Breaking Down Barriers to Care

In the United States, one in eight adults is age 65 or older. It is estimated that by 2030, 20% of the American population will be 65 or older.¹ The cohort of adults age 85 and older is expected to experience the most significant growth, with a projected increase of 224% by the year 2050.² Approximately 1.5 million adults age 65 and older reside in long-term care facilities (LTCFs).³ With this number poised to increase along with the average lifespan, it is predicted that the number of older adults living in nursing homes will double between the years 2000 and 2050.⁴

For those living in nursing homes or LTCFs, performing the typical activities of daily living—such as bathing, dressing, toileting, transferring, continence, and eating—requires the assistance of caregivers.⁵ This aging population is also more likely to retain their natural teeth,⁶ increasing the need for oral hygiene care to prevent dental diseases and related systemic diseases⁷ that may impact oral function and quality of life. Approxi­mately 60% of LTCFs have a program in place to provide professional dental services, but the care is often delivered on an as needed basis determined by the facility’s management.³

Unfortunately, the oral health status of many LTCF residents is poor due to reduced access to regular professional oral health care services and because of their difficulty maintaining effective oral self-care regimens.⁸ Older adults often take a variety of medications, many of which exert negative oral health effects.⁹ LTCF residents are at great risk of xerostomia/hyposalivation, hypersalivation, swallowing problems, periodontal diseases, and dental caries.⁹

While institutionalized populations may receive professional oral care services periodically, daily oral hygiene—which is considered an everyday essential need, along with grooming and bathing—is often a neglected part of most nursing home care.^10,11 The federal government mandates that residents of LTCFs accepting Medicaid and Medicare payments receive assistance with daily oral hygiene.¹² According to this law, “A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.”¹²

The responsibility of oral hygiene care, such as daily brushing of natural teeth and cleaning and proper storage of dental prostheses, often falls to nursing staff with varying degrees of training.^13,14 Oral health education for LTCF nursing staff, frequently called dental in-service, is not required by the federal government—though some states have laws that mandate nursing homes to provide an annual dental in-service for their nursing staff (Table 1).

Nurses employed in LTCFs are required to examine the oral cavity during resident admission assessment. Research shows that oral assessments of nursing home residents are more accurate when provided by nurses who have attended a dental in-service.^15,16 Studies have also demonstrated that dental educational programs for nursing staff in LTCFs improve oral health outcomes.^17,18 Thus, oral health education among staff members has the potential to help nursing homes enhance the quality of care for residents, while improving compliance with federal mandates for providing daily oral hygiene care. For these reasons, it is likely that more dental hygienists will be needed to provide oral health education for nursing staff in LTCFs.

This article will prepare clinicians for delivering meaningful oral health education in LTCFs—with a focus on providing oral health professionals with guidelines regarding appropriate curriculum, as well as a list of resources.

IMPORTANCE OF DAILY ORAL HYGIENE

Appropriate oral health education for nursing staff delivered by dental professionals has been shown to improve the plaque scores of LTCF residents.¹⁵ Providing information on the importance of daily oral hygiene is a key component of successful oral health educational programs in LTCFs,¹⁹ and may increase the likelihood that nursing staff will provide residents with the help they need to perform daily oral hygiene. Research suggests that nearly 80% of LTCF residents need help with daily oral hygiene care.^20,21 Few residents, however, receive the assistance they need.¹⁰

Associations between oral and systemic health, such as the increased risk of aspiration pneumonia in those with poor oral hygiene, should be incorporated into oral health education programs for nursing staff. For example, 15 studies have shown daily oral hygiene decreases the risk of aspiration pneumonia in hospitalized patients and LTCF residents.²² Discussion of pneumonia may be a particularly powerful topic—it is a significant predictor of death in nursing homes,²³ and is responsible for a large proportion of hospitalizations for residents in LTCFs.²⁴ Under the Affordable Care Act, hospitals are now reimbursed based on the percentage of preventable readmissions.²⁵ When hospitals need to send patients to a LTCF upon discharge, they have a financial incentive to choose facilities that will prevent readmissions for conditions like pneumonia. The nursing home also has financial incentives to prevent pneumonia. When a nursing home resident is hospitalized, the facility is often required by state regulations to hold the resident’s bed until he or she returns from the hospital, and reimbursement to the nursing home during this hold is often reduced.²⁶

Approximately 24% of LTCF residents have been diagnosed with diabetes.³ Thus, research²⁷describing the link between periodontal diseases and poor glycemic control should be discussed, as well as studies that associate severe periodontal diseases with the risk of cardiovascular complications in patients with diabetes.²⁸

SAFETY PRECAUTIONS OF ORAL HYGIENE REGIMENS

Safety precautions for the provision of daily oral hygiene are important to discuss during oral health education. For instance, LTCF residents—who are often evaluated for swallowing problems by speech-language pathologists—may be placed on a restricted diet to lessen the risk of choking or aspiration. These restricted diets may prohibit consuming thin liquids, including water. Thus, a daily oral hygiene regimen that includes water, mouthrinse, and toothpaste could pose a choking hazard.

Minimizing potential risks is further complicated because conditions experienced by residents change quickly, and they often directly impact dietary restrictions. For example, a resident who is approved to consume thin liquids on Monday may be reevaluated mid-week, at which time his or her status could change to no thin liquids. In addition, some residents who have dementia may not understand that they need to expectorate mouthrinse and may swallow or hold the liquid in their mouths. Regardless of dietary restrictions and existing conditions, daily oral hygiene care may be provided by moistening a toothbrush with a small amount of water or mouthrinse and brushing the teeth. Flossing should follow, when possible.

Patient positioning is also a safety topic. A 2006 observational study of oral hygiene provided by staff in nursing homes found that residents were often inappropriately positioned.¹⁰ The best position for oral hygiene care is standing or sitting; however, some LTCF residents may be unable to do either. Performing oral hygiene care while a resident lies supine in bed may lead to aspiration or choking. This can be prevented by raising the head of the bed prior to providing care. A suction toothbrush may also help prevent aspiration among this patient population.

Appropriate infection control when providing oral care should also be addressed. Coleman and Watson¹⁰ conducted a study in New York nursing homes in which nursing assistants were observed during their work but were unaware of what was being evaluated. The study found that not one nursing assistant provided oral hygiene care to LTCF residents while wearing clean examination gloves. In fact, nursing assistants sometimes brushed residents’ teeth after cleaning the perineal region without changing gloves. Nursing staff are to be reminded that clean gloves should be donned before any form of oral care is delivered. In addition, once gloves are donned, the caregiver should not touch anything except the patient’s oral hygiene supplies, as bacteria from inanimate objects (eg, light switch, bed controls, door knobs) will contaminate the resident’s mouth, increasing the risk for infections and illnesses.

HOW TO ADDRESS CARE RESISTANCE

LTCF residents with cognitive impairments often need help with oral hygiene care but may resist it. Nursing staff need strategies to cope with care-resistant behaviors when providing daily oral hygiene services.¹⁴ A study of certified nursing assistants working in LTCFs found that 96% of the nursing staff reported receiving training on how to provide daily oral hygiene care, but only 16% noted feeling comfortable providing these services for care-resistant residents.10 Behaviors that will lead to greater patient acceptance of oral care include:^29,30

1. Eliminating baby talk/elderspeak
2. Approaching patients from the front at eye level and maintaining eye contact
3. Moving slowly around patient
4. Ensuring the room is quiet with only necessary people present
5. Encouraging independence, putting toothbrush in hand of resident, and leading hand toward mouth
6. Providing care gently, and offering smiles and encouragement

Rita Jablonski, PhD, RN, ANP, of the University of Alabama at Birmingham School of Nursing, created an excellent educational video on reducing care-resistant behaviors among institutionalized patients (Table 1).

IMPLEMENTING ORAL HYGIENE TOOLS

One of the barriers to maintaining oral health among residents of LTCFs is the lack of appropriate oral hygiene supplies.¹⁴ Although foam swabs are not as effective as toothbrushes in plaque removal, they are often used in LTCFs instead of tooth­brushes.^10,14 Nursing staff need to be educated about proper oral hygiene supplies, particularly the importance of using a soft toothbrush with a small head to effectively remove plaque. The age of toothbrushes, recent patient illnesses, and toothbrush storage should be also addressed to prevent bacterial and mold growth, which compromise the health of older adults who are at increased risk of illness due to weakened immune systems.

The nursing staff attending the oral health education course are probably not the purchasing decision makers in the facility. Personal care supplies, including toothbrushes, are typically ordered by a central supply director. This individual may not understand the importance of ordering quality toothbrushes with small heads and soft bristles. Often, budgetary limitations yield inexpensive toothbrushes with large heads and hard bristles. Oral health professionals need to advocate for appropriate oral hygiene supplies with the LTCF leadership (eg, administrator, director of nursing, social worker). Some residents may receive monthly stipends for the purchase of personal care items that can be used to buy suitable oral hygiene supplies. If residents are unable to go shopping, a family member or the facility activity director may assist in such purchases. For this reason, oral health education should also be provided for families and residents through a team approach.

EDUCATIONAL RESOURCES FOR PROVIDING IN-SERVICES

There are many educational resources to help dental professionals train nursing staff to provide daily oral care in LTCFs (Table 1). The Dental Trade Alliance Foundation has funded the resource “Nursing Home Oral Health: A Blueprint for Success,” which includes interactive 30-minute to 90-minute PowerPoint presentations and an 11-minute video to help dental professionals provide training to LTCF nursing staff. The materials are available for download by oral health professionals. The site also has information for nursing home staff and families of residents in LTCFs.

The materials for dental professionals include a narrated wound care animation showing a mouth with generalized periodontal disease and plaque around the teeth. The surface area of the intraoral “wound” created by periodontal disease is compared to a wound that covers the palm of the hand. The bacteria in the plaque is shown filtering into the blood vessels of the surrounding gingiva, while the narrator explains the potential harm to the systemic health of the patient when large amounts of periodontal bacteria enter the systemic bloodstream. This animation may be particularly relevant because wound care is an important part of nursing services in LTCFs. Depicting the mouth as an overlooked bacteria-infected wound—and discussing the importance of cleaning and debriding this wound—may resonate with nursing staff.

The American Dental Hygienists’ Association offers a kit to aid dental hygienists in developing a relationship with nursing homes and working with nursing home staff to improve the oral hygiene of residents. The free kit includes an “invitation for nursing homes” and “introductory letter to trainer” templates. The resource also contains a flip chart, inventory list, audience handout, product guide, and oral health curriculum for LTCFs. Upon completion of the presentation, the clinical trainer receives three continuing education units.

Another continuing education opportunity, “Mini-Residency in Nursing Home and Long-Term Care for the Dental Team,” offers a course for dental professionals who wish to partner with local LTCFs to improve the oral health of frail institutionalized older adults in their communities (tuition fee required). In addition to providing information on how to provide high-quality, comprehensive dental services for nursing home residents, the course provides information helpful when planning a dental in-service—such as who to contact at the nursing home to set up the educational session and when to schedule the in-service. This 4-day course is presented by the University of Minnesota, School of Dentistry.

The Minnesota Department of Health and the University of Minnesota School of Dentistry’s Oral Health Services for Older Adults Program developed a DVD and workbook “Growing Old with a Smile: Oral Care for Older Adults in Long-Term Care” to help train nursing staff to provide appropriate daily oral care for LTCF residents. The program’s topics include brushing and flossing techniques, hygiene care of dental prostheses, checking the resident’s mouth for problems, managing difficult situations, and providing oral care for unconscious patients. A pretest and post-test are provided. The DVD and workbook are available for the cost of shipping and handling through the support of the Minnesota Dental Association.

The American Dental Association (ADA) has created “Overcoming Obstacles to Oral Health” for dental professionals who want to implement an oral health program to train and educate direct caregivers in providing oral health services to people in LTCFs. The program includes CDs with printable forms, tests, manuals, and workbooks, as well as videos for both the trainer and trainee. It is offered for a fee through the ADA catalog.

The educational resource, “Brushing Up On Mouth Care: Facilitating Uptake of a Daily Oral Care Program in Continuing Care,” assists dental professionals in training nursing staff about oral care and implementing a daily oral care program in LTCFs. Funded by the Nova Scotia Health Research Foundation and created by Mary McNally, MSc, DDS, MA, of Dalhousie University in Halifax, Nova Scotia, the resource package includes a detailed instruction manual, five education videos, oral care tool-kits, assessment and care planning tools, and guidelines for organizationally mapping oral care.

CONCLUSION

Daily oral hygiene care is a fundamental requirement, especially for residents of LTCFs who tend to disproportionately experience oral disease compared to their counterparts who live at home.^31–33 Nursing staff of LTCFs often have limited knowledge regarding oral health, dental services, and the oral health needs of residents—creating unnecessary barriers to care.³⁴ As such, there is a need to augment the training of nursing staff regarding the daily oral care of residents.

Oral health professionals are the most likely resource to offer oral health education to improve the provision of dental care in LTCFs. This type of community involvement creates a sense of connectedness and fulfillment. Nursing home staff who receive such education, through in-service training or the aforementioned resources, are better prepared to deliver optimal oral hygiene care. This knowledge prepares them for many situations, including residents who are care resistant, confined to bed, or at risk of infection due to compromised immune systems.

The nature in which oral hygiene should be delivered to LTCF residents is subjective, but laws have been enacted to protect their health and well-being. By preserving the oral health of patients who reside in such facilities, clinicians and nursing home staff are enhancing the quality of life for this patient population.

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From Dimensions of Dental Hygiene. April 2014;12(4):53–56,59.