulated. The level of significance selected was p<0.001. An extensive review of literature and guidance by experts formed the foundation to the development of tool.
An experimental approach, two group pretest-posttest design was used to achieve the objectives of the study. The present study was conducted at Apollo Main Hospital,
Chennai by using systemic random sampling technique and the data were collected from 01 May 2010 to 30 July 2010 from 60 patients who were self care deficit of which 30 belonged to control group and 30 belonged to experimental group.
An extensive review of literature and guidance by experts formed the foundation to the development of demographic variables proforma, clinical variables proforma, Beck’s Oral Assessment Guide and satisfactory scale for the administration of modified oral care protocol. The data collection tools were validated and reliability was established by split – half technique, with r = 0.82. After the pilot study, the data for the main study was collected.
Major findings of the study were
¾ A significant percentage of self care deficit patients in control group were in the age group of 61-75 years (60%) and experimental group were in the age group of 41 to 60 years (50%).
¾ Majority of them were men in control and experimental group (73.3%) and wholly dependent were (70%, 56.7%). The majority of days of hospitalization in control group were one week (40%) and less than two days in experimental group (56.7).
¾ Tobacco chewing habits wholly addict in control group and experimental group were (40%, 20%). Smoking habits in both control group and experimental group were same 50%, but period of smoking > 5 years in the control group and the experimental group were (43.3%, 30%). Most of them were studied in control and experimental group were (80%, 83.3%).
¾ All participants in the control and experimental group had natural teeth (100%), medications causing oral side effects due to narcotic analgesics in the control and experimental group were (36.7%, 53.3%), enteral feeding (83.3%, 80%), habit of brushing (70%, 73.3%), diseases causing oral health problems due to others than cerebrovascular accident and diabetes (36.7%, 53.3), treatment causing oral problems due to intermittent suction at present (43.3%, 60%).
Almost all the participants were using tooth paste in control and experimental group (86.7%, 80%).
¾ The frequency and percentage distribution of level of oral dysfunction before the administration of modified oral care protocol revealed that both in control and experimental group were (53.3%, 63.3%). Whereas after the administration of modified oral care protocol revealed that mild level of oral dysfunction in the both control and experimental group were (33.3%, 56.7%), but the normal level of oral hygiene status attained only by the experimental group were (23.3%).
¾ In control group, the severe oral dysfunction status attained before and after oral care was (26.7%, 20%). In experimental group, before administration of modified oral care protocol the severe oral dysfunction status was (20%), on the other hand after the administration of modified oral care protocol none of them had severe oral dysfunction in the experimental group.
¾ Majority of the participants in the experimental group (80%) expressed highly satisfied regarding administration of modified oral care protocol. This attributed to the effectiveness of modified oral care protocol.
¾ The level of oral dysfunction status in control group were high after administration of oral care (M = 12.43, SD = 5.14) in comparison with before administration of oral care (M = 12.2, SD = 3.29). In experimental group, after the administration of modified oral care protocol the level of oral dysfunction status was low (M= 7.5, SD = 3.22) when compared to the level of oral dysfunction before administration of modified oral care protocol (M = 12.2, SD
= 3.245). Hence the null hypothesis H01 was not accepted.
¾ There was a significant association between the demographic variables and the oral hygiene level in the experimental group of self care deficit patients before and after the administration of modified oral care protocol such as age and days of hospitalization. Hence the null hypothesis Ho3 was rejected in regard to the age and days of hospitalization.
¾ There was no significant association between clinical variables and the oral hygiene status in the experimental group of self care deficit patients before and after the modified oral care procedure. Hence the Null hypothesis Ho4 was accepted.
Recommendations
¾ The same study could be conducted on a large sample to generalize the results.
¾ The study could be replicated in different settings with similar facilities.
¾ A study could be done with different brushing technique methods.
¾ The same study could be conducted for different groups such as critical care patients, unconscious patients, conscious patients etc.
¾ A study could be conducted to find out the others factors affecting oral hygiene along with self care deficit patients during the hospital stay.
TABLE OF CONTENTS
Chapter Contents Page No.
I INTRODUCTION
Background of the Study
Need for the Study
Statement of the Problem
Objectives of the Study
Operational Definitions
Assumptions
Null Hypothesis
Delimitations
Conceptual Frame work
Summary
Organization of the Report
II REVIEW OF LITERATURE Oral hygiene and oral problems
Tooth brushing and Bass method
III RESEARCH METHODOLOGY
Research Approach
Research Design
Research Setting
Population, Sample, Sampling Technique
Sampling Criteria Selection and Development of Study Instruments
Validity of the Study Instruments
Reliability of the Study Instruments Pilot Study
Data Collection Procedure
Problems Faced During Data Collection Plan for Data Analysis
Summary
IV ANALYSIS & INTERPRETATION
V DISCUSSION
VI SUMMARY, CONCLUSION, IMPLICATIONS &
RECOMMENDATIONS
REFERENCES
APPENDICES
LIST OF TABLES
Table No. Description Page No.
1 Frequency and Percentage Distribution of Demographic Variables in the Control and Experimental group of Self Care Deficit patients with oral dysfunction.
2 Frequency and Percentage Distribution of Clinical Variables in the Control and Experimental group of Self Care Deficit patients with oral dysfunction.
3 Frequency and Percentage Distribution of oral hygiene before and after providing modified oral care protocol in the Control and Experimental group.
4 Frequency and Percentage Distribution on the Level of Satisfaction upon administration of Modified Oral Care Protocol in the Experimental group of self care deficit patients.
5 Comparison of Mean and Standard Deviation of Level of oral dysfunction in the Control and Experimental group of self care deficit patients Before and After the Administration of Modified Oral Care Protocol.
6 Association between Demographic Variable and the Level of oral dysfunction in the Experimental group of Self Care Deficit patients Before and After the Modified Oral Care Protocol.
7 Association between Clinical Variable and the Level of oral dysfunction in the Experimental group of Self Care Deficit patients Before and After the Modified Oral Care Protocol.
LIST OF FIGURES
Fig. No Description Page No.
1 Conceptual framework based on Orem’s Self Care Deficit Theory.
2 Schematic design of the Study
3 Frequency and Percentage Distribution of Self Care Deficit
4 Frequency and Percentage distribution of Days of Hospitalization
5 Frequency and Percentage distribution of Habit of Tobacco Chewing
6 Frequency and Percentage distribution of Habit of brushing
7 Percentage distribution of level of satisfaction.
LIST OF APPENDICES
Appendix Title Page No.
A Letter seeking permission to conduct the study
B Letter permitting to conduct the study
C Ethical committee letter
D Letter seeking permission for content validity
E List of experts for content validity
F Certificate for content validity
G Research Participants Consent Form
H1 Demographic variable proforma
H2 Clinical variable proforma
H3 Modified Oral Care Protocol
H4 Beck’s Oral Assessment Guide
I Rating scale to asses the level of satisfaction regarding
Modified Oral Care Protocol
J Data code sheet
K Master code sheet
CHAPTER-I INTRODUCTION
Background of the study“Every tooth in a man’s head is more valuable than a diamond.”
-Miguel de Cervantes, Don Quixote.
The state of a person’s teeth is counted most and not its shape. If the teeth are white, it will compensate for any structural imperfections and irregularities. Good oral hygiene ensures healthy teeth and an appealing smile. Oral health means more than just an attractive smile. Poor oral health and untreated oral diseases and conditions can have a significant impact on quality of life. In many cases, the condition of the mouth mirrors the condition of the body as a whole.
“Oral health is considered as reflection of overall health. In the spring of 2000, the first-ever Surgeon General’s report on oral health was released. This report highlighted that good oral health and general health are inseparable. The mouth and face are highly accessible parts of the body, sensitive to and able to reflect changes occurring internally. The mouth is the major portal of entry to the body and is equipped with formidable mechanisms for sensing the environment and defending against toxins or invading pathogens. Oral health involves more than just filling cavities, it includes the prevention and treatment of several forms of gum disease and oral cancer.
Oral health is part of total health and essential to quality of life. The World Health Organisation’s Oral Health Programme therefore gives priority to integration of
oral health with general health programmes at community or national levels. In addition, global goals for oral health by the year 2020 are specified for development of quality of oral health systems. The programme works for application of evidence based strategies in oral health promotion, prevention and treatment of oral diseases worldwide, health systems research and development.
Oral health is an essential component of health throughout life. They can affect the most basic human needs, including the ability to eat and drink, swallow, maintain proper nutrition, smile, and communicate. A healthy mouth and healthy body go hand in hand. Good oral hygiene and oral health can improve the overall health, reducing the risk of serious disease and perhaps even preserving the memory in our golden years.
The phrase "healthy mouth, healthy you" really is true and backed by growing scientific evidence.
Ghaffarpour (2008) states most people have been brushing the teeth twice to thrice a day since childhood such as daily routine. The people should stop and think about the proper way of doing the brushing. The primary purpose of having teeth cleaned is to prevent or delay the progression of gum disease. The children and adults should have professional teeth cleaning at least once or twice a year to prevent gum disease. Abstaining from tobacco use, maintaining good oral hygiene, and having teeth cleaned professionally are the most effective ways to prevent periodontal disease.
Decayed teeth and gum disease are often associated not only with an unsightly mouth but very bad breath so bad it can affect the confidence, self-image, and self- esteem. In a healthy mouth that's free of gum disease and cavities, the quality of life is
also bound to be better and the person can eat properly, sleep better, and concentrate with no aching teeth or mouth infections to distract others.
Jenkins, (1989) states that oral care is a fundamental hygiene needed for people both sick and well. It has been widely revealed that the majority of terminally ill patients suffer from oral problems. Oral dysfunction severely impacts on the terminally ill patient’s quality of life. Oral care aims to keep the oral cavity clean, therefore promoting dental hygiene helps to prevent infection and consequently helps to prevent secondary problems. A healthy mouth promotes comfort and self esteem. (Mallet and Picharel, 1992).
The dangers of poor oral health are not only cosmetic. Despite the fact that oral health is sometimes overlooked by physicians, it is an important part of primary care and a good indicator of overall health. If caught in its early stage, most oral diseases are easily treatable.
Research indicates that a clean mouth prevents aspiration pneumonia, gum disease, and helps to prevent heart disease. Salivary flow is reduced by some medications and medical treatments. Reduced saliva flow results in less natural washing away of oral bacteria.
Need for the study
The oral cavity has physiological as well as psychosocial significance. It is necessary for proper chewing, swallowing and digestion of food, and is important for both verbal and nonverbal communication. (Allbright 1984). According to Kay and Locker (1997) the accepted definition of oral health is: “a standard of health of the oral
and related tissues which enables an individual to speak and socialize without active disease, discomfort or embarrassment and which contributes to general well-being.”
Oral hygiene is a crucial nursing skill and it is always a neglected part of nursing especially for self care deficit patients. In a patient with caring requires special skills of assessment and interventions on the part of nurses. Impaired level of consciousness place a high risk for complications, so quality nursing care is needed for speedy recovery.
Brushing the teeth twice a day can save hundreds of dollars sometimes thousands in dental work. But in spite of it being such a simple task, lots of people brush their teeth incorrectly, either skipping around so much they don't really clean anything, or rubbing so hard that they actually damage their teeth and gums. So, the learning of proper way to brush the teeth is necessary.
Brushing interrupts the growth of plaque which is a thin, sticky film of bacteria that plays a primary role in tooth decay and gum disease. When the people brush the teeth, they remove most of the plaque-causing bacteria. But some stay behind. These bacteria can set up a colony and begin damaging the teeth within 24 hours that is the primary reason dentists recommend brushing twice a day to consistently interrupt their growth.
In a normal healthy mouth, harmless florae combine with salivary proteins and glycoproteins to form water-insoluble plaque. For most individuals the mechanical motions of chewing facilitate the production and movement of saliva around the mouth.
Because saliva contains several components that are important in suppressing bacterial
and fungal colonization, these motions serve both antiplaque and antibacterial roles (Kite & Pearson et al, 1995)
Physical and or mental health problems may impact upon the ability to independently meet needs, including oral care. For example, reduced vision and motor control associated with cerebrovascular accident, joint pain and stiffness because of musculoskeletal disorders (Simpson & New 1999), acute confusional states or dementia (Norman 1999) and the impact of cardiac and respiratory conditions may all influence self care ability, requiring care needs to be met either partially or wholly by nurses and care staff.
When patients are unable or reluctant to eat or are taking nil by mouth, the mouth becomes dry. These patients need appropriate and adequate oral care to keep the mouth clean and reduce the risk of infection. Saliva, which is produced by the salivary glands, consists of 98% water, but also contains enzymes, electrolytes, mucus, and anti- bacterial compounds. Saliva serves to lubricate and protect the tongue, teeth, and tender tissues of mouth. If dry mouth is not properly treated, it can lead to more serious dry mouth symptoms such as gum disease and cavities. This is because the saliva that normally protects the gums and teeth is significantly reduced or is no longer present.
Lack of saliva can leave the mucosa of the mouth vulnerable to infections or decrease protection against other infections of the mouth such as thrush.
Oral hygiene has significant impact on patients’ general well-being and their quality of life. Patients need adequate oral care to eat and talk comfortably, feel happy with their appearance, maintain self-esteem and normal standards of hygiene. However, the circumstances surrounding hospitalisation and ill-health can lead to neglect of oral
hygiene. Care of the mouth is one of the most basic nursing activities. It is an important aspect of care that needs to be carried out consistently. Nurses play a vital role in providing effective oral care and promoting oral hygiene. To draw attention to this area, the researcher selected this study.
Statement of the Problem
An experimental study to assess the effectiveness of modified oral care protocol over routine oral care on improvement of oral hygiene among patients with self care deficit in selected Hospitals, Chennai.
Objectives of the study
6. To find the prevalence of oral care problems among self care deficit patients.
7. To compare the effectiveness of modified oral care and routine oral care in the experimental and control group of self care deficit patients.
8. To find out the association between the selected demographic variables with modified oral care in the experimental group of self care deficit patients.
9. To find out the association between the selected clinical variables with modified oral care in the experimental group of self care deficit patients.
10. To assess the level of satisfaction after oral care in the experimental group of self care deficit patients.
Operational definitions
Effectiveness
In this study, it is referred to the extent of positive changes in oral hygiene after providing modified oral care protocol for 5 days.
Modified Oral Care
A systemic procedure to give oral care to self care deficit patients with modified brushing technique that includes brushing the teeth with toothbrush bristles directed towards the base of the tooth at the gum line, 45 degree angle to the long axis of the tooth, twice a day brushing and moisturizing.
Routine oral care
Daily care of the mouth with regular brushing technique with normal long size brush.
Oral Hygiene
Oral hygiene refers to healthy lips and tongue, oral cleanliness, decreased dental pain, and oral plaque.
Self Care Deficit
A state in which a person experiences an impaired ability to perform self care activities using the mnemonic “DEATH” Dress, Eat, Ambulate, Transfer/Toilet,
Hygiene, and fully dependent on nurse to do those activities irrespective of their disease condition.
Assumptions The study assumed that,
¾ Incidence of periodontal diseases are higher than normal.
¾ Oral plaque and debris depositions cause systemic complications such as pneumonia, endocarditis, septicemia etc.
¾ Self care deficit patients lack oral hygiene and need effective oral care.
¾ Modified oral care improves oral hygiene.
Null Hypotheses
H01 There will be no significant relationship between modified oral care protocol and oral hygiene in the experimental group.
H02 There will be no significant relationship between routine oral care protocol and oral hygiene in the control group.
H03 There will be no significant association between selected demographic variables and modified oral care in the experimental group.
H04 There will be no significant association between selected clinical variables and modified oral care in the experimental group.
Delimitations
¾ The study was conducted among self care deficit patients who were admitted in Apollo Main Hospitals, Chennai.
¾ The duration of study was only 4 weeks.
¾ The study was limited to only self care deficit patients.
Conceptual Framework of the study
The conceptual framework deals with the interrelated concepts that are assembled together in some rational schemes by virtue of their relevance to a common theme. (Polit and Beck, 2004). Basic to any professional discipline is the development of a body of knowledge that can be applied to its practice. Such knowledge is often expressed in terms of concepts. A concept is a generalized idea of some group of the objects or an abstract idea generalized from several specific instances. Conceptual framework is a process of ideas, which are formed and utilized for the development of research designs. It helps the researcher to know what data needs to be collected and gives direction to an entire research process.
The conceptual framework for research study presents the reasoning on which the purposes of the proposed study are based. The framework presents the perspective from which the investigator views the problems. The conceptual framework deals with the interrelated that are assessable together in some rational schemes virtue of their relevance to a common theme (Polit and Beck, 2004). The conceptual framework of the present study is based on Orem’s self care theory.
The conceptual framework for the present study is based on Orem’s self care concept. The self care concept provides not only a guideline for practice but also a
philosophy of nursing. Orem sees nursing as “an art through which the practitioner of nursing gives specialized assistance to persons with disabilities of such a character that greater than ordinary assistance is required to meet daily needs for self care and to intelligently participate in the medical care they are receiving from the physician”.
Orem used the term dependent care system that is applied to a coordinated system of action performed over time to meet self care requirements of a dependent person. The role of the nurse was to facilitate and increase self care abilities of patients.
The framework conceptualizes patients with oral care deficit. The patient is liable for oral complications that may develop into systemic complications.
1. Explains the oral care deficit (dependency) of patients on nursing system.
2. Ineffective self care and the complications arise due to disease condition, age, sex, risk medication, and nil per oral.
3. Self care demands of patients related to oral care such as debris accumulation, dry mouth, tongue coating, and thick ropy saliva.
• Nursing agency using newer techniques provided efficient care and skills such as modified oral care protocol.
• Improvement in oral hygiene, prevention of systemic complications and promotion of oral health.
Summary
This chapter has dealt with the background, need for the study, statement of the problem, objectives, operational definitions, assumptions, Null hypotheses, delimitations and conceptual framework.
Organisation of the report
Further aspects of the study are presented in the following chapters.
In chapter II: Review of literature
In chapter III: Research methodology which includes research approach, research design, setting, population, sample and sampling technique, tool description, validation and reliability of tools, pilot study, data collection procedure and plan for data analysis.
In chapter IV: Analysis and interpretation of the data In chapter V: Discussion.
In chapter VI: Summary, conclusion, implication and recommendation.
CHAPTER-II
REVIEW OF LITERATURE
Review of literature is an essential component of the research process. It is critical examination of a publication related to a topic of interest. Review should be comprehensive and evaluative. Review of literature helps to plan and conduct the study in a systematic manner.
Review of literature helps the researcher to build on existing work he/ she should understand what is already known in the topic (Polit and Hungler 2007).
This chapter deals with the review of published research studies and related materials for the present study. The review helped the investigator in building the foundation of the study. It helps the researcher to find the accurate data that could be used for supporting the present findings and drawing conclusions.
The review of literature in this chapter is presented under the following headings.
¾ Studies related to oral hygiene and oral problems.
¾ Studies related to tooth brushing and bass method.
Studies related to oral problems and oral hygiene
Bill Hendrick (2010) suggests that brushing the teeth is not only good for the pearly whites, it also decreases the chance of suffering a heart attack. Poor oral hygiene is the major cause of periodontal disease, a chronic infection of the tissues surrounding the
teeth. Thus, gum infections seem to add to the inflammatory burden on individuals and increasing cardiovascular risk.
Shu Abe et al. (2006) conducted a study to establish criteria for the visual evaluation of oral hygiene and number of oral bacteria in saliva for use in predicting the development of pneumonia. Dentate patients with poor oral hygiene as indicated by their Dental Plaque Index (DPI) and Tongue Plaque Index (TPI) scores demonstrated significantly higher salivary bacterial counts than those with a good score for oral hygiene (p< 0.01 and p< 0.05, respectively). Both the number of febrile days was significantly higher (p= 0.0012), and number of patients developing pneumonia larger (p< 0.01) in dentate patients. These results demonstrate a significant positive correlation between salivary bacteria and visual evaluation of oral hygiene.
In Tokyo, a study was conducted by Kazuyuki Ishihara (2007) to investigate the relationship between presence of tongue-coating and number of oral bacteria in saliva and episodes of pneumonia. A tongue plaque index (TPI) was used to evaluate quantity of tongue-coating, with TPI0 signifying no tongue-coating and TPI1 signifying presence of tongue-coating. Edentate elderly with TPI1 demonstrated significantly higher salivary bacterial counts than those with TPI0 (p< 0.05). The number of elderly patients developing aspiration pneumonia was larger (p< 0.005) in patients with TPI-based poor scores (average TPI > 0.5) than in those with TPI-based good scores. The results demonstrate that tongue-coating is associated with number of viable salivary bacterial cells and development of aspiration pneumonia.
Scannapieco et al (1992) found that the bacterial species most commonly implicated in nosocomial pneumonia- methylene resistant staphylococcus aureus (MRSA), pseudomonas aeruginosa and Klebsiella pneumoniae were also the pathogens found within the dental plaque and buccal mucosa of critically ill patients who were unable to take fluids orally. It can then be hypothesized that a more rigorous.
In May 2000, the U.S. surgeon general’s office publishedits first report on oral health in America, emphasizing thatoral health means much more than healthy teeth and that it isintegral to general health. Included in the report is an extensivereview of the burden that oral health problems place on vulnerable populations. The surgeon general confirmed that many systemicdiseases and conditions have oral manifestations that may bethe initial signs of clinical disease. In addition, the mouthis a portal of entry as well as the site of disease for microbialinfections that affect general health status.
In another study Sally et al in 2005, secondary analysis of a prospective observational study, the tooth or mouth problems had their cancer diagnosed on average 2.9 years before and 83.3% were found clinically to be cancer free. Patients with these problems had significantly lower global (p=0.003) and subscale score on QOL analysis and higher levels of anxiety and depression.
Hospitalized patients who cannot provide their own oral care may not be receiving appropriate oral care and may receive treatments that cause or exacerbate xerostomia (dry mouth); Andersson, Westergren, Karlsson, Hallberg, & Renvert, 2002;
Clarke, 1993; Stiefel, Damron, Sowers, & Velez, 2000). As a consequence, local tissue inflammation can occur because of increased plaque deposition, decreased saliva
production, and decreased clearance of debris. Inflammation of tissues weakens the mucosal lining. A break in the mucosal lining allows for the entry of bacteria into surrounding tissues and possible local or systemic infection (Rakel, 1997; Kite &
Pearson, 1995).
Aetna and Columbia University College of Dental Medicine (2006) conducted a study that found a relationship between periodontal treatment and the overall cost of care for several chronic diseases. The results of the study, which included approximately 145,000 Aetna members with continuous dental and medical coverage, indicate that periodontal care appears to have a positive effect on the cost of medical care, with earlier treatment resulting in lower medical costs for members with diabetes, coronary artery disease and cerebrovascular disease or stroke.
Scannapieco et al. (1992) found that 65% of the plaque and/or oral mucosa in 34 medical ICU patients was colonized by respiratory pathogens, compared with only 16%
in 25 preventive dentistry clinic patients (P <0.05). Similarly Treloar and Stechmiller (1995) showed that cultures grown from oropharyngeal and sputum specimens of 37Æ5% of orally intubated critical care patients grew either nosocomial bacterial or fungal pathogens.
Studies related to tooth brushing and Bass Method
Ammar Yashir, (April 2007) published article about tooth brushing techniques.
The author says that one of the major causes of tooth destruction is the wrong brushing technique that many of people use daily. He advised the modified bass technique for adults.
M. Poyato-Ferrara et al., (2005) conducted a study to compare the efficacy in supragingival plaque removal of normal toothbrushing technique and the modified bass method. The modified Bass (Mod-Bass) technique was significantly (P< 0.05) more effective in removing supragingival plaque than normal toothbrushing practices both in all buccal and lingual sites. The results showed that a particular toothbrushing technique as modified Bass method is significantly superior to normal toothbrushing practices in supragingival plaque removal.
The Colgate Oral Care Report (2002) suggested that comparing to the all techniques of brushing only the modified Bass technique effectively cleans the sulcus, while the Modified Charters technique is useful for cleaning fixed orthodontic appliances.
Charles Bass a Mississippi physician is known as the “Father of Preventive Dentistry”. He pointed up that if one worked hard to keep the area of the tooth at and below the gum clean and free of germs or bacteria, even the elderly could keep their teeth. Bass proposed placing toothbrush partly on the tooth and partly on the gum with the toothbrush bristles angled toward the gums. As the person vibrate the toothbrush back and forth, the tips of the bristles slid below the gums to clean off plaque, bacteria or germs below the gum or gingival margin.
A study related to oral hygiene was conducted by Emma Laing et al (2008) on oral hygiene products and techniques. According to Emma Laing et al, the Bass technique superseded the roll technique owing to its superior cleaning of the gingival cervice. In this, the bristles of the toothbrush are held at about 45 degree to the long axis of the tooth, pointing towards the gingivae. The brush was pressed against the gingivae and moved with a small circular motion so that the bristles go into the cervice
and between the teeth. This is currently the most effective method for dental plaque removal.
According to Jepsen (1998) innumerable toothbrush movements have been recommended over time, and then abondaned that were rolling, vibrating, circular, vertical, and horizontal. The mostly and frequently recommended method by dentists and dental hygienists was modified Bass technique.
Adair et al., (2001) suggested that brush teeth at least twice a day, preferably soon after awakening in the morning and before going to bed. Sjogren et al., (1995) suggested that brushing twice a day is a social norm that is generally accepted.
According to Bowsher et al., (1999) soft bristled, small ended toothbrush is efficient in plaque removal with minimal gingival trauma. Miller & Kearney (2001) found that soft bristled, small ended toothbrush is an effective means for cleaning teeth even when individuals are unable to do so independently.
Somerville (1999) suggested nurses, in particular intensive care nurses, are fearful of using toothbrushes especially in intubated patients preferring to the use of sponge sticks. This is not effective in the removal of plaque and debris. There is also the danger of the sponge becoming separated from the stick. Then it was concluded that sponge sticks are not recommended for oral care.
Chlorhexidine is rapidly absorbed onto the bacterial cell surface. It disrupts the cytoplasmic membrane binding to oral tissue for extended periods, resulting in sustained release effect. Thus, twice daily use is recommended. (Ransier et al, 1995; Weitz et al, 1992)
Care of the mouth is an important nursing procedure and should be performed as part of the routine general hygiene of a patient. Nurses play an important role in providing effective oral care and promoting oral hygiene. Oral hygiene has often been overlooked by health care workers and performed on an ad hoc basis. In some instances, it has become a ritualistic and banal activity. Sporadic research has generated conflicting advice. Furthermore, it was reported that the delivery of oral care within institutional settings is fragmented (Roberts, 2001).
Evans, G. (2001) reviewed about oral hygiene practices in clinical setting using anectodotal evidence and subjective assessments. Oral hygiene is an essential aspect of care for every patient admitted in hospital, it would appear that oral care procedure are not based on research evidence but on tradition. There is substantial literature on mouth care but research does not substantiate current methods of oral care. Research based education on mouth care should be promoted within the nursing curricula.
Summary
This chapter has dealt with review of literature related to the problem stated. The literatures presented here were extracted from 4 primary and 17 secondary sources. It has helped the researcher to understand the impact of the problem under study. It has also enabled the investigator to design the study, develop the tool, plan the data collection procedure and to analyze the data.
CHAPTER-III
RESEARCH METHODOLOGY
Methodology is the most important part of any research study, which enables the researcher to form a print for the study undertaken. This chapter represents the methodology adopted by the researcher for the study. It included the research approach the settings population, sampling, techniques, selection of tool, content validity&
reliability, pilot study data collection, procedure & plan for analysis. The present study was aimed to assess the effectiveness of modified oral care protocol over traditional oral care on improvement of oral hygiene among patients with self care deficit in selected Hospitals, Chennai.
Research approach
Research approach is the most significant part of the research, the appropriate choice of research approach depends on the purpose of research study which is undertaken. According to Polit & Hungler (2004) experimental research is an extremely applied form of research and involves findings out how well a programme, practice (or) policy is working. Its goal is to assess or evaluate the success of the programme. An experimental research is generally applied where the primary objective is to determine the extent to which a given procedure meets the desired results.
To accomplish the objective of this study, experimental approach was considered most appropriate, since the researcher wanted to assess the effectiveness of modified oral care protocol on improvement of oral hygiene.
Research design
Polit and Beck (2008) stated that a research design incorporates the most important methodology called decisions that the researcher make in conducting a research study. It helps the research in the selection of subjects, manipulation of independent variables to be studied.
An Experimental research design with pre test and post test design was adopted for conducting this study. In this study the researcher randomly selected the control and experimental group then manipulated the independent variable that is modified oral care protocol, which was administered only to the experimental group. Then the oral hygiene were assessed by Beck’s oral assessment guide for both control and experimental group. Finally the effectiveness of modified oral care protocol was assessed by using Rating Scale on level of satisfaction. True experimental two group pretest posttest research design was adopted for conducting the study. It fulfilled the criteria such as randomization, manipulation and control.
The research design is represented diagrammatically as follows.
R 01 X 02
R 01 - 02
R -- Randomization
01 -- Assessment of oral hygiene before oral care.
X -- Administration of modified oral care.
02 -- Assessment of oral hygiene after oral care.
Fig.2. Schematic Design of the Study
Accessible Population
Patients with self care deficit admitted in selected Hospital, Chennai.
Systematic Random Sampling
Experimental Group 30 patients with self care deficit Control Group
30 patients with self care deficit.
Assessment of oral hygiene before oral care.
Assessment of oral hygiene before oral care
Providing modified oral care.
Assessment of oral hygiene after oral care.
Assessment of oral hygiene after oral care.
Analysis and Interpretation by Descriptive and Inferential Statistics
Target Population Patients with self care deficit.
Research setting
Research setting is the most specific place where data collection will occur (Polit and Beck 2008). The present study was conducted in Apollo Main Hospital, Chennai.
Apollo Main Hospital is a 900 bedded multi speciality hospital with JCIA accreditation and it provides comprehensive care to all the patients. The researcher did the study in the stroke ward as E-extension, separate post CABG ward, ortho ward as M-ward with excellent facilities for providing care for the patients who were unable to carry out self care themselves.
Population
Population is the entire aggregation of cases which meet designed set of criteria (Polit and Beck 2008). The Target population is the group of population that the researcher aimed to study and to whom the study findings were generalized. In this study the target population comprised of all the self care deficit patients who were in the age group of 20-75years. The Accessible population is the list of population that the researcher finds in the study area. The accessible population in this study were self care deficit patients in Apollo Main Hospitals, Chennai.
Sample
Polit & Beck (2008) stated that a sample consists of a subset of the units that comprises the population.
The sample size for the present study were 60 self care deficit patients in the age group of 20-75 years, who satisfied the inclusion criteria out of which 30 were randomly assigned to control group and 30 to experimental group. Sampling is the process of selecting a portion of the population to represent the entire population (Polit and Beck, 2004).
Sampling Technique
Sampling is the process of selecting a portion of population to represent the entire population (Polit and Beck, 2006).
The participants of the present study were selected by systematic random sampling technique by which the researcher selected the participants based on the inclusion criteria.
Sampling criteria
Inclusion Criteria
The study included self care deficit patients who were
¾ in the age group of 20-75 years
¾ had minimum of 24 teeth
¾ not able to perform the activities of daily living.
¾ willing to participate in the study.
Exclusion Criteria
The study excluded self care deficit patients
¾ with endotracheal tubes.
¾ with any systemic disease /associated illness.
¾ with gingival inflammation.
¾ having stained teeth and loose teeth.
Selection and development study instruments
As the study was aimed to assess the effectiveness of modified oral care protocol over self care deficit patients, the data collection instruments and related information were developed by the researcher through an extensive review of literature, consultation with experts and opinion of faculty members. The instruments used in the study were demographic variable proforma, clinical variable proforma, Beck’s oral assessment guide, and rating scale on satisfaction of modified oral care.
Demographic variable Proforma
Demographic variable proforma consisted of age in years, sex, types of self care deficit, days of hospitalization, habit of tobacco chewing, period of smoking and educational status.
Clinical variable proforma
This proforma was used to assess the clinical variables such as type of teeth, presence of denture, medications causing oral side effects, type of feeding, habit of brushing, disease causing oral health problems, presence of any oral problems, and materials used previously for brushing.
Beck’s oral assessment guide
Modified Beck’s oral assessment Guide consists of five items related to status of mouth such as lips, saliva, oral mucosa, teeth and tongue. A minimum score of five was
given to the client whose oral health is good and a maximum score twenty was given to poor oral health. The greater the score shows improper oral health and lesser score indicates proper oral care.
Score - Interpretation Mild - 6-10
Moderate - 11-15
Severe 16-20
Level of satisfaction
Rating scale on the satisfaction of modified oral care protocol. This scale is used to measure the level of satisfaction of the patients who participated. The scale is administered to the experimental group. It comprises of 10 items.
Score Percentage Level of satisfaction
<10 ≤20 Dissatisfied 11-20 21-80 Satisfied
>20 >80 Highly satisfied
Validity of the study instrument
The content validity refers to the adequacy of the sampling of the domain being studied. The content validity of the tool was obtained by getting opinion from seven experts in the field of nursing and medicine. The validation has suggested some specific modifications in the objectives and rating scale. The modifications and suggestions of experts were incorporated in the final preparation of the tool.
Reliability of the study
Reliability refers to the accuracy and consistency of measuring tool. The reliability of the tool was elicited by using split half technique; Karl Pearson’s ‘r’ was computed for finding out the reliability. The ‘r’ value of the instrument was 0.88 which was highly significant.
Pilot study
Polit and Beck (2008) states that pilot study is a miniature of the actual study in which the instruments are administered to the subjects drawn from the same population.
The purpose is to find out the feasibility and practicability of the study. A small scale version was done in preparation for a major study.
A pilot study was conducted among 10 subjects in Apollo Main Hospital after obtaining oral permission from the authorities of Apollo Main Hospital, Chennai. The subjects were chosen by systematic random sampling 5 in control group and 5 in experimental group. Oral hygiene was assessed for both the control and experimental group. Modified oral care protocol was administered twice a day in morning and evening for one week for the experimental group. After which oral hygiene was assessed for both the control and experimental group. Then the level of satisfaction on modified oral care protocol administration was assessed using the rating scale for experimental group. On the whole the modified oral care protocol administration was found to be feasible and acceptable.
Data collection procedure
Data collection is the gathering of information needed to address a research problem. The data collection was done for a period of one month. The researcher introduced herself and obtained consent from the subjects and the patient’s attenders to participate in the study. An assurance was given regarding confidentiality while the actual data was collected. Researcher collected the data from patient’s attenders. The subjects were selected by using systematic random sampling technique and one group was selected for control and one was for experimental group. The study was primarily concerned to assess the effectiveness of modified oral care protocol among self care deficit patients. The level of oral hygiene was assessed for both the control and experimental group of self care deficit patients. By simple random sampling 30 self care deficit patients were selected from each group to participate in the study.
Subjects for the study had undergone the pre assessment of oral hygiene by using Beck’s Oral Assessment Guide. The experimental group received oral care based on modified oral care protocol 2 times per day for 5 days consecutively. The control group received oral care based on routine method. Post assessment of oral hygiene was done for both the experimental group and control group.
Problem faced during data collection
The problems faced during the process of this study were,
• some patients were not willing to participate in the study.
• the researcher had a problem of doing brushing in the early morning.
• some participants wanted only one time brushing.
Plan for data analysis
Data analysis is the systematic organization and synthesis of research data and testing of research hypothesis based on the obtained data (Polit and Beck 2008).
Analysis and interpretation of data were carried out with descriptive statistics like mean, percentage, standard deviation and inferential statistics like paired ‘t’ test and chi-square test. The association between demographic data and depend variables were analyzed with the help of chi-square test.
Summary
This chapter has dealt with the selection of research approach, research method, research design, setting, population, sample and sampling technique, sample criteria, selection and development of the study instrument, validity, reliability of the study instrument, pilot study, data collection procedure and plan for data analysis.
CHAPTER-IV
ANALYSIS AND INTERPRETATION
This chapter includes both inferential and descriptive statistics. statistics is a field of study concerned with techniques or method of collection of data, classification, summarizing, interpretation, drawing inferences, testing of hypotheses, making recommendation,etc. (Mahajan ,2004).
The data was collected from 60 patients with self care deficit, 30 in the control group and 30 in the experimental group, to assess the effectiveness of modified oral care protocol upon improvement of oral hygiene. Data was analyzed based on the objectives and hypotheses of the study. Data analysis was computed after transferring the collected data into a master coding sheet. The researcher used descriptive and inferential statistics for the analysis.
The data tabulated, analyzed and interpreted using descriptive and inferential statistics in the sequence as follows:
Organization of finding
¾ Frequency and percentage distribution of demographic variables in the control and experimental group of self care deficit patients with oral dysfunction.
¾ Frequency and percentage distribution of clinical variables in the control and experimental group of self care deficit patients with oral dysfunction
¾ Frequency and percentage distribution of oral hygiene before and after providing modified oral care protocol in Control and Experimental group among self care deficit patients.
¾ Comparison of mean and standard deviation of Oral hygiene before and after providing modified oral care protocol in the Control and Experimental group of Self Care Deficit patients.
¾ Frequency and Percentage Distribution of Level of satisfaction on Modified Oral Care Protocol in Experimental group of Self Care Deficit patients.
¾ Association between the selected demographic variables and oral dysfunction level before and after the Modified Oral Care Protocol in the experimental group.
¾ Association between the selected clinical variables and oral dysfunction level before and after the Modified Oral Care Protocol in the experimental group.
Table 1
Frequency and Percentage Distribution of Demographic Variables in the Control and Experimental group of Self Care Deficit patients with oral dysfunction.
(N=60)
Control Group (n=30)
Experiment Group (n=30) Demographic
Variables
n p n p
Age in Years
20-40 - - 2 6.7
41-60 12 40 15 50
61-75 18 60 13 43.3
Sex
Male 22 73.3 22 73.3
Female 8 26.7 8 26.7
Self Care Deficit
Wholly dependent 21 70 13 43.3
Partially dependent 9 30 17 56.7
Days of
Hospitalization
<2 days 3 10 17 56.7
3-6 days 4 13.3 6 20
One week 12 40 4 13.3
>One week 11 36.7 3 10
Habit of tobacco
chewing
Wholly addict 12 40 6 20
Occasional 18 60 17 56.7
None - - 7 23.3
Habit of smoking
Wholly addict 15 50 15 50
Occasional 7 23.3 7 23.3
None 8 26.7 8 26.7
Period of Smoking
<1 year - - 1 3.33
1-2 years - - 6 20
2-5 years 9 30 6 20
>5 years 13 43.3 9 30
None 8 26.7 8 26.7
Educational Status
Illiterate 6 20 5 16.7
Primary 3 10 6 20
Secondary 4 13.3 7 23.3
Higher secondary 9 30 8 26.7
Graduate 8 26.7 4 13.3
The data from table 1 revealed that a significant percentage of self care deficit patients in control group were in the age group of 61-75 years (60%) and experimental group were in the age group of 41 to 60 years (50%), majority of them were wholly dependent (70%) in control group whereas (56.7%) were partially dependent in experimental group. Almost most of them in both the control and experimental group were men (73.3%) and majority of them were studied (80%, 83.3%). Majority of them had habit of tobacco chewing and smoking in the control (60%, 44.7%) and experimental group (57%, 50%).
Table 2
Frequency and Percentage Distribution of Clinical Variables in the Control and Experimental group of Self Care Deficit patients with oral dysfunction.
N=60
Control Group
(n=30) Experiment Group
(n=30) Clinical Variables
n p n p
Type of teeth
Natural teeth 30 100 30 100
Artificial teeth - - - -
Medications causing
oral side effects
Narcotic analgesics 11 36.7 16 53.3
Anticholinergics 6 20 6 20
Others 13 43.3 8 26.7
Type of Feeding
Oral 2 6.7 5 16.7
Enteral 25 83.3 24 80
Parenteral 3 10 1 3.3
Habit of brushing
Only one time 21 70 22 73.3
More than one time
including night time 5 16.7 6 20
More than one time
not night 4 13.3 2 6.7
Diseases causing oral
health problems
Diabetes mellitus 9 30 7 23.3
Cerebrovascular
accident 10 33.3 7 23.3
Others 11 36.7 16 53.3
Treatments causing
any oral problems at present
Oxygen therapy 8 26.7 8 26.7
Intermittent suction 13 43.3 18 60
Others 9 30 4 13.3
Material used previously for
brushing
Tooth powder 4 13.3 6 20
Tooth paste 26 86.7 24 80
Others - - - -
It could be inferred from table 2 All of them (100%) had natural teeth in control as well as experimental group. Majority of them had enteral type of feeding in the control and experimental (83.3%, 80%), had habit of brushing only one time (70%, 73.33%), had intermittent suction (43.3%, 60%), and used tooth paste previously for brushing (86.7%, 80%). Most of them suffered with oral side effects due to narcotic analgesics in experimental (53.3) than control (36.7).
Table 3
Frequency and Percentage Distribution of oral dysfunction before and after providing modified oral care protocol in Control and Experimental group among Self Care Deficit patients.
(N=60) Control group
n=30
Experimental group n=30
Oral Dysfunction
N p n p
Before
Normal - - - -
Mild 6 20 5 16.7
Moderate 16 53.3 19 63.3
Severe 8 26.7 6 20
After
Normal - - 7 23.3
Mild 10 33.3 17 56.7
Moderate 14 46.7 6 20
Severe 6 20 - -
The data presented in table 3 revealed that before the modified level of oral care protocol half of the self care deficit patients (53.3%, 63.3%) had moderate level of oral dysfunction, a significant percentage of them (20%, 16.7%) experienced mild level of oral dysfunction in the control and experimental group, where as majority of them experienced mild level of oral dysfunction (56.7), and only few of them experienced
moderate level of oral dysfunction (20%) in the experimental group after the modified oral care protocol. This could be attributed to the effectiveness of modified oral care protocol.
Table 4
Frequency and Percentage Distribution of Level of satisfaction on Modified Oral Care Protocol in Experimental group of Self Care Deficit patients.
(N=30) Experimental group
Level of satisfaction
N p
Dissatisfied - -
Satisfied 6 20
Highly Satisfied 24 80
The data presented in table 4 showed that majority of the self care deficit patients 80% were highly satisfied with modified oral care protocol, 20% were satisfied, and none of them expressed dissatisfy action. It could be interpreted from the study findings that modified oral care protocol is simple, easy to practice and effective in reducing oral dysfunction symptoms.
Table 5
Comparison of Mean and Standard Deviation of Level of Oral Hygiene in the Control and Experimental group of Self Care Deficit patients Before and After the Modified Oral Care Protocol.
(N=60) Control
(n=30)
Experimental (n=30)
Group M SD t value M SD t value
Before 12.2 3.29 -0.368 12.2 3.245 12.689***
After 12.43 5.14 7.5 3.22 (df =29)
Improvement
score -0.23 -1.85 4.7 0.025
***p<0.001
The data presented in table 5 depicted that the mean and standard deviation of oral hygiene in control group and experimental group before practice of modified oral care procedure were (M=12.2, SD=3.29), and (M=12.2, SD=3.245), were as after administration of modified oral care protocol the mean and standard deviation were less in the experimental group (M=7.5, SD=3.22). The difference was found statistically significant at P<0.001 level of confidence and it can be attributed to the effectiveness of administration of modified oral care protocol.
Table 6
Association between the Selected Demographic Variables and Oral dysfunction level before and after the Modified Oral Care Protocol in the experimental group.
(N=30) Oral Hygiene among experimental group
Before administration After administration Demographic
Variables Mild Moderate Severe Χ2 Norm
al
Mild Moder ate
Χ2
Age in years
20-40 years 1 1 - 1 1 -
41-60 years 4 10 1 4 9 2
61-75 years - 7 6
9.783*
df=4
2 6 5
3.666 df=4
Sex
Male 4 15 3 6 12 4
Female
1 4 3
2.053 df=2
1 5 2
0.7 df=2
Self Care Deficit Wholly
dependent 2 6 5 3 6 4
Partially
dependent 3 13 1
5.001 df=2
4 11 2
1.778 df=1
Days of Hospitalization
<2 days 4 12 1 5 10 2
3-6 days 1 5 -
18.5**
df=6
2 4 -
7.41 df=6
One week - 2 2 - 2 2
>One week - - 3 - 1 2
Habit of Tobacco
1.142 3.339
Chewing
Wholly addict 1 4 1 2 2 2
Occasional 2 11 4 3 12 2
None 2 4 1
df=4
2 3 2
df=4
Habit of smoking
Wholly addict 3 10 2 4 8 3
Occasional 1 5 1 2 4 1
None 1 4 3
2.44 df=4
1 5 2
0.852 df=4
Period of Smoking
<1 year - 1 - - - 1
1-2 years 1 5 - 1 5 -
2-5 years 3 3 - 4 2 -
>5 years - 6 3 1 5 3
None 1 4 3
16.024 df=8
1 5 2
14.629 df=8
Educational Status
Illiterate - 2 3 - 3 2
Primary 2 3 1 3 2 1
Secondary 1 6 - 2 4 1
Higher secondary 2 4 2 2 4 2
Graduate - 3 1
8.99 df=8
- 4 -
10.166 df=8
*p<0.05, p<0.01
Table 6 showed there was a significant association between the demographic variables and the oral hygiene level in the experimental group of self care deficit patients before and after the administration of modified oral care protocol such age and days of hospitalization. Hence the null hypothesis Ho3 was rejected in regard to the age and days of hospitalization. The nurses need to concentrate on increased hospital stay and increased age of the patients for oral care.
Table 7
Association between the Selected Clinical Variables and Oral hygiene before and after the Modified Oral Care Protocol in the experimental group of Self Care Deficit patients.
(N=30) Oral Hygiene among experimental group
Before After
Clinical variables
Mild Mode
rate Severe χ2 Norm
al Mild Modera
te Χ2
Medications causing oral side effects
Narcotic analgesics 3 9 4 3 9 4
Anticholinergics 1 4 1 1 3 2
Others 1 6 1
0.889 df=4
3 4 1
1.671 df=4
Type of Feeding
Oral 1 3 1 1 3 1
Enteral 4 15 5 6 13 5
Parenteral - 1 -
0.633 df=4
- 1 -
0.861 df=4
Habit of brushing
Only one time 5 13 4 7 11 4
More than one time including night time
- 4 2 - 4 2
More than one time
not night - 2 -
3.274
df=4 - 2 -
4.517 df=4 Diseases causing
oral health problems
Diabetes mellitus - 7 -
5.104
1 5 1
