Abstract

Introduction

The maintenance of oral health in inpatients is essential, particularly to avoid complications arising from periodontal disease, which not only affect oral health but can also exacerbate systemic issues during hospitalization. Objective: This study aimed to assess nursing staff’s knowledge regarding the management of periodontal disease and its association with systemic diseases.

Material and method

This cross-sectional observational study was conducted in a general referral hospital of the Brazilian National Health System (SUS). A total of 504 nursing professionals completed a self-administered 24-item questionnaire on relating to oral care procedures and the importance of oral health in hospitalized patients. Data were analyzed using descriptive analysis and the chi-squared test (α = 0.05).

Result

Most respondents (97.8%) believed that oral infections can affect a patient's general health and that oral hygiene is important during hospitalization. However, knowledge deficits were identified. The oral effect of periodontal disease was considered moderate by 49.3% of the participants, and 74.6% believed that sugar was the most common cause of periodontal disease.

Conclusion

Nursing professionals are aware of the importance of maintaining oral hygiene and the relationship between periodontal and systemic diseases. However, their dental hygiene practice knowledge is limited. A training program on oral healthcare for inpatients and the inclusion of oral hygiene topics in the curricula of nursing professionals are recommended.

Desciptors:
Periodontal diseases; disease; nursing staff; oral health; inpatients

Resumo

Introdução

A manutenção da saúde bucal em pacientes internados é essencial, especialmente para evitar complicações decorrentes da doença periodontal, que não apenas afetam a saúde bucal, mas também podem agravar problemas sistêmicos durante a hospitalização. Objetivo: Este estudo teve como objetivo avaliar o conhecimento da equipe de enfermagem em relação ao manejo da doença periodontal e sua associação com doenças sistêmicas.

Material e método

Este estudo observacional transversal foi conduzido em um hospital geral de referência do Sistema Único de Saúde (SUS) do Brasil. Um total de 504 profissionais de enfermagem completaram um questionário autoaplicável com 24 questões, abordando procedimentos de cuidados bucais e a importância da saúde bucal em pacientes hospitalizados. Os dados foram analisados por meio de análise descritiva e teste qui-quadrado (α = 0,05).

Resultado

A maioria dos entrevistados (97,8%) acreditava que infecções bucais podem afetar a saúde geral do paciente e que a higiene bucal é importante durante a hospitalização. No entanto, foram identificados déficits de conhecimento. O efeito oral da doença periodontal foi considerado moderado por 49,3% dos participantes, e 74,6% acreditavam que o açúcar era a causa mais comum da doença periodontal.

Conclusão

Profissionais de enfermagem reconhecem a importância da manutenção da higiene bucal e a relação entre doença periodontal e doenças sistêmicas. No entanto, seu conhecimento prático em higiene bucal é limitado. Recomenda-se um programa de treinamento em cuidados bucais para pacientes internados e a inclusão de tópicos de higiene bucal nos currículos dos profissionais de enfermagem.

Descritores:
Doenças periodontais; doença; equipe de enfermagem; saúde bucal; pacientes internados

INTRODUCTION

Oral health care is an essential component of inpatient medical care and is primarily provided by nurses and healthcare staff professionals¹1 Kim Y, Ku HM, Jun MK. Knowledge evaluation of oral diseases and perception of cooperation with dental experts for oral care of nurses in intensive care units in Korea: a preliminary study. Nurs Rep. 2023 Mar;13(1):528-38. http://dx.doi.org/10.3390/nursrep13010048. PMid:36976700.
http://dx.doi.org/10.3390/nursrep1301004... . Knowledge and awareness of oral health measures for these patients are critical for preventing oral pathologies and systemic bacterial dissemination²2 Philip P, Villarosa A, Gopinath A, Elizabeth C, Norman G, George A. Oral health knowledge, attitude and practices among nurses in a tertiary care hospital in Bangalore, India: a cross-sectional survey. Contemp Nurse. 2019 Apr-Jun;55(2-3):261-74. http://dx.doi.org/10.1080/10376178.2019.1647790. PMid:31340719.
http://dx.doi.org/10.1080/10376178.2019.... ,³3 Cianetti S, Anderini P, Pagano S, Eusebi P, Orso M, Salvato R, et al. Oral health knowledge level of nursing staff working in semi-intensive heart failure units. J Multidiscip Healthc. 2020 Feb;13:165-73. http://dx.doi.org/10.2147/JMDH.S224453. PMid:32103976.
http://dx.doi.org/10.2147/JMDH.S224453... . Moreover, oral hygiene usually deteriorates after hospitalization⁴4 Terezakis E, Needleman I, Kumar N, Moles D, Agudo E. The impact of hospitalization on oral health: a systematic review. J Clin Periodontol. 2011 Jul;38(7):628-36. http://dx.doi.org/10.1111/j.1600-051X.2011.01727.x. PMid:21470276.
http://dx.doi.org/10.1111/j.1600-051X.20... ,⁵5 Sousa LL, Silva Filho WL, Mendes RF, Moita JM No, Prado RR Jr. Oral health of patients under short hospitalization period: observational study. J Clin Periodontol. 2014 Jun;41(6):558-63. http://dx.doi.org/10.1111/jcpe.12250. PMid:24617503.
http://dx.doi.org/10.1111/jcpe.12250... .

Absence or poor toothbrushing leads to plaque accumulation on the tooth surfaces, resulting in periodontal disease (PD)⁶6 Lasserre JF, Brecx MC, Toma S. Oral microbes, biofilms and their role in periodontal and peri-implant diseases. Materials (Basel). 2018 Sep;11(10):1802. http://dx.doi.org/10.3390/ma11101802. PMid:30248991.
http://dx.doi.org/10.3390/ma11101802... . PD is characterized by the destruction of the supporting tissues of the teeth, causing tooth mobility and tooth loss⁶6 Lasserre JF, Brecx MC, Toma S. Oral microbes, biofilms and their role in periodontal and peri-implant diseases. Materials (Basel). 2018 Sep;11(10):1802. http://dx.doi.org/10.3390/ma11101802. PMid:30248991.
http://dx.doi.org/10.3390/ma11101802... . Periodontal pathogens produce endotoxins that are directly related to systemic diseases⁷7 Bui FQ, Almeida-da-Silva CLC, Huynh B, Trinh A, Liu J, Woodward J, et al. Association between periodontal pathogens and systemic disease. Biomed J. 2019 Feb;42(1):27-35. http://dx.doi.org/10.1016/j.bj.2018.12.001. PMid:30987702.
http://dx.doi.org/10.1016/j.bj.2018.12.0... . Studies have shown an interaction between PD and several systemic diseases, including atherosclerosis, stroke, chronic kidney disease, cancer, cardiovascular diseases, type 2 diabetes, and respiratory tract infection⁷7 Bui FQ, Almeida-da-Silva CLC, Huynh B, Trinh A, Liu J, Woodward J, et al. Association between periodontal pathogens and systemic disease. Biomed J. 2019 Feb;42(1):27-35. http://dx.doi.org/10.1016/j.bj.2018.12.001. PMid:30987702.
http://dx.doi.org/10.1016/j.bj.2018.12.0... ,⁸8 Kramer A, Splieth C. Health promotion through structured oral hygiene and good tooth alignment. GMS Hyg Infect Control. 2022 May;17:Doc08. http://dx.doi.org/10.3205/dgkh000411. PMid:35707231.
http://dx.doi.org/10.3205/dgkh000411... . Controlling PD may reduce systemic inflammation, and therefore, contribute to controlling diabetes, cardiovascular disease, and other systemic complications⁹9 Taşdemir Z, Alkan BA. Knowledge of medical doctors in Turkey about the relationship between periodontal disease and systemic health. Braz Oral Res. 2015;29:55. http://dx.doi.org/10.1590/1807-3107BOR-2015.vol29.0055. PMid:25885023.
http://dx.doi.org/10.1590/1807-3107BOR-2... . Healthcare professionals must be informed of the potential impact of periodontal disease on a patient's overall health, so that they can, in turn, inform their patients¹⁰10 Sanz M, Marco Del Castillo A, Jepsen S, Gonzalez-Juanatey JR, D’Aiuto F, Bouchard P, et al. Periodontitis and cardiovascular diseases: Consensus report. J Clin Periodontol. 2020 Mar;47(3):268-88. http://dx.doi.org/10.1111/jcpe.13189. PMid:32011025.
http://dx.doi.org/10.1111/jcpe.13189... .

The ability of nursing staff to prioritize and adhere to inpatient oral care is a challenge¹¹11 Adib-Hajbaghery M, Ansari A, Azizi-Fini I. Intensive care nurses’ opinions and practice for oral care of mechanically ventilated patients. Indian J Crit Care Med. 2013 Jan;17(1):23-7. http://dx.doi.org/10.4103/0972-5229.112154. PMid:23833472.
http://dx.doi.org/10.4103/0972-5229.1121...

12 Saddki N, Mohamad Sani FE, Tin-Oo MM. Oral care for intubated patients: a survey of intensive care unit nurses. Nurs Crit Care. 2017 Mar;22(2):89-98. http://dx.doi.org/10.1111/nicc.12119. PMid:25349099.
http://dx.doi.org/10.1111/nicc.12119... -¹³13 Dagnew ZA, Abraham IA, Beraki GG, Mittler S, Achila OO, Tesfamariam EH. Do nurses have barriers to quality oral care practice at a generalized hospital care in Asmara, Eritrea? A cross-sectional study. BMC Oral Health. 2020 May;20(1):149. http://dx.doi.org/10.1186/s12903-020-01138-y. PMid:32434570.
http://dx.doi.org/10.1186/s12903-020-011... . Insufficient time for instruction, lack of instructional materials, and unwilling patients appear to be the main factors contributing to non-adherence to inpatient oral care¹³13 Dagnew ZA, Abraham IA, Beraki GG, Mittler S, Achila OO, Tesfamariam EH. Do nurses have barriers to quality oral care practice at a generalized hospital care in Asmara, Eritrea? A cross-sectional study. BMC Oral Health. 2020 May;20(1):149. http://dx.doi.org/10.1186/s12903-020-01138-y. PMid:32434570.
http://dx.doi.org/10.1186/s12903-020-011... ,¹⁴14 Coker E, Ploeg J, Kaasalainen S, Carter N. Nurses’ oral hygiene care practices with hospitalised older adults in postacute settings. Int J Older People Nurs. 2017 Mar;12(1):e12124. http://dx.doi.org/10.1111/opn.12124. PMid:27353475.
http://dx.doi.org/10.1111/opn.12124... . The prevention and control of periodontal disease should be considered integral to various disease control and risk minimization⁹9 Taşdemir Z, Alkan BA. Knowledge of medical doctors in Turkey about the relationship between periodontal disease and systemic health. Braz Oral Res. 2015;29:55. http://dx.doi.org/10.1590/1807-3107BOR-2015.vol29.0055. PMid:25885023.
http://dx.doi.org/10.1590/1807-3107BOR-2... . Oral care should include the use of a fluoridated toothpaste, interproximal brush, and dental floss⁸8 Kramer A, Splieth C. Health promotion through structured oral hygiene and good tooth alignment. GMS Hyg Infect Control. 2022 May;17:Doc08. http://dx.doi.org/10.3205/dgkh000411. PMid:35707231.
http://dx.doi.org/10.3205/dgkh000411... . Training nursing staff with oral hygiene technicians as instructors may improve their oral care knowledge and skills⁵5 Sousa LL, Silva Filho WL, Mendes RF, Moita JM No, Prado RR Jr. Oral health of patients under short hospitalization period: observational study. J Clin Periodontol. 2014 Jun;41(6):558-63. http://dx.doi.org/10.1111/jcpe.12250. PMid:24617503.
http://dx.doi.org/10.1111/jcpe.12250... ,¹⁵15 Gibney J, Wright C, Sharma A, Naganathan V. Nurses’ knowledge, attitudes, and current practice of daily oral hygiene care to patients on acute aged care wards in two Australian hospitals. Spec Care Dentist. 2015 Nov-Dec;35(6):285-93. http://dx.doi.org/10.1111/scd.12131. PMid:26297474.
http://dx.doi.org/10.1111/scd.12131... .

To the best of our knowledge, few studies on nursing staff knowledge of the importance of managing periodontal disease are available. Therefore, this study aimed to assess the knowledge of nursing staff (nurses, technicians, and nursing assistants) regarding periodontal disease, its association with systemic diseases, and the clinical management of patients with periodontal disease.

MATERIALS AND METHODS

Study Design and Ethical Issues

This cross-sectional observational explorative study was developed according to the ethical guidelines for human research and approved by the Ethics Committee on Human Research of the Federal University of Uberlândia, Brazil (CAAE:52673321.3.0000.5152).

Sampling, Context, and Study Participants

The study used a convenience sample of 504 nursing professionals (130 nurses, 286 nursing technicians, 87 nursing assistants) employed by the Public Clinical Hospital and Dental Hospital of the Federal University of Uberlândia, Brazil. The nursing staff work within a regional referral hospital of the Brazilian National Health System (SUS). A total of 526 questionnaires were completed between April 2022 and December 2022 by nursing professionals of both sexes, across all ages, and working in all shifts (morning, afternoon, and evening). However, 22 professionals (5%) were excluded because they did not disclose whether they were nurses, nursing technicians, or assistants. Nursing staff who refused to participate, and those on vacation or work leave were excluded from the study.

Data Collection Tool

The 24-item questionnaire was developed by a collaborative team that included dental professionals and nurses. The first part of the questionnaire identified the nursing team demography including professional categories, age, sex, income, and professional training experiences. The second part included questions relating to participation within a multidisciplinary team, interactions with dental professionals, knowledge on periodontal disease and its relationship with general health, oral care knowledge and practice routinely performed in the hospital environment, level of interest in receiving oral health-related information, and relevance to their work as nursing staff.

Data Collection

The participants were informed about the study. After written informed consent was obtained, one interviewer (ER) offered an anonymous, self-administered questionnaire. The questionnaire took approximately 30 min to complete. Questions from the participants were answered by the interviewer. For greater participant engagement, all inpatient departments of the Clinical Hospital were visited during the morning, afternoon, and evening shifts during nursing staff breaks (breaks for snacks, lunch, dinner, and overnight rest).

Data Analysis

Data were tested for normal distribution (Shapiro-Wilk test) and homogeneity of variance (Levene’s test), and a descriptive chi-square test was performed. Contingency coefficients were used to identify differences between nurses and nursing auxiliaries concerning socioeconomic variables and knowledge of oral health. All tests were performed using Jamovi Software (version 2.3.21), with a significance value of 5%.

Study Impact on Practice

At the end of the study, a comprehensive interdisciplinary training course on periodontal disease and inpatient oral healthcare was offered by dental professionals to interested nursing professionals. The training addressed patient management at hospitals, oral health education for the prevention of periodontal disease, and the use of hospital resources to assist in inpatient periodontal hygiene care. A standard protocol was also created to facilitate nursing professionals’ access to continued oral healthcare education.

RESULTS

Responses from the 504 nursing professionals who participated in this study are presented in Table 1. The study consisted of mostly females (380, 75.4%), with family income between levels 2 and 4 (221, 43.8%) of the minimum national wages. The mean age was 41.3 ± 10.0 years. There were no significant differences between nurses and auxiliary nursing staff.

Approximately 66.5% of the respondents were able to identify normal gingiva. Nursing assistants reported higher knowledge of gum normality than graduated nurses (p < 0.05). Most participants (99.8%) reported that oral hygiene was important during hospitalization, and 98.6% reported that dental professionals should perform routine examinations for inpatients (Table 2). No significant difference was found between the graduate and auxiliary nursing staff (p = 0.861). Only 28% of the participants reported knowledge in toothbrushing techniques.

Staff responses regarding the effects of PD on general health demonstrated that the topic was not widely discussed, and their knowledge ranged between moderate (49.3%) to poor (31.1%). Additionally, 74.6% of the participants believed that sugar consumption was the most important etiological factor for PD. Knowledge of the influence of PD on systemic diseases was reported by 96.7% of participants. A significative percentage of respondents (88.9%) expressed an interest in specific training to deepen their knowledge about the impact of PD on the oral cavity and general health.

The participants’ answers to questions regarding inpatients’ oral hygiene instructions are shown in Table 3. It was found that 70.8% had never asked their inpatients whether they had been diagnosed with PD. Only 27.5% reported that they routinely instructed patients on the importance of maintaining oral hygiene during hospitalization. A moderate proportion of the participants (49.6%) had never or rarely (25.5%) instructed their patients about the general health consequences of PD.

DISCUSSION

The results of this study showed that most nursing professionals were aware of the systemic consequences of PD and had the knowledge that oral infections could harm patients’ general health. These findings are similar to the results in previous studies¹⁶16 Herrera D, Sanz M, Shapira L, Brotons C, Chapple I, Frese T, et al. Association between periodontal diseases and cardiovascular diseases, diabetes and respiratory diseases: Consensus report of the Joint Workshop by the European Federation of Periodontology (EFP) and the European arm of the World Organization of Family Doctors (WONCA Europe). J Clin Periodontol. 2023 Jun;50(6):819-41. http://dx.doi.org/10.1111/jcpe.13807. PMid:36935200.
http://dx.doi.org/10.1111/jcpe.13807... . However, patients were almost never instructed about the systemic effects of "diseased gums”.

Poor oral health directly affects the quality of life and overall health of hospitalized patients³3 Cianetti S, Anderini P, Pagano S, Eusebi P, Orso M, Salvato R, et al. Oral health knowledge level of nursing staff working in semi-intensive heart failure units. J Multidiscip Healthc. 2020 Feb;13:165-73. http://dx.doi.org/10.2147/JMDH.S224453. PMid:32103976.
http://dx.doi.org/10.2147/JMDH.S224453... . The host immune response to PD can trigger dysbiosis, resulting in the progressive loss of tooth-supporting tissues¹⁶16 Herrera D, Sanz M, Shapira L, Brotons C, Chapple I, Frese T, et al. Association between periodontal diseases and cardiovascular diseases, diabetes and respiratory diseases: Consensus report of the Joint Workshop by the European Federation of Periodontology (EFP) and the European arm of the World Organization of Family Doctors (WONCA Europe). J Clin Periodontol. 2023 Jun;50(6):819-41. http://dx.doi.org/10.1111/jcpe.13807. PMid:36935200.
http://dx.doi.org/10.1111/jcpe.13807... . Moreover, periodontal pathogens can directly or indirectly trigger the development of systemic diseases³3 Cianetti S, Anderini P, Pagano S, Eusebi P, Orso M, Salvato R, et al. Oral health knowledge level of nursing staff working in semi-intensive heart failure units. J Multidiscip Healthc. 2020 Feb;13:165-73. http://dx.doi.org/10.2147/JMDH.S224453. PMid:32103976.
http://dx.doi.org/10.2147/JMDH.S224453... ,⁷7 Bui FQ, Almeida-da-Silva CLC, Huynh B, Trinh A, Liu J, Woodward J, et al. Association between periodontal pathogens and systemic disease. Biomed J. 2019 Feb;42(1):27-35. http://dx.doi.org/10.1016/j.bj.2018.12.001. PMid:30987702.
http://dx.doi.org/10.1016/j.bj.2018.12.0... . The presence of endotoxin-producing bacteria is directly associated with systemic diseases⁷7 Bui FQ, Almeida-da-Silva CLC, Huynh B, Trinh A, Liu J, Woodward J, et al. Association between periodontal pathogens and systemic disease. Biomed J. 2019 Feb;42(1):27-35. http://dx.doi.org/10.1016/j.bj.2018.12.001. PMid:30987702.
http://dx.doi.org/10.1016/j.bj.2018.12.0... . The risk of oral pathogens entering the bloodstream is part of the intricate relationship between PD and chronic conditions, such as diabetes, cardiovascular disease, kidney disease, and respiratory problems¹⁰10 Sanz M, Marco Del Castillo A, Jepsen S, Gonzalez-Juanatey JR, D’Aiuto F, Bouchard P, et al. Periodontitis and cardiovascular diseases: Consensus report. J Clin Periodontol. 2020 Mar;47(3):268-88. http://dx.doi.org/10.1111/jcpe.13189. PMid:32011025.
http://dx.doi.org/10.1111/jcpe.13189... . Additionally, the oral cavity structures, including the lips, tongue, mucosa, and gums, can serve as indicators of underlying systemic issues¹⁷17 Ahsan H. Biomolecules and biomarkers in oral cavity: bioassays and immunopathology. J Immunoassay Immunochem. 2019;40(1):52-69. http://dx.doi.org/10.1080/15321819.2018.1550423. PMid:30497330.
http://dx.doi.org/10.1080/15321819.2018.... .

It is valuable for the healthcare team to have knowledge and awareness of the systemic consequences of PD⁹9 Taşdemir Z, Alkan BA. Knowledge of medical doctors in Turkey about the relationship between periodontal disease and systemic health. Braz Oral Res. 2015;29:55. http://dx.doi.org/10.1590/1807-3107BOR-2015.vol29.0055. PMid:25885023.
http://dx.doi.org/10.1590/1807-3107BOR-2... . In this study, nurses' self-reported knowledge of the influence of PD on patients’ overall health was good. However, most had never applied this guidance to their patients.

The participants in this study reported the importance of oral hygiene during hospitalization. A similar result was found in a previous study that showed that nurses agreed that oral health should be a priority in patient care, although they found it difficult to maintain patients' oral hygiene¹²12 Saddki N, Mohamad Sani FE, Tin-Oo MM. Oral care for intubated patients: a survey of intensive care unit nurses. Nurs Crit Care. 2017 Mar;22(2):89-98. http://dx.doi.org/10.1111/nicc.12119. PMid:25349099.
http://dx.doi.org/10.1111/nicc.12119... . This difficulty may be related to challenges with toothbrushing. Some participants in this study had no knowledge about toothbrushing techniques. As demonstrated by a previous nurses are not trained regarding the proper toothbrushing techniques for cleaning patients' teeth¹⁴14 Coker E, Ploeg J, Kaasalainen S, Carter N. Nurses’ oral hygiene care practices with hospitalised older adults in postacute settings. Int J Older People Nurs. 2017 Mar;12(1):e12124. http://dx.doi.org/10.1111/opn.12124. PMid:27353475.
http://dx.doi.org/10.1111/opn.12124... .

Nursing care frequently uses technology to provide patient health support¹⁸18 Rantz MJ, Marek KD, Aud M, Tyrer HW, Skubic M, Demiris G, et al. A technology and nursing collaboration to help older adults age in place. Nurs Outlook. 2005 Jan-Feb;53(1):40-5. http://dx.doi.org/10.1016/j.outlook.2004.05.004. PMid:15761399.
http://dx.doi.org/10.1016/j.outlook.2004... . In healthcare, technology is commonly understood as the use of high technology equipment¹⁹19 Barnard A. Philosophy of technology and nursing. Nurs Philos. 2002 Apr;3(1):15-26. http://dx.doi.org/10.1046/j.1466-769X.2002.00078.x.
http://dx.doi.org/10.1046/j.1466-769X.20... . However, technology encompasses a range of professional skills, starting with soft technologies or interpersonal skills¹⁹19 Barnard A. Philosophy of technology and nursing. Nurs Philos. 2002 Apr;3(1):15-26. http://dx.doi.org/10.1046/j.1466-769X.2002.00078.x.
http://dx.doi.org/10.1046/j.1466-769X.20... ,²⁰20 O’Mathúna DP. Nursing ethics education: thinking, feeling, and technology. Nurs Clin North Am. 2022 Dec;57(4):613-25. http://dx.doi.org/10.1016/j.cnur.2022.06.009. PMid:36280299.
http://dx.doi.org/10.1016/j.cnur.2022.06... . Health care through soft-hard technologies includes the professional use of structured knowledge and does not require complex equipment²¹21 Souza EFDC, Pina-Oliveira AA, Shimo AKK. Effect of a breastfeeding educational intervention: a randomized controlled trial. Rev Lat Am Enfermagem. 2020 Sep;28:e3335. http://dx.doi.org/10.1590/1518-8345.3081.3335. PMid:33027400.
http://dx.doi.org/10.1590/1518-8345.3081... . Oral health and oral disease-related knowledge are soft-hard technologies necessary for nursing staff in the hospital environment²¹21 Souza EFDC, Pina-Oliveira AA, Shimo AKK. Effect of a breastfeeding educational intervention: a randomized controlled trial. Rev Lat Am Enfermagem. 2020 Sep;28:e3335. http://dx.doi.org/10.1590/1518-8345.3081.3335. PMid:33027400.
http://dx.doi.org/10.1590/1518-8345.3081... .

Knowledge of healthy gingival characteristics and possible pathological changes is important²²22 Leite RS, Marlow NM, Fernandes JK, Hermayer K. Oral health and type 2 diabetes. Am J Med Sci. 2013 Apr;345(4):271-3. http://dx.doi.org/10.1097/MAJ.0b013e31828bdedf. PMid:23531957.
http://dx.doi.org/10.1097/MAJ.0b013e3182... . Some participants demonstrated a lack of awareness regarding the normal gingival appearance. This may be a consequence of the lack of oral health content in the nursing curriculum¹1 Kim Y, Ku HM, Jun MK. Knowledge evaluation of oral diseases and perception of cooperation with dental experts for oral care of nurses in intensive care units in Korea: a preliminary study. Nurs Rep. 2023 Mar;13(1):528-38. http://dx.doi.org/10.3390/nursrep13010048. PMid:36976700.
http://dx.doi.org/10.3390/nursrep1301004... ,¹¹11 Adib-Hajbaghery M, Ansari A, Azizi-Fini I. Intensive care nurses’ opinions and practice for oral care of mechanically ventilated patients. Indian J Crit Care Med. 2013 Jan;17(1):23-7. http://dx.doi.org/10.4103/0972-5229.112154. PMid:23833472.
http://dx.doi.org/10.4103/0972-5229.1121... ,²³23 Andrade-Leite DB, Martins-Santos SC, Marques-Gomes SM, Oliveira IJ. Knowledge, attitudes and practices of nurses regarding oral hygiene of dependent inpatients. Enferm Clin (Engl Ed). 2023 Jan-Feb;33(1):22-9. http://dx.doi.org/10.1016/j.enfcle.2022.05.003. PMid:35680116.
http://dx.doi.org/10.1016/j.enfcle.2022.... ,²⁴24 Bhagat V, Hoang H, Crocombe LA, Goldberg LR. Australian nursing students’ perception, knowledge, and attitude towards oral healthcare of older people and associated factors: a national cross-sectional survey. BMC Nurs. 2023 Jun;22(1):190. http://dx.doi.org/10.1186/s12912-023-01366-x. PMid:37277753.
http://dx.doi.org/10.1186/s12912-023-013... . The knowledge gap in oral health also resulted in most participants not asking whether their patients had previously been diagnosed with PD.

Knowledge of the potential risks of PD to the health of hospitalized patients makes it essential to conduct continued preventive evaluations in hospital²⁵25 Duque AD, Malheiros Z, Stewart B, Romanelli HJ. Strategies for the prevention of periodontal disease and its impact on general health in Latin America. Section III: Prevention. Braz Oral Res. 2020 Apr 9;34(suppl 1):e025. https://doi.org/10.1590/1807-3107bor-2020.vol34.0025. PMid: 32294678.
https://doi.org/10.1590/1807-3107bor-202... . It is important for nursing teams to have comprehensive knowledge on oral health and oral diseases¹⁵15 Gibney J, Wright C, Sharma A, Naganathan V. Nurses’ knowledge, attitudes, and current practice of daily oral hygiene care to patients on acute aged care wards in two Australian hospitals. Spec Care Dentist. 2015 Nov-Dec;35(6):285-93. http://dx.doi.org/10.1111/scd.12131. PMid:26297474.
http://dx.doi.org/10.1111/scd.12131... . The present study demonstrated that the participants' knowledge of PD was rated as moderate or unsatisfactory.

Both participating groups, nurses and nursing assistants, believed that excessive sugar consumption was the primary causal factor of periodontal disease, which contradicts the scientific evidence²⁵25 Duque AD, Malheiros Z, Stewart B, Romanelli HJ. Strategies for the prevention of periodontal disease and its impact on general health in Latin America. Section III: Prevention. Braz Oral Res. 2020 Apr 9;34(suppl 1):e025. https://doi.org/10.1590/1807-3107bor-2020.vol34.0025. PMid: 32294678.
https://doi.org/10.1590/1807-3107bor-202... ,²⁶26 Santonocito S, Giudice A, Polizzi A, Troiano G, Merlo EM, Sclafani R, et al. A cross-talk between diet and the oral microbiome: balance of nutrition on inflammation and immune system’s response during periodontitis. Nutrients. 2022 Jun;14(12):2426. http://dx.doi.org/10.3390/nu14122426. PMid:35745156.
http://dx.doi.org/10.3390/nu14122426... . A patient’s diet influences the development of PD only when oral hygiene is insufficient or ineffective²⁵25 Duque AD, Malheiros Z, Stewart B, Romanelli HJ. Strategies for the prevention of periodontal disease and its impact on general health in Latin America. Section III: Prevention. Braz Oral Res. 2020 Apr 9;34(suppl 1):e025. https://doi.org/10.1590/1807-3107bor-2020.vol34.0025. PMid: 32294678.
https://doi.org/10.1590/1807-3107bor-202... . Moreover, sugar consumption is not a primary factor in the development of PD²⁶26 Santonocito S, Giudice A, Polizzi A, Troiano G, Merlo EM, Sclafani R, et al. A cross-talk between diet and the oral microbiome: balance of nutrition on inflammation and immune system’s response during periodontitis. Nutrients. 2022 Jun;14(12):2426. http://dx.doi.org/10.3390/nu14122426. PMid:35745156.
http://dx.doi.org/10.3390/nu14122426... . The nursing staff who participated in this study also misunderstood the etiologies of PD and caries, both of which are common in hospitalized patients²⁷27 Đorđević V, Jovanović M, Miličić B, Stefanović V, Đukić-Dejanović S. Prevalence of dental caries in hospitalized patients with schizophrenia. Vojnosanit Pregl. 2016 Dec;73(12):1102-8. http://dx.doi.org/10.2298/VSP150917111D. PMid:29341566.
http://dx.doi.org/10.2298/VSP150917111D... .

The importance of the presence of dental professionals in the inpatient monitoring team was an important finding in this study. This finding is consistent with the results of previous studies²⁸28 Araújo RJ, Oliveira LC, Hanna LM, Corrêa AM, Carvalho LH, Alvares NC. Perceptions and actions of oral care performed by nursing teams in intensive care units. Rev Bras Ter Intensiva. 2009;21(1):38-44. http://dx.doi.org/10.1590/S0103-507X2009000100006. PMid:25303127.
http://dx.doi.org/10.1590/S0103-507X2009... ,²⁹29 Hashem IW, Gillway D, Doshi M. Dental care pathways for adult inpatients in an acute hospital: a five-year service evaluation. Br Dent J. 2020 May;228(9):687-92. http://dx.doi.org/10.1038/s41415-020-1446-5. PMid:32385463.
http://dx.doi.org/10.1038/s41415-020-144... . Nearly 86% of the nursing staff working in intensive care units in the city of Belém, Brazil, reported benefits of having dental professionals in the hospital teams²⁸28 Araújo RJ, Oliveira LC, Hanna LM, Corrêa AM, Carvalho LH, Alvares NC. Perceptions and actions of oral care performed by nursing teams in intensive care units. Rev Bras Ter Intensiva. 2009;21(1):38-44. http://dx.doi.org/10.1590/S0103-507X2009000100006. PMid:25303127.
http://dx.doi.org/10.1590/S0103-507X2009... . However, most hospitals do not include dentists in their interdisciplinary teams²⁹29 Hashem IW, Gillway D, Doshi M. Dental care pathways for adult inpatients in an acute hospital: a five-year service evaluation. Br Dent J. 2020 May;228(9):687-92. http://dx.doi.org/10.1038/s41415-020-1446-5. PMid:32385463.
http://dx.doi.org/10.1038/s41415-020-144... .

The lack of knowledge and self-confidence of untrained nursing professionals results in inadequate patient management¹³13 Dagnew ZA, Abraham IA, Beraki GG, Mittler S, Achila OO, Tesfamariam EH. Do nurses have barriers to quality oral care practice at a generalized hospital care in Asmara, Eritrea? A cross-sectional study. BMC Oral Health. 2020 May;20(1):149. http://dx.doi.org/10.1186/s12903-020-01138-y. PMid:32434570.
http://dx.doi.org/10.1186/s12903-020-011... ,²³23 Andrade-Leite DB, Martins-Santos SC, Marques-Gomes SM, Oliveira IJ. Knowledge, attitudes and practices of nurses regarding oral hygiene of dependent inpatients. Enferm Clin (Engl Ed). 2023 Jan-Feb;33(1):22-9. http://dx.doi.org/10.1016/j.enfcle.2022.05.003. PMid:35680116.
http://dx.doi.org/10.1016/j.enfcle.2022.... ,²⁹29 Hashem IW, Gillway D, Doshi M. Dental care pathways for adult inpatients in an acute hospital: a five-year service evaluation. Br Dent J. 2020 May;228(9):687-92. http://dx.doi.org/10.1038/s41415-020-1446-5. PMid:32385463.
http://dx.doi.org/10.1038/s41415-020-144... . Most participants reported a desire for further training. Only a few participants answered differently, and this may be explained as perceiving oral hygiene practice for patients as unpleasant²³23 Andrade-Leite DB, Martins-Santos SC, Marques-Gomes SM, Oliveira IJ. Knowledge, attitudes and practices of nurses regarding oral hygiene of dependent inpatients. Enferm Clin (Engl Ed). 2023 Jan-Feb;33(1):22-9. http://dx.doi.org/10.1016/j.enfcle.2022.05.003. PMid:35680116.
http://dx.doi.org/10.1016/j.enfcle.2022.... , and a lack of time to do it³⁰30 Ghauri SK, Javaeed A, Chaudhry A, Khan AS, Mustafa KJ. Knowledge and attitudes of Pakistani intensive care unit nurses regarding oral care delivery to mechanically ventilated patients. J Pak Med Assoc. 2020 Jul;70(7):1203-8. http://dx.doi.org/10.5455/JPMA.5630. PMid:32799274.
http://dx.doi.org/10.5455/JPMA.5630... . Awareness and training should be offered to nursing staff and updated continuously in the hospital environment²2 Philip P, Villarosa A, Gopinath A, Elizabeth C, Norman G, George A. Oral health knowledge, attitude and practices among nurses in a tertiary care hospital in Bangalore, India: a cross-sectional survey. Contemp Nurse. 2019 Apr-Jun;55(2-3):261-74. http://dx.doi.org/10.1080/10376178.2019.1647790. PMid:31340719.
http://dx.doi.org/10.1080/10376178.2019.... ,²⁴24 Bhagat V, Hoang H, Crocombe LA, Goldberg LR. Australian nursing students’ perception, knowledge, and attitude towards oral healthcare of older people and associated factors: a national cross-sectional survey. BMC Nurs. 2023 Jun;22(1):190. http://dx.doi.org/10.1186/s12912-023-01366-x. PMid:37277753.
http://dx.doi.org/10.1186/s12912-023-013... .

This study has some limitations. The use of a convenience sample from a single teaching hospital limits the generalizability of the results. Additionally, the use of a self-administered questionnaire requires participant cooperation. Thus, there may have been a response bias due to favorable responses and data loss.

Strategies to overcome these issues may include comprehensive nursing training on oral care techniques for inpatients and hospital provision of all requisite materials and instruments for the optimal maintenance of patients' oral hygiene. Creating a dedicated daily schedule to guide and assist patients with oral hygiene practices and for assessing oral health as part of general health should also be considered.

CONCLUSION

Our study on nursing staff demonstrated a lack of knowledge regarding the presence, development, and prevention of periodontal disease. This may be due to a lack of specific training within nursing education. To address this, a well-structured training program with comprehensive guidelines on oral healthcare and hygiene of hospitalized patients should be considered in the nursing curriculum.

ACKNOWLEDGMENTS

This study was supported by grants from the Fundação de Amparo à Pesquisa de Minas Gerais (FAPEMIG), the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior- Brazil (CAPES) – Finance Code 001 and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) - INCT Saúde Oral e Odontologia - Grants n. 406840/2022-9.

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