J Clin Periodontol 2014; doi: 10.1111/jcpe.

12250

Oral health of patients under Lucas L. A. Sousa1, Wagner S. e.

Silva Filho2, Regina F. Mendes1,
! M. Moita Neto3 and Raimundo

short hospitalization period:

Jose
R. Prado Junior1
1
Postgraduation Program in Dentistry,

observational study
Federal University of Piau!ı (UFPI), Teresina,
Brazil; 2Department of Pathology and Dental
Clinics, Federal University of Piau!ı (UFPI),
Teresina, Brazil; 3Postgraduation Program in
Chemistry, Federal University of Piau!ı
(UFPI), Teresina, Brazil
Sousa LLA, Silva Filho WSe, Mendes RF, Moita Neto JM, Prado Junior RR.
Oral health of patients under short hospitalization period: observational study.
J Clin Periodontol 2014; doi: 10.1111/jcpe.12250.

Abstract
Objective: To assess the impact of hospitalization on the oral health status of
individuals hospitalized for a short period of time.
Material and Methods: This was an observational study of hospitalized patients.
The plaque index (PI), gingival index (GI) was measured at baseline (T0 – first
24 h of hospital admission), and at 3 (T1), 7 (T2), 14 (T3) days.
Results: One hundred and sixty-two patients were examined at baseline (T0), 35
examined at 3 days (T1), 23 at 7 days (T2) and 16 at 14 days (T3). The main rea-
son for loss of patients was hospital discharge. The mean PI increased at T1
(0.97–1.21; p < 0.001), at T2 (1.06–1.30; p < 0.007) and at T3 (1.19–1.44;
p < 0.03). Gingival index (GI) increased at T2 (0.74–0.96; p < 0.04) and at T3 Key words: hospitalization; inpatients; oral
(0.74–0.96; p < 0.02). health
Conclusion: Oral health, assessed through PI and GI, deteriorates after a short
period of hospitalization. Accepted for publication 6 March 2014

Hospitalization changes an individ- hygiene habits, such as tooth brush-
ual’s routine, causing stress and anx- ing (Carrilho Neto et al. 2011). The
iety due to the imminence of pain scenario is worse when a patient has
and discomfort and because patho- a physical limitation and/or the hos-
logical changes make the body more pital environment creates barriers or
fragile (Delfini et al. 2009). It also difficulties that interfere with the
tends to reduce patients’ self-esteem adoption of healthy oral health hab-
and they often neglect to care prop- its (Zhu et al. 2008).
erly for themselves. They lose moti- Poor oral hygiene contributes to
vation to carry out routine oral the development and maturation of
dental biofilm, the aetiological agent
Conflict of interest and source of
of most oral diseases. Pathogenic
funding statement
microorganisms in the dental biofilm
have been implicated in infectious
The authors of the manuscript had no and/or inflammatory processes that
conflict of interest during the develop- compromise the function of organs
ment of the study nor the publication and systems, contributing to increased
of its results. morbidity and mortality (Seneviratne
The study was funded by its authors.
et al. 2011). Thus, pre-existing oral
The first author received a scholarship
conditions of hospitalized patients
granted by CAPES - Brazil during his
master’s course.
can deteriorate or new conditions can
onset (Needleman et al. 2012). An
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
example are pulmonary infections
caused by microorganisms of the oral
cavity (Linden & Herzberg 2013).
Furthermore, failure in maintaining
adequate oral health status in the hos-
pital environment can negatively
affect the quality of life and the well
being of patients (Dhaussy et al.
2012).
Studies that assess the association
between hospitalization and oral
health have been conducted in inten-
sive care units (with critically ill
patients; Terezakis et al. 2011, Nee-
dleman et al. 2012); however, the
majority of hospitalized patients are
not treated in this environment.
Thus, the objective of this study
was to investigate the impact of hos-
pitalization on the oral health status
of patients hospitalized for a short
period of time in non-intensive care
1
2 Sousa et al.
units. Our hypothesis was that the
oral health of patients deteriorates
after hospitalization.
Materials and Methods
Study design and location
The study was carried out at one pub-
lic and one private hospital in the city
of Teresina, Piau!ı state, Brazil. It
assessed hospitalized patients who
were not in intensive care units. The
patients had received various diagno-
ses for elective hospitalization and
surgery, but had low levels of depen-
dency and physical limitations. The
private hospital had 16 beds and the
public hospital had 52, for this type of
hospitalization.
This study followed the guidelines
of Resolution 196/96 of the National
Health Council of Brazil and the
Declaration of Helsinki (2008), gov-
erning research involving human sub-
jects; it was approved by the Ethics
Committee of the Federal University
do Piau!ı – UFPI under protocol
(05976112.9. 0000.5214).
Sample
All patients admitted to non-intensive
care units were considered to be
potential study participants. They
were recruited within the first 24 h of
admission to evaluate oral changes
after hospitalization.
The hospitals were selected based
on the nature of the services pro-
vided (one public and one private
service); however, both hospitals
offered the same type of medical ser-
vices. The examiner recruited a con-
venience sample over a 3-month
period.
Eligibility criteria
Inclusion criteria for participation in
the study were as follows: being over
18 years and having more than six
teeth. Patients were ineligible for the
study when: their health condition
meant examination of the oral cavity
was not possible; they could not ade-
quately respond to the questionnaire
(e.g., psychological/cognitive disor-
ders or being unconscious); they
were using medications with a
proven adverse effect on periodontal
tissues, such as phenytoin and carba-
mazepine; they were undergoing
radiotherapy or chemotherapy; or
they were undergoing orthodontic
treatment. Patients who had less
than six teeth were excluded from
the study after clinical examination.
Consent/assent
Those patients who fulfilled the
above mentioned criteria were ver-
bally and individually invited to take
part in the study after an explanation
of the objective and the methods to
be adopted. They had to sign a con-
sent form before answering the ques-
tionnaire and undergoing the clinical
examination, according to the inter-
national guidelines for research with
human beings.
Data collection
Data collection took place from June
to September 2012 for the private
hospital, and from October to
December 2012 for the public hospi-
tal. Patients were invited to partici-
pate in the study, which consisted of
two stages: Stage 1 – Answering a
questionnaire addressing aspects of
socioeconomic and demographic
variables, and Stage 2 – the intra-
oral examination.
Data collection from the questionnaire
Each participant’s socioeconomic and
demographic data were collected
along with his or her history of previ-
ous oral and medical health. Other
collected data included: routine tooth
brushing habits before and after hos-
pitalization; and the existence of bar-
riers or difficulties in the hospital that
hindered them from carrying out oral
health care procedures. During the
interview, patients were in a hospital
bed and remained in a comfortable
position.
Clinical intra-oral examination
After the interview, clinical examina-
tion was carried out using an oral
mirror and periodontal probe (North
Carolina Probe, Milennium!, Cerri-
tos, CA, USA) under artificial light-
ing (a flashlight). Teeth were dried
with gauze pad for better visualiza-
tion of clinical parameters. Patients
were preferably examined lying on
the bed so that their oral cavity was
easy to visualize. A single dentist
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
carried out the evaluations. A helper
held the flashlight during the exam-
inations. The patients were not
informed of their oral health status
and no oral health orientation was
given to them.
Outcome assessment
The plaque index (PI) (Silness & Loe
1964) was used to assess the amount
of biofilm. The patient’s teeth were
individually scored according to the
PI as follows:
0 = No plaque.
1 = A film of plaque adhering to
the free gingival margin and adja-
cent area of the tooth. The plaque
may be seen in situ only after
application of disclosing solution
or by using the probe on the
tooth surface.
2 = Moderate accumulation of
soft deposits within the gingival
pocket, or the tooth and gingival
margin which can be seen with
the naked eye.
3 = Abundance of soft matter
within the gingival pocket and/or
on the tooth and gingival margin.
Four sites per tooth (mesial, dis-
tal, buccal and lingual) were assessed.
The mean of the four scores was the
tooth’s score. The mean score of all
teeth was the patient’s mean score.
Thus, the means for each observation
period were compared to each other.
The gingival index (GI) was pro-
posed by L€ oe & Silness (1963) and
modified by L€ oe (1967) and was
used to score gingival inflammation
on probing, as follows.
Modified gingival index (L€ oe
1967)
0 = Healthy gingivae.
1 = Gingivae look inflamed, but
do not bleed when probed.
2 = Gingivae look inflamed and
bleed when probed.
3 = Ulceration and spontaneous
bleeding.
Four sites (mesio buccal, central
buccal, disto buccal and lingual) of
each tooth were probed. The mean
score of the four sites was the
tooth’s score and the individual’s
score was the mean score of all
teeth. The mean of the observation
period was the mean score of all
 Oral health of hospitalized patients 3

individuals, which were compared
with each other.
Examiner’s training
The examiner was trained and cali-
brated by a Periodontist on how to
conduct the clinical examinations
and how to score the indices. During
the first 2 weeks of the data collec-
tion, at baseline examination one in
10 patients was re-examined at the
end of the data collection shift to
calculate the intra-examiner agree-
ment index. Five patients were re-
examined and the agreement indices
were 68.8% for the PI and 72.1%
for the GI.
Efforts to address potential sources of
bias
In our study, the same examiner was
assigned to both baseline and fol-
low-up visits to minimize variability.
As a consequence, the patient’s iden-
tity could not be masked from the
examiner; therefore, changes in the
primary outcome might be due to
assessment bias. The method found
to minimize this bias was to prevent
the examiner from having access to
the data between visits.
Evaluation periods during hospitalization
After examination at baseline (T0 –
n = 162), the follow-ups took place
exactly on the third (n = 32 – T1),
seventh (n = 23 – T2) and fourteenth
(n = 16 – T3) of hospitalization.
During the study, some patients
were discharged; therefore there was
an unintentional reduction in the
sample after T0. At each observation
period, the variables of a patient
who remained in the study were
compared with his/her own variables
that had been recorded at the previ-
ous time period.
Samples t-test) and non-parametric
tests (Mann Whitney and Wilcoxon).
The significance level adopted was
95% (p < 0.05).
Results
One hundred and ninety-eight
patients were initially examined. One
hundred and sixty-two (81.8%) were
selected according to the inclusion
criteria; 51.9% (n = 84) of them
were at the private hospital and
47.1% (n = 78) at the public hospi-
tal. Sixteen patients were assessed
throughout the four observation
periods (Fig. 1).
There was no statistically signif-
icant gender predominance in the sam-
ple (p = 0.776 – Table 1). The mean
age of patients was similar in both
the private (51.1 ! 18.8 years) and
public hospital (47.7 ! 17.9 years;
p = 0.205). However, patients admit-
ted to the private hospital had a higher
educational level (p < 0.001) and
income (p < 0.001) than patients in
the public hospital (Table 1).
The diagnosed systemic diseases
of the patients were grouped accord-
ing to the International Classification
of Diseases ICD-10. The private hos-
pital had more hospitalizations due
to digestive diseases (15.2%, n = 30),
and the public hospital had more
The patients
analized within 24 3 days
h of admission. (n = 32 – T1),
(n = 16 – T0),
Fig. 1. Patients analysed in the observational study.
Table 1. Socio-demographic characteristics of the sample according to type of hospital
Variable
hospitalizations due to musculoskele-
tal system and connective tissue dis-
eases (20.7%, n = 41; p < 0.001).
Patients at the different hospitals
had the same oral health status at
baseline (Table 2). The mean number
of teeth per patient was 18.8 (SD 8.6
– minimum six teeth and maximum
28 teeth). The PI increased at the first
observation period and onwards
(Table 3). After 3 days (T1), the PI
of the patients at the private hospital
was significantly higher (p < 0.018).
Patients remained in the public hospi-
tal for longer, which enabled a longer
observation period. The GI increased
at 07 days (T2; p < 0.04) and at
14 days (T3; Table 4).
There was a statistically signifi-
cant reduction (p < 0.01) in the
frequency of daily tooth brushing
(as reported by the patients) during
hospitalization, when compared
with the frequency before hospital-
ization (Table 5). Despite the fact
that 72% of patients reduced their
daily tooth brushing frequency,
82.7% reported no type of barrier
that compromised the implementa-
tion of tooth brushing during hospi-
talization (Table 6). Neither of the
studied hospitals had an oral health
care protocol for non-intensive
care unit patients at the time of this
study.
7 days 14 days 21 days
(n = 23 – T2), (n = 16 – T3) (n = 9 – T4)
Private Public p Total
hospital hospital

% n % n % n
Data analysis
Gender
The collected data were processed Male 47.6 40 50 39 0.205 48.8 79
using SPSS software (Statistical Pack- Female 52.4 44 50 39 51.2 83
age for Social Sciences, Armonk, NY, Total 100 84 100 78 100 162
USA) version 15.0 for Windows. Schooling (years of study) 9.86 84 5.15 78 <0.001* 7.6 162
Quantitative variables were assessed Income
for normality using the Komolgorov– Less than US$ 500 41.4 67 48.1 78 <0.001* 89.5 145
Smirnoff test. For qualitative vari- Between US$ 500 and 1500 9.3 15 0 0 9.3 15
Above US$ 1500 1.2 2 0 0 1.2 2
ables, chi-squared test and Fisher’s
Total 51.9 84 48.1 78 100 162
exact test were used. To compare
means we used parametric (Paired *Statistically significant difference.

© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
4 Sousa et al.

Table 2. Oral health status at T0, accord- Table 5. Sample distribution according to tooth brushing frequency before and after hospi-
ing to the type of hospital talization
Oral Private Public Total p Before After Total
health hospital hospital
index None Once Twice Three times
or more
PI
Mean 1.03 1.14 1.08 0.244 Once
SD 0.69 0.50 0.60 n 11 3 0 0 14
GI % 6.8 1.9 0 0 8.6
Mean 1.07 1.18 1.12 0.436 Twice
SD 0.76 0.65 0.71 n 33 15 21 5 74
% 20.4 9.3 13.0 3.1 45.7
GI, gingival index; PI, plaque index. Three times or more
n 31 15 12 16 74
% 19.1 9.3 7.4 9.9 45.7
Table 3. The PI according to hospitaliza- Total
tion time n 75 33 33 21 162
PI Mean n Standard p % 46.3 20.4 20.4 13.0 100.0
deviation
Wilcoxon (p < 0.001).
T0 0.97 35 0.42 <0.001*
T1 1.22 35 0.42
T1 1.06 23 0.32 0.007* during hospitalization in non-ICUs. Table 6. Sample distribution according to
T2 1.30 23 0.57 Non-ICU patients are more numer- the barrier or difficulty that precludes oral
T2 1.20 16 0.40 0.03* ous than ICU patients and are usu- hygiene procedures during hospitalization
T3 1.44 16 0.54 ally admitted for a shorter period of Barrier n %
time.
PI, plaque index.
*Statistically significant difference.
One of the possible causes of the Lack of adequate place 3 1.9
oral health status deterioration was for oral hygiene
the reduction in tooth brushing and Physical impairment 4 2.5
flossing frequency. Many hospital- Difficulty to get to 21 13.0
Table 4. The GI according to hospitaliza- the washroom
tion time ized patients reported brushing their
No barrier or difficulty 134 82.7
teeth daily, however, with a lower Total 162 100.0
GI Mean n Standard p frequency than before hospitaliza-
deviation tion. The lower frequency may have
T0 0.94 35 0.60 0.471 caused dental biofilm to accumulate,
T1 0.99 35 0.58 which leads to the onset of or the Other possible factors that might
T1 0.89 23 0.60 0.382 increase in gingival inflammation, as have contributed to PI and GI
T2 0.94 23 0.62 seen from the PI and GI increases. increases are pre-existing systemic con-
T0 0.79 23 0.61 <0.04* Surprisingly, the PI increased even ditions and the use of medication dur-
T2 0.94 23 0.62 among the patients in the private ing the hospitalization period. Both
T2 0.74 16 0.45 <0.02* hospital, despite the fact that they factors have the potential to alter the
T3 0.96 16 0.58
had a higher schooling level and a oral environment and the normal sym-
GI, gingival index. higher income. It is important to biotic relationship of the host with its
*Statistically significant difference. control dental biofilm control to pre- resident microorganisms (Marsh &
vent oral diseases (Seneviratne et al. Devine 2011). Furthermore, stress,
2011). anxiety and discomfort during hospi-
One limitation of the study was talization also have a negative impact
Discussion
the number of drop-outs throughout on oral health. (Akcali et al. 2013).
Short-term hospitalization at non- the observation periods. This seems Individuals with strong personality
intensive care units had a negative to be a drawback that is also true traits are better equipped to cope with
impact on the oral health status of of other studies (Needleman et al. stressful situations (such as hospital-
patients, corroborating studies that 2012, Sachdev et al. 2013). How- ization) and have a better periodontal
were carried out at intensive care ever, we addressed this issue by response (Sam & Keung Leung 2006,
units (ICU; Fourrier et al. 1998, comparing the individual in one Preeja et al. 2013). However, the
Dennesen et al. 2003, Munro et al. given observation period to him/her- abovementioned factors (medication
2006, Needleman et al. 2012). This self, instead of to the entire sample use, stress and anxiety levels) were not
study is unprecedented because it of the previous observation period. assessed in this study.
assesses non-ICU patients rather Furthermore, as the frequency of Another surprisingly revealing
than ICU patients. Therefore, this daily tooth brushings significantly datum of the study was that the vast
study contributes to address the reduced after hospitalization, there majority of the sample reported no
existing scarcity of information in was no reason to believe that a lar- external barriers that prevented them
the literature (Sj€
ogren 2011), regard- ger sample would have produced from carrying out their usual oral
ing the oral health status of patients different results. health care procedures. Physical
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

barriers or inadequate infrastructure,
such as the failure to provide wash-
rooms, can make it difficult to per-
form oral health care procedures.
Therefore, it is likely that the daily
tooth brushing frequency fell
because of psychological factors,
such as the patients worrying about
their health problem, as this reduc-
tion cannot be explained by the fact
that they were physically limited by
their illness.
This study found that the hospi-
tals had no policies in place for
routine oral health practices, and
that no members of the multidisci-
plinary hospital teams assessed the
patients’ oral health conditions dur-
ing the hospitalization period. A
properly executed protocol could
help to maintain, or improve the
oral health status of the patients.
To implement such a protocol, a
patient’s oral needs must be assessed
(Costello & Coyne 2008). However, it
is difficult to implement oral health
protocols in hospitals due to the lack
of information among the staff
regarding oral health, the inadequate
training of nurses and the fact that
these institutions do not have the
right equipment to provide patients
with proper oral hygiene (Chan &
Hui-Ling Ng 2012).
Oral hygiene promotion measures
could benefit those patients with no
physical impairment during hospital-
ization, thus creating a healthy oral
environment even in the short term
(Hausen 2005). Furthermore, offer-
ing psychological support to patients
with low self-esteem, and emphasiz-
ing the importance of good hygiene
habits, could also prevent the deteri-
oration of oral health (Renz et al.
2007).
Patients who are bed bound, are
unable to move or have physical dis-
abilities would benefit from an oral
care protocol carried out by a prop-
erly trained professional from the
nursing team. The dentist could work
together with the hospital’s multi-
professional team, either by applying
the oral care protocols, by supervising
such activities or by aiding the nurs-
ing team in implementing the proto-
cols (Kuramoto et al. 2011). In fact,
promoting oral health may play an
important role in improving overall
health and have a positive impact on
the quality of life of these patients
(Davies & Davies 2008).
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Oral health of hospitalized patients
Further analysis would be needed
to assess the susceptibility of specific
groups of patients to oral disorders
during the hospitalization period.
Furthermore, studies that document
quantitative and qualitative bacterial
changes in the oral cavity of patients
hospitalized outside the ICU envi-
ronment and the impact on tissue
response should also be encouraged.
Interventional studies should also be
designed to assess the effect of oral
health programs that aim to create
good hygiene habits during hospital-
ization.
Conclusion
The oral health status of hospitalized
patients deteriorated after short peri-
ods of time. This was evident from
the increase in dental biofilm and the
increase in gingival inflammation.
The implementation of oral care
protocols for patients hospitalized in
non-ICUs, and the promotion of
oral health measures could be used
to prevent this scenario.
Acknowledgements
We thank the board of directors of the
hospitals involved in the study who
authorized the use of the hospitals, the
professionals that made the study pos-
sible, CAPES for granting a scholar-
ship for the development of this study
and Jonathan Spottiswoode for the
translation of the manuscript.
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Clinical Relevance
Scientific rationale for the study:
Studies have shown that the oral
health status of hospitalized patients
deteriorates. However, few studies
have provided data on the oral
health status of patients who are
not under hospital intensive care.
Terezakis, E., Needleman, I., Kumar, N., Moles,
D. & Agudo, E. (2011) The impact of hospital-
ization on oral health: a systematic review.
Journal of Clinical Periodontology 38, 628–636.
Zhu, H. W., McGrath, C., McMillan, A. S. & Li,
L. S. W. (2008) Can caregivers be used in
assessing oral health-related quality of life
among patients hospitalized for acute medical
conditions? Community Dentistry and Oral
Epidemiology 36, 27–33.
Principal findings: The plaque index
increased at 3 days and gingival
index increased at 7 days of hospi-
talization.
Practical implications: Because oral
health deteriorates, patients would
benefit from effective oral health
care, which could be easily imple-
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Address:
Raimundo R. Prado J! unior
Department of Restorative Dentistry
Federal University of Piau!ı
Rua Wilson do Egito Coelho 3655 Ininga –
Teresina – Piau!ı 64003-000
Brazil
E-mail: rosendo_prado@ig.com.br
mented through the creation of
an oral health protocol. Barriers
to implementation must be consid-
ered.