SENSITIVITY OF BEDSIDE ORAL EXAM (BOE) AND LITMUS IN EVALUATING

ORAL CARE IN PATIENTS WITH LOSS OF CONSCIOUSNESS: A INTEGRATIVE

REVIEW

Awal Darmawan1, Ariyati Amin2, Selviani Ice Rerung3, Rosydah Arafat4, Titi Iswanti Afelya5

1
Student of magister nursing programe Hasanuddin University Makassar, Indonesia
2
Student of magister nursing programe Hasanuddin University Makassar, Indonesia.
arie.ns.08@gmail.com. +6285399876910
3
Student of magister nursing programe Hasanuddin University Makassar, Indonesia
4
Lecturer at Hasanuddin University Makassar, Indonesia
5
Lecturer at Hasanuddin University Makassar, Indonesia

Corresponding Author: Rosydah Arafat

1
 SENSITIVITY OF BEDSIDE ORAL EXAM (BOE) AND LITMUS IN EVALUATING
ORAL CARE IN PATIENTS WITH LOSS OF CONSCIOUSNESS: AN INTEGRATIVE
REVIEW

Abstract

Aim : To see the sensitivity of the Bedside Oral Exam (BOE) and litmus paper in evaluating a
patient's oral hygiene.
Method : An integrative review design was used. Electronic databases used are Pubmed, Science
Direct, Proquest and Google Scholar. The research was published in English between 2010
and 2019. The studies reviewed were studies of the Bedside Oral Exam (BOE) and litmus
paper related to oral hygiene care.
Result : Five articles were identified and included in this review: 1 study with the descriptive
case method, 1 study with prospective observational study and 3 studies with literature
review method. Of the five journals reviewed, three studies described the Oral Care
Assessment Tools "Bedside Oral Exam (BOE) capable of assessing and guiding oral care.
Two other studies describe litmus paper as having a role in detecting oral pathogenic
bacteria characterized by pH levels of the oral mucosa through changes in colour on litmus
paper.
Conclusion : Bedside Oral Exam Assessment (BOE) and litmus paper can be used by nurses as a
tool to detect oral health conditions, especially in patients with loss of consciousness. This
method is not only easy and can be done independently by nurses, but also the BOE
method also provides cost-effective benefits. So it is very possible to become one of the
evidence base care in oral care procedures for patients with loss of consciousness.
Therefore, nurses easily carry out assessments so nurses will quickly and accurately find
out the patient's oral care needs.

Keywords: Unconsciousness/Neurological patients, Bedside Oral Exam, Litmus Paper, Oral

Hygiene, oral care

INTRODUCTION
Oral health problems are one of the problems that often occurs in patients who are treated
in intensive care with decreased awareness, use of medical devices (ventilarors, NGT, etc.), and
patients who have neurological disorders (Prendergast, 2012), as well as in elderly patients (Anil
et al., 2016). Oral health problems include oral assessments, namely evaluation of the tongue,
lips, saliva, teeth, gums, bad breath, mucous membrane conditions (Celik & Eser, 2017).
Complications that can arise if oral health is not treated properly are cardiovascular
problems such as endocarditis, where in fact poor oral hygiene has been explored as a
mechanism for transient bacteremia from dental procedures and is also a factor causing bacterial
endocarditis for individuals with abnormal heart valves (Prendergast, 2012), lung problems such
as pneumonia (Ventilator Associated Pneumonia), where poor oral hygiene can stimulate an
inflammatory response to its state, contributing to the pathogenesis of pneumonia (Scannapieco,
Bush, & Paju, 2003; Sumi et al., 2003; Terpenning, 2005), as well as infections of the central
nervous system where destructive periodontal disease, oral abscesses, or both have been
identified as causative factors in various reports of cerebral abscess development (Mueller et al.,
2009; Rahamat-Langendoen et al., 2011).
Oral care methods/assessments that have been carried out by several studies have proven to
reduce the incidence of complications due to oral hygiene problems, giving patients comfort and
relief (Prendergast, Jakobsson, Renvert, & Hallberg, 2012; Yildiz, Durna, & Akin, 2013). The
Bedside Oral Exam Assessment (BOE) method is a method that can be applied in oral care,
which is a revision of the Oral Assessment Guide (OAG) method, and the BOE method has been
used in identifying oral hygiene in patients with neurological disorders. The total BOE score
ranges from 8 (very good oral health) to 24 (poor oral health) with a systematic assessment so
that nurses are easy to apply this method (Prendergast et al., 2012).
In the BOE method, the "Voice" items included in the original OAG (Eilers et al., 1988),
were replaced with the "Smell" category. The foul odour formed from bacteria is most often
found on the surface of the back of the tongue and serves as an indicator of oral health
(Outhouse, Al-Alawi, Fedorowicz, & Keenan, 2016).
In addition to using the Bedside Oral Exam (BOE), there is one indicator that can be used
in determining the oral hygiene of patients, namely by using litmus paper (Tram et al., 2016).
Litmus paper is used to determine the Potential of Hydrogen (PH) or a measure to describe the
degree of acidity or alkali content of a solution. Changes in colour on litmus paper will indicate
the pH level of the solution, the lower the acidity level will facilitate the growth of bacteria in the
mouth. Litmus paper is the most practical, simple, low-cost acid-base indicator and broad
adaptability so that it is easy to use (Tram, Kanda, Salena, Huan, & Li, 2014). Litmus paper can
be considered as a portable sensor that can help in medical surveillance measures by minimizing
the use of resources. The colourimetric sensor on litmus paper is an attractive option because
colour changes can be easily detected with both eyes. A litmus test for pH is an accurate,
inexpensive, simple, fast, effective colourimetric sensor and has been widely used today (Tram et
al., 2016).

AIM
To see the sensitivity of the Bedside Oral Exam (BOE) and litmus paper in evaluating a
patient's oral hygiene. Then more specifically provide information on the best tools that can be
used to evaluate oral hygiene in patients with decreased consciousness. Therefore, based on the
results of this review, it is expected that in the future it can be used as EBN in the
implementation of oral care in patients with reduced awareness, especially in the stage of
assessment/evaluation of patient oral hygiene.

METHODS
Design
An Integrative Review

Eligibility Criteria
The formulation of questions follows the PICO guidelines (patient, intervention,
comparison/control and outcome), while the PICO in this article is P: Decreased Awareness, I:
Bedside Oral Exam Assessment, C: Litmus Paper, O: Oral Hygiene. A literature search was
carried out to identify all the Bedside Oral Exam Assessment and Litmus Paper clinical trials.
Electronic databases used are PUBMED, Google Scholar, Science Direct and Proquest. All types
of studies that have been published between 2010 and 2019 have been searched. The search
terms are The Bedside Oral Exam Assessment, Oral Care, Litmus Paper, Unconsciousness,
Neurological Patients. All potentially eligible studies are taken, and full papers are reviewed to
determine whether they meet the selection criteria. The author also manually checks the
reference list from relevant reviews and includes studies to take additional studies that are
potentially eligible. Search keywords are based on the database in the abstract title (Table 1).

Table 1. Description of Keywords Used in Literature Search Using the PICO Method
PICO Components
P Unconsciousness OR Neurological Patients
I Bedside Oral Exam
C Litmus Paper
O Oral Hygiene
PICO (population, intervention, comparison, and outcome)

Search Strategy
This review was guided by the definition of Medical Subject Headings (MeSH). The search
terms were as follows:
(((((((unconsciusness[MeSH Terms]) OR [MeSH Terms]) OR neurological patients[MeSH
Terms]) AND bedside oral exam[MeSH Terms]) AND litmus paper[MeSH Terms]) AND oral
hygiene[MeSH Terms]) OR [MeSH Terms] oral care.
A copy of the literature that met the inclusion criteria and identified during the search was used
for data synthesis. The literature found in the reference list was considered to be taken as
material for the literature review as long as the literature was relevant.

Study Selection inc. PRISMA flow diagram

This literature was analyzed using PRISMA guidelines for systematic review (Moher, Liberati,
Tetzlaff, Altman, & Group, 2010).
A total of 95 articles were identified from four literature search data published from 2010-2019;
All research focuses on humans and deals with research questions. The author evaluates all
articles independently identified for inclusion in a systematic review. Of the 95 potential articles,
90 were excluded because 10 articles were double published, 20 articles were not full text, 57
articles did not fit the research question, 1 article was not in English, and 2 articles were not
research results. Thus resulting in 5 studies reviewed by the author.
The five studies were published between 2013 and 2018 with a research design: 1 study with the
descriptive case method, 1 study with prospective observational study and 3 studies with
literature review method. The 5 studies that met the criteria are summarized in Table.5 by
describing the authors, year of publication, study location, purposes, sample, intervention,
outcome measurement, and research results.

Evaluation of Quality of Articles

Quality assessments were performed separately by three reviewers (AD, AA, SIR), and
disagreements were discussed. The methodological quality of selected studies were assessed with
the critical appraisal tools of the JBI (table 2,3,4). Disagreement regarding quality of studies for
their inclusion was resolved by discussion between the researchers (AD, AA, SIR).

Data extraction
Articles selected for full-text review and analysis are mapped to identify the most relevant
categories. Three authors perform data extraction using a data extraction sheet. This list contains
information about the author, country of origin, research design, study objectives, samples,
interventions, outcomes measurement and research results. After complete the mapping process,
we synthesize the results for summary findings associated with the observed variables.

RESULT
Five studies reviewed by the author were published between 2013 and 2018 with a research
design: 1 study using the Descriptive Case method, 1 study with a prospective observational
study and 3 studies using the review literature method. Study characteristics are clearly presented
in Table 5. Three studies describe the intervention of The Bedside Oral exam assessing and
guiding oral care in patients (Kothari et al., 2016; Prendergast & Hinkle, 2018; Prendergast et al.,
2013), two other studies describe litmus paper as having a role in detecting pathogenic bacteria
by changing PH through changes in color on paper litmus (Tram et al., 2014, 2016).

Bedside Oral Exam (BOE)

The BOE protocol was assessed as consisting of 8 categories (Swallow, lips, tongue, saliva,
mucous meembranes, gingiva, teeth or dentures and odor), the evaluation method was stated in
descriptive and numerical statements. The assessment is carried out in each category that is
evaluated by giving 1 point for normal (healthy), 2 points for moderate function loss and 3 points
for severe function loss. BOE scores ranging from 8 points descriptively for very good oral
health and 24 points for poor oral health.
BOE assessment carried out in post stroke patients and head injury patients while rehabilitation
is very effective for nurses in assessing and guiding oral care provided (Kothari et al., 2016;
Prendergast & Hinkle, 2018). In a study conducted by Predergast (Prendergast et al., 2013),
explaining the BOE protocol in oral care was carried out in two stages. Phase 1 of the
preparation, namely educational planning including training, color coding, pictures showing oral
health and the creation of a series of 'frequently asked questions'. The BOE was also entered into
the medical record as an additional vital sign for each patient. BOE's cumulative score as a guide
to oral care therapy for the next shift. Phase 2 implementation, steps for oral health assessment
based on the BOE total score. Non-intubating patients with good oral health scores (BOE 8-10)
receive a basic oral care protocol consisting of erosion of the tongue, brushing with a pediatric
toothbrush and a thin layer of petroleum jelly applied to the lips twice daily. If a patient has
sufficient oral health disorders (BOE 11-14), mucosal care is performed every 4 hours in
addition to the basic oral care protocol. All intubated patients, or patients with significant
damage (BOE 15-24), received an electric toothbrush. Staff are instructed to tilt the toothbrush
towards the gums at an angle of 45o so that the toothbrush head can clean the teeth surface and
gum line effectively. One hour after brushing, a chlorhexidine-soaked swab was applied to the
entire oral cavity. Mucosal care is given every 2 hours for this patient.
Picture 1. Bedside Oral Exam (BOE)
 Picture 2. The Barrow OralCare Protocol

Litmus Paper
Bacterial examination can be done by looking at an increase in pH in the mouth, which can be
detected using litmus paper. The use of litmus paper is very simple, efficient, economical (lower
cost), and extensive adaptability (Tram et al., 2014). In the study of E. coli bacteria in food and
water, litmus paper can detect with bacteria within 10 minutes where there is a color change on
litmus paper by determining the sensitivity of the test using red phenol (Tram et al., 2014).
According to Tram's 2016 study, 107 E. Coli Cells produced a gradual increase in pH by 3 units
within 10 minutes, conversely if there were no E. Coli there was no change in pH (Tram et al.,
2016). This research has never been done on human saliva so further research needs to be done,
and the results of this study can only be found E.Coli bacteria while other bacteria can not be
found using litmus paper. As for humans, especially in the oral cavity certainly there are many
kinds of bacteria that can affect human health when ill. Pneumonia is caused by a number of
infectious agents including viruses, bacteria and fungi, the most common being streptococcus
pneumonia which is a common cause in children and the second common cause is bacterial
pneumonia (Haemophilus influenzae) as well as in HIV patients (WHO, 2019).
Thus litmus paper is used to determine the Potential of Hydrogen (PH) or a measure to describe
the degree of acidity or alkali content of a solution. Changes in color on litmus paper will
indicate the pH level of the solution, the lower the acidity will facilitate the growth of bacteria in
the mouth. Litmus paper is the most practical, simple, low cost acid base indicator and broad
adaptability so that it is easy to use.

DISCUSSION
Correspond of outcomes with existing knowledge
This integrative review aims to identify new evidence of effective interventions / assessments in
oral care to reduce the incidence of existing complications. Five studies were identified and
reviewed in this review. Three studies have shown BOE assessment to be effective in assessing
oral hygiene of patients and as a guide in oral care. From these three studies, the individuals
evaluated were those who had oral health problems that made it possible for them to not be able
to carry out treatments related to illnesses such as post stroke problems, head injuries and
patients with total care (Kothari et al., 2016; Prendergast & Hinkle, 2018; Prendergast et al.,
2013).
BOE assessment provides benefits in oral care. BOE provides narration and visual references in
the practice of oral health assessment, BOE is fast, easy to do / dependent on images and clinical
symptoms, seen objectively through the eyes of the nursing staff (trained), BOE score results are
significantly related to the results of periodontal status examination with p = 0.01, BOE guides
comprehensive oral care that is cost effective and effective in reducing VAP. The weakness of
the BOE assessment is that this assessment is difficult for patients who have a device such as an
endtracheal tube attached.
Indicators of oral hygiene assessment are carried out with litmus paper. Two studies show the
advantage of using litmus paper, which is bacterial detection translates into an increase in PH
through simple color changes, low cost, fast, effective and broad adaptability so that it is easily
applied, especially in developing countries (Tram et al., 2014, 2016). One of the weaknesses of
litmus paper is that the color changes shown cannot accurately indicate the pH level of the
solution.
From this explanation, this evidence shows that assessment of BOE and litmus paper as
indicators can be applied to patients with oral health problems as a guide in oral care to prevent
and reduce complications.

Limitation
This integrative review still has limitations as the sample size is still small, therefore further
studies should pay more attention in determining the sample so that the study can show more
significant results.

CONCLUSION
Bedside Oral Exam Assessment (BOE) can be used by nurses as a tool to detect oral health
conditions, especially in patients with loss of consciousness. These methods are not only very
easy and can be done independently by nurses, but also BOE also provides cost-effective
benefits as well as litmus paper can be used as an indicator in detecting oral pathogens. So it is
very possible to become one of the evidence base care in oral care procedures for patients with
loss of consciousness. Because nurses easily conduct assessments, nurses will quickly and
precisely find out the patient's oral care needs.
ETHICAL ASPECTS AND CONFLICT OF INTEREST
The author states there is no conflict of interests.

ACKNOWLEDGEMENTS
The authors thank all who participated in writing this integrative review.

AUTHOR CONTRIBUTIONS
Concept and design (RA,AD,AA,SIR), analysis and data interpretation (AD,AA,SIR ),
preparation of the manuscript (AD,AA,SIR), manuscript critical revision (RA,AD,AA,SIR), final
revision (RA,AD,AA,SIR,TIA).

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Google Scholar
PubMed Science Direct Proquest

25 5 5 60

Identified article
Identification (n= 95)

Exclusion:
Double publikasi (n=
10)
Screening Screening Results
(n= 85)

Exclusion:
No Full Text (n = 20)
Not according to
research questions (n =
57)
Non-English: 1

In accordance with the research

Eligibility
question
(n= 7)

Exclusion:
Not research results (n
= 2)

Inclusion
Inclusion article (n= 5)

Figure 1. Study Selection and Exclusion Process (PRISMA Flow Diagram)

Table 2. Critical Appraisal Checklist for prospective Observasional Study By Joanna Briggs Institute
(Moola et al., 2017)
(Kothari, Spin-
JBI Critical Appraisal Checklist for Prospective Observational Study Neto, & Nielsen,
2016)
1 Were the criteria for inclusion in the sample clearly defined? Yes
2 Were the study subjects and the setting described in detail? Yes
3 Was the exposure measured in a valid and reliable way? Yes
Were objective, standard criteria used for measurement of the
4 Yes
condition?
5 Were confounding factors identified? Yes
6 Were strategies to deal with confounding factors stated? Yes
7 Were the outcomes measured in a valid and reliable way? Yes
8 Was appropriate statistical analysis used? Yes

Table 3. Critical Appraisal Checklist for Case Series By Joanna Briggs Institute (The Joanna Briggs
Institute, 2016)

(Prendergast, Kleiman, & King,

JBI Critical Appraisal Checklist For Case Series
2013)
1 Were there clear criteria for inclusion in the case series? Yes
Was the condition measured in a standard, reliable way for all
2 Yes
participants included in the case series?
Were valid methods used for identification of the condition for all
3 Yes
participants included in the case series?
4 Did the case series have consecutive inclusion of participants? Yes
5 Did the case series have complete inclusion of participants? Yes
Was there clear reporting of the demographics of the participants
6 Unclear
in the study?
Was there clear reporting of clinical information of the
7 Yes
participants?
8 Were the outcomes or follow up results of cases clearly reported? Yes
Was there clear reporting of the presenting site(s)/clinic(s)
9 Yes
demographic information?
1
Was statistical analysis appropriate? Yes
0

Table 4. Critical Appraisal Checklist for Text and Opinion Papers by Joanna Briggs Institute (Joanna
Briggs Institute, 2017)
(Prendergast
JBI Critical Appraisal Checklist For Text And Opinion (Tram et (Tram et
& Hinkle,
Papers al., 2014) al., 2016)
2018)
1 Is the source of the opinion clearly identified? Yes Yes Yes
2 Does the source of opinion have standing in the field of Yes Yes Yes
 expertise?
Are the interests of the relevant population the central
3 Yes Yes Yes
focus of the opinion?
Is the stated position the result of an analytical process,
4 Yes Yes Yes
and is there logic in the opinion expressed?
5 Is there reference to the extant literature? Yes Yes Yes
Is any incongruence with the literature/sources logically
6 Yes Yes Yes
defended?
 Table 5. Sintesis Grid

Author, Research
Objectives Sample Intervention Outcome measurement Result
City Design
(Prenderga Descriptive To introduce the 32 beds in a Double-sided Primary Outcome: The incidence of VAP dropped significantly from
st et al., case Bedside Oral mixed adult handouts containing implementation and evaluation of 4.21 to 2.1 per 1000 ventilator days (p = 0.04). 65%
2013) Exam (BOE) and intensive care BOE and BOCP. oral assessment and oral hygiene of cost savings were recorded monthly for oral
United Barrow Oral Care unit in a large Oral hygiene was by looking at a statistical hygiene care. Staff reported increased satisfaction in
State Protocol (BOCP) urban tertiary carried out comparison of the incidence of providing oral hygiene with a combination of oral
to guide oral care referral hospital periodically by ventilator acquired pneumonia care products. Significant reductions in VAP were
for intensive care in the Critical Nurse in (VAP) in 2011 to 2012 obtained recorded using BOCP. BOE guides individual oral
unit patients Southwestern the unit assigned to from hospital infection control care. Comprehensive oral care was cost-effective
United States clarify BOE committee report data intervention and effective in reducing VAP.
findings
1. Secondary outcome:
Comparison of pre-post
implementation oral care
costs
2. Staff response (critical nurse)
(Kothari et Prospective To carry out 13 patients with Assessment of the 1. Social history and behaviour All individuals evaluated were diagnosed with a
al., 2016) observation detailed oral acquired brain Bedside Oral Exam concerning oral health were generalization of chronic periodontitis. The BOE
Denmark al study. health injury (ABI) (BOE) score, measured by a self- score assessment results were significantly related to
assessments and individual social administered structured the results of periodontal status examination with a p-
assess social and and behavioural questionnaire value = 0.01
behavioural history, as well as a 2. Functional levels and
aspects related to thorough neurological conditions of
oral health in examination of the individuals with ABI were
individuals with condition of the measured by the Early
acquired brain teeth and functional ability (EFA) scale
injury (ABI). periodontal status 3. Periodontal and gum
examination is measured by
Full-mouth clinical
examination
(Prenderga Review Describing oral Stroke patients Conducting surveys An overview of some oral care Some oral care assessment tools applied include The
st & Literature biofilms, threats in 70 stroke of the use of oral assessment tools and oral hygiene Oral Assessment Guide (OAG), The Revised Oral
Hinkle, to units in care assessment programs after a stroke Assessment Guide, The Bedside Oral Exam (BOE),
2018) oral health, Scotland and tools and the The General Oral Health Assessment Index, The
America current oral England implementation of Revised Oral Cavity Assessment. Oral care was
assessment tools, oral hygiene after a recommended in some evidence-based
and oral hygiene stroke guidelines.
programs for
patients who have
 had a stroke.

(Tram et Review To develop a Solution with E. The pH paper strip The acidity of the solution using Bacterial detection translated into an increase in pH,
al., 2014) Literature pathogen coli sample and detected empty pH strip paper which can and was easily detected using litmus
Canada detection method empty solution solutions and colouring or pH paper. Simplicity, low cost, and
that is cheap and as a control solutions with E. extensive adaptability make this litmus test attractive
easy to use with group coli samples for 10 for field applications, especially in developing
Litmus test minutes. Test countries.
sensitivity by using
several E. coli
sample solutions
with each specific
number of different
E. coli cells

(Tram et Review For the Bacterial cells Detecting E. coli Report the pH of a test sample A litmus test for pH was simple, fast, and effective
al., 2016) Literature development of (E.coli) bacteria by looking through simple color changes because it reports the pH of the test sample through
Canada simple but still at staining on pH using pH strip paper simple colour changes. Ureases released into the test
effective methods paper (Litmust test) solution to hydrolyze urea to ammonia produced an
that can be used increase in pH that can be visualized using a classic
to detect specific litmus test.
pathogens