This course was published in the May 2016 issue and expires 05/31/19. The authors have no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.
After reading this course, the participant should be able to:
- Describe the federal mandate regarding assistance with daily oral hygiene in long term care facilities (LTCFs).
- Discuss safety concerns during the provision of daily oral hygiene for LTCF residents.
- Detail six strategies for overcoming care-resistant behavior.
- Identify educational resources for training LTCF staff on how to perform daily oral hygiene services.
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 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 life span, projections indicate the number of older adults living in nursing homes will double between 2000 and 2050.4
For those living in nursing homes or LTCFs, performing typical daily activities, such as bathing, dressing, transferring and eating, requires assistance from caregivers.5 Compared to previous generations, this aging population is also more likely to retain the natural dentition6 — which increases the need for oral hygiene care to prevent dental issues and related systemic diseases7 that may impact oral function and quality of life. This article will prepare dental professionals to deliver meaningful oral health education in LTCFs — with a focus on providing LTCF staff with appropriate recommendations and resources.
Unfortunately, many LTCF residents experience poor oral health due to reduced access to professional dental services, as well as difficulty maintaining effective oral self-care.8 Older adults often take a variety of medications, many of which exert negative oral health effects.9 This is one of the reasons LTCF residents are at risk of xerostomia/hyposalivation, hypersalivation, swallowing problems, periodontal disease and dental caries.9
While institutionalized populations may receive professional oral care services periodically, daily oral hygiene — which is considered an 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 This law stipulates that “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 toothbrushing, 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 staff — frequently called dental in-service — is not federally mandated, although some states have laws requiring 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 are more accurate when provided by nurses who have attended dental in-service training.15,16 Studies have also demonstrated that dental education programs for nursing staff in LTCFs improve oral health outcomes.17,18 Thus, oral health education 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.
IMPORTANCE OF ORAL HYGIENE
Appropriate oral health education for nursing staff 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
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 Discussing pneumonia may be a particularly powerful topic, as it is a significant predictor of death in nursing homes23 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 such as 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 is often reduced during this hold.26
Approximately 24% of LTCF residents have been diagnosed with diabetes.3 Thus, research describing the link between periodontal disease and poor glycemic control should be discussed.27 These conversations should also cover studies that associate severe periodontal disease 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 an important part of educational discussions. For example, LTCF residents — who are often evaluated for swallowing problems — may be placed on a restricted diet to lessen the risk of choking or aspiration. These restrictions 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 LTCF residents change quickly, and they often directly impact dietary restrictions. A resident who is approved to consume thin liquids on Monday, for example, may be reevaluated midweek, at which time his or her dietary restrictions could change to a recommendation of no thin liquids. In addition, some residents with dementia may not understand 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. 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 during oral care should also be addressed. Coleman and Watson10 conducted a study in New York nursing homes in which nursing assistants were observed, but were unaware of what was being evaluated. The study found that none of the assistants provided oral hygiene care to LTCF residents while wearing clean examination gloves. In some cases, in fact, after cleaning a resident’s perineal region, nursing assistants would brush the individual’s teeth without changing gloves. Nursing staff should be reminded that clean gloves should be donned before any form of oral care is delivered. In addition, once gloved, the caregiver should not touch anything except the patient’s oral hygiene supplies, as pathogens from inanimate objects (e.g., bed controls or light switches) can increase the risk of infection and illness.
ADDRESSING RESISTANCE TO CARE
Individuals with cognitive impairments often need help with oral hygiene care, but may resist it. Thus, 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 receiving training on how to provide daily oral hygiene care, but only 16% felt comfortable providing these services for care-resistant residents.10 Behaviors that will lead to greater patient acceptance of oral care include:29,30
- Eliminating baby talk/elderspeak
- Approaching patients from the front at eye level and maintaining eye contact
- Moving slowly around the patient
- Ensuring the room is quiet, with only necessary people present
- Encouraging independence (e.g., putting the toothbrush in the resident’s hand and leading it toward the mouth)
- Providing gentle care, while offering smiles and encouragement
IMPLEMENTING ORAL HYGIENE TOOLS
One of the barriers to maintaining oral health among residents of LTCFs is the lack of appropriate supplies.14 Although foam swabs are not as effective as toothbrushes in removing plaque, 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. The recommended lifespan of toothbrushes, recent patient illnesses, and toothbrush storage should be also addressed to prevent the proliferation of pathogens and mold, which can compromise the health of individuals who are at increased risk of illness due to weakened immune systems.
It’s important to recognize that nursing staff attending oral health education courses are probably not the purchasing decision-makers in the facility. Personal supplies, such as toothbrushes, are typically ordered by a central supply director, who 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 LTCF leadership. 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-based approach.
Numerous resources are available to help dental professionals train nursing staff to provide daily oral care in LTCFs (Table 1). As one example, the University of Kentucky College of Dentistry, with funding from the Dental Trade Alliance Foundation, has produced “Nursing Home Oral Health: A Blueprint for Success.” This comprehensive resource includes interactive PowerPoint presentations to help dental professionals train LTCF nursing staff. It also provides information for nursing home staff and families of residents in LTCFs. The materials include a video showing a mouth with generalized periodontal disease and plaque. The surface area of the intraoral “wound” created by periodontal disease is compared to a wound that covers the palm of the hand. The pathogens in the plaque are shown filtering into the blood vessels of the surrounding gingiva, while the narrator explains the potential harm to systemic health when large amounts of periodontal pathogens enter the systemic bloodstream.
This animation may be particularly relevant because wound care is an important part of nursing services in LTCFs. Depicting the oral cavity as an overlooked, bacteria-infected wound — and discussing the importance of cleaning and debriding this wound — may resonate with nursing staff.
As another example, the American Dental Association has created an “Overcoming Obstacles to Oral Health” program for dental professionals who wish to help train caregivers in providing oral health services in LTCFs. The program includes CDs with printable forms, tests, manuals and workbooks, as well as videos for both trainers and trainees.
Daily oral hygiene care is a fundamental requirement, especially for residents of LTCFs, who tend to experience oral disease disproportionately when 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, which creates unnecessary barriers to care.34 As such, we need to augment the training of nursing staff regarding residents’ daily oral care.
Oral health professionals are particularly well qualified to offer education that will help improve the provision of oral hygiene care in LTCFs. This type of community involvement creates a sense of connectedness and fulfillment. Nursing home staff who receive such training — through in-service education or the aforementioned resources — are better prepared to deliver effective oral hygiene care. This knowledge prepares them for numerous 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 these individuals’ health and well-being. By preserving the oral health of patients who reside in such facilities, dental professionals and nursing home staff are enhancing this patient population’s quality of life.
- U.S. Census Bureau. The Next Four Decades: The Older Population in the United States: 2010 to 2050. Available at: https://www.census.gov/prod/2010pubs/p25 -1138.pdf. Accessed April 13, 2016.
- AARP Public Policy Institute. Across the state: profiles of long term services and supports. Available at: http://www.aarp.org/ content/dam/aarp/research/public_policy_in stitute/ltc/2012/across-the-states-2012- full-report-AARP-ppi-ltc.pdf. Accessed April 13, 2016.
- Jones AL, Dwyer LL, Bercovitz AR, Strahan GW. The National Nursing Home Survey: 2004 overview. Vital Health Stat 13. 2009;167:1–155.
- U.S. Department of Health and Human Services. The Future Supply of Long Term Care Workers in Relation to the Aging Baby Boom Generation. Available at: https://aspe.hhs.gov/basic-report/futuresupply- long-term-care-workers-relationaging- baby-boom-generation. Accessed April 13, 2016.
- Forsell M, Sjogren P, Johansson O. Need of assistance with daily oral hygiene measures among nursing home resident elderly versus the actual assistance received from the staff. Open Dent J. 2009;3:241–244.
- Burt BA, Eklund SA. Dentistry, Dental Practice, and the Community. 5th ed. Philadelphia: Elsevier Saunders; 1999.
- National Institute of Dental and Craniofacial Research. Oral Health in America: A Report of the Surgeon General. Available at: nidcr.nih.gov/ DataStatistics/SurgeonGeneral/sgr/. Accessed April 13, 2016.
- Branson B, Simmer-Beck M. Addressing the oral health needs of long term care facility residents. Dimensions of Dental Hygiene. 2013;11(8):31–35.
- Johnson VB. Evidence-based practice guidelines: oral hygiene care for functionally dependent and cognitively impaired older adults. J Gerontol Nurs. 2012;38:11–19.
- Coleman P, Watson NM. Oral care provided by certified nursing assistants in nursing homes. J Am Geriatr Soc. 2006;54:138–143.
- Wardh I, Andersson L, Sorensen S. Staff attitudes to oral health care. A comparative study of registered nurses, nursing assistants and home care aides. Gerodontology. 1997;14:28–32.
- Cornell University Law School, Legal Information Institute. 42 CFR 483.25 – Quality of care. Available at: law.cornell.edu/cfr/text/42/483.25. Accessed April 13, 2016.
- Boyle S. Assessing mouth care. Nurs Times. 1992;88:44–46.
- Jablonski R, Munro CL, Grap MJ, Schubert CM, Ligon M, Spigelmyer P. Mouth care in nursing homes: knowledge, beliefs, and practices of nursing assistants. Geriatr Nurs. 2009;30:99–107.
- Kullberg E, Forsell M, Wedel P, et al. Dental hygiene education for nursing staff. Geriatr Nurs. 2009;30:329–333.
- Le P, Dempster L, Limeback H, Locker D. Improving residents’ oral health through staff education in nursing homes. Spec Care Dentist. 2012;32:242–250.
- Nicol R, Petrina Sweeney M, McHugh S, Bagg J. Effectiveness of health care worker training on the oral health of elderly residents of nursing homes. Community Dent Oral Epidemiol. 2005;33:115–124.
- Peltola P, Vehkalahti MM, Simoila R. Effects of 11-month interventions on oral cleanliness among the long term hospitalized elderly. Gerodontology. 2007;24:14–21.
- Charteris P, Kinsella T. The Oral Care Link Nurse: a facilitator and educator for maintaining oral health for patients at the Royal Hospital for neuro-disability. Spec Care Dentist. 2001;21:68–71.
- Kaz ME, Schuchman L. Oral health care attitudes of nursing assistants in long term care facilities. Spec Care Dentist. 1988;8:228–231.
- Miller M. Ombudsmen on the front line: Improving quality of care and preventing abuse in nursing homes. Generations. 2012;36(3):60–63.
- Sjogren P, Nilsson E, Forsell M, Johansson O, Hoogstraate J. A systematic review of preventive effect of oral hygiene on pneumonia and respiratory infections in elderly people in hospitals and nursing homes: effect estimates and methodological quality of randomized controlled trials. J Am Geriatr Soc. 2008;56:2124–2130.
- Mehr DR, Zweig SC, Kruse RL, et al. Mortality from lower respiratory infection in nursing home residents. A pilot prospective community-based study. J Fam Pract. 1998;47:298–304.
- Givens JL, Selby K, Goldfield KS, Mitchell SL. Hospital transfers of nursing home residents with advanced dementia. J Am Geriatr Soc. 2012;60:905–909.
- Democratic Policy and Communications Center. The Patient Protection and Affordable Care Act. Detailed summary. Available at: dpc.senate.gov/healthreformbill /healthbill04.pdf. Accessed April 13, 2016.
- The National Long Term Care Ombudsman Resource Center. Medicaid Bed Hold Policies by State. Available at: http://ltcombudsman.org/uploads/files/issues/s tate-bedhold-chart-oct2012.pdf. Accessed April 13, 2016.
- Taylor GW, Borgnakke WS. Periodontal disease: associations with diabetes, glycemic control and complications. Oral Dis. 2008;14:191–203.
- Kinane D, Bouchard P, Group E of European Workshop on Periodontology. Periodontal diseases and health: Consensus report of the sixth European workshop on periodontology. J Clin Periodontol. 2008;35(Suppl 8):333–337.
- Jablonski RA. Examining oral health in nursing home residents and overcoming mouth care-resistive behaviors. Annals of Long Term Care. 2010;18(1):21–26.
- Kayser-Jones J, Bird WF, Redford M, Schell ES, Einhorn SH Strategies for conducting dental examinations among cognitively impaired nursing home residents. Spec Care Dentist. 1996;16:46–52.
- Coleman P. Opportunities for nursingdental collaboration: addressing oral health needs among the elderly. Nurs Outlook. 2005;53:33–39.
- De Visschere LM, Grooten L, Theuniers G, Vanobbergen JN. Oral hygiene of elderly people in long term care institutions — a cross-sectional study. Gerodontology. 2006;23:195–204.
- Jablonski R, Munro CL, Grap MJ, Elswick RK. The role of biobehavioral, environmental, and social forces on oral health disparities in frail and functionally dependent nursing home elders. Biol Res Nurs. 2005;7:75–82.
- Simons D, Baker P, Jones B, Kidd EA, Beighton D. An evaluation of an oral health training programme for carers of the elderly in residential homes. Br Dent J. 2000;188:206–210.