Hands-On Solutions for Long-Term Care Nurses Providing Oral Healthcare

Providing oral healthcare to long-term care residents is often impeded by a multitude of obstacles, and there are few evidence-based resources on which direct care workers can rely. Annals of Long-Term Care^® asked Rita Jablonski, PhD, about her experience providing oral care to residents, the barriers that she has encountered, and her research for overcoming care-resistant behavior in residents with dementia. She also offers insight on the short-term solutions to common oral health problems (eg, xerostomia, stomatitis), the long-term goals of integrating oral healthcare practices into widespread culture change, and the role of family caregivers in the care team.

Nearly 15 years ago, the Surgeon General’s report Oral Health in America called upon policymakers, healthcare professionals, and citizens to take a greater responsibility in oral care. Yet, routine oral hygiene in long-term care settings remains a neglected facet of care, placing these vulnerable individuals at risk of poor outcomes and diminished quality of life. Without proper oral hygiene, bacteria in the mouth can cause oral problems and infections. A number of systemic diseases, such as cardiovascular disease, pneumonia, and diabetes, have been associated with oral infections, especially periodontitis.

More than any other member of an interprofessional care team, nurses are the ones providing the greatest amount of direct care to residents; as such, they are in a unique position to meet residents’ oral health needs. However, providing this care is often impeded by a multitude of obstacles, and there are few evidence-based resources on which to rely.

Annals of Long-Term Care^® (ALTC) had the opportunity to speak with Rita Jablonski, PhD, CRNP, FAAN, associate professor, School of Nursing, University of Alabama at Birmingham, about the role of nurses in providing oral healthcare to long-term care residents. Jablonski is also the principal investigator for a study funded by the National Institutes of Health titled “Reducing Care-Resistant Behaviors During Oral Hygiene in Persons with Dementia.”

ALTC: In your experience as a nurse practitioner, what do you see as the major barriers to providing oral healthcare to residents in long-term care facilities?

Jablonski: Accountability. If a nursing assistant fails to get someone out of bed, or the licensed practical nurse fails to change a dressing, those items are easily observed and attributable to a specific member of the care team. Lack of mouth care, on the other hand, is easily missed until an extreme issue arises. Primary care providers are also part of the problem. As a nurse practitioner in long-term care, I was the only clinician at my facility who looked in mouths and removed residents’ dentures to assess the gingival tissues. My physician colleagues and physician assistant colleagues rarely looked in residents’ mouths. A corollary to accountability is the perception by long-term care nurses and nursing assistants that oral hygiene is a personal care nicety, like a manicure. By putting mouth care in that category, nursing assistants can rationalize skipping it when schedules become tight.

What challenges have you observed in providing oral healthcare to residents with dementia?

Persons with dementia are the most likely to resist care. Agitation decreases as dementia progresses, but care-resistant behavior does not. It increases exponentially. Mouth care is invasive, and nursing assistants are not aware that their approach may be causing the care-resistant behavior. Even if the resident is unable to learn new information, the neural pathways that govern threat perception and fear responses are capable of generating new associations. Passivity associated with dementia is another challenge because these individuals will simply not open their mouths for oral hygiene. One of the techniques we have successfully used is placing residents in front of a mirror and providing mouth care from behind them. Persons with dementia do demonstrate dental pain, but one has to be tuned in to how the pain is expressed; moaning, grimacing, holding the jaw, and refusing to eat are some of the signs.

Are there any “quick fixes” to overcome some of these barriers?

One of the easiest activities administration can do is to stop purchasing sponge-covered swabs. These swabs should be banned from all facilities. The swabs do not remove plaque, which then matures and mineralizes into calculus, and becomes colonized with Gram-negative anaerobic bacteria. This bacteria contributes to aspiration pneumonia in long-term care. I cringe every time I see a nursing assistant use a swab like a toothbrush. One argument I hear all of the time is that the swabs are necessary for edentate residents. Edentate residents do not benefit from swabs; a soft toothbrush is fine to gently clean the gums.

The right supplies must be available as well. Soft toothbrushes, which should be replaced at least every 6 months or after a respiratory or gastrointestinal illness, are necessary to clean teeth, gums, and tongues. Tongues have to be brushed because bacteria live on the dorsal surface.¹ In fact, the Gram-negative bacteria on the tongue produce methyl mercaptan (methanethiol), which contributes to foul breath.² Additional supplies include fluoride-containing toothpaste and fluoride-containing alcohol-free mouth rinse. If a resident is at risk for ingesting the products, keep small travel- sized products at the bedside. Dentures must be cleaned with denture brushes and denture products. Simply rinsing them off and plopping them into a denture cup with a dissolving tablet is ineffective; plaque forms on dentures just like on teeth. If the resident tolerates an electric toothbrush, use it.

The next step is to have the supplies available and accessible. In one nursing home where I conducted my research, the supervisor insisted on locking up mouth care supplies and no resident was allowed to have these items in their rooms. The locked supplies placed extra burdens on the nursing assistants. Mouth care supplies can be kept at the bedside; have all items marked with the resident’s name using an indelible marker.

What about the long-term solutions to overcome these barriers?

Oral hygiene needs to be seen as oral infection control, and treated with the same seriousness as skin integrity. Proper and consistent oral hygiene has been shown to reduce pneumonia in nursing homes, improve swallowing, enhance cough sensitivity, and to improve saliva production.^3,4

As for staffing, I am seeing the same nursing assistant-to-resident ratio that I encountered 30 years ago when I was a nursing assistant. Back then, about one-third of my nine residents (on a day shift) were wholly dependent; one-third required supervision; and one-third were fairly independent. With more elders remaining at home and other available housing options, such as assisted living communities, the residents who enter long-term care are extremely frail and functionally dependent. Staffing ratios are overdue for re-evaluation, but that is an issue that transcends mouth care.

Evidence-based protocols are published, but passive dissemination is not going to get them to the nursing homes. Mouth care protocols for persons with dysphagia and who require thickened liquids are difficult to find. Dissemination and implementation of protocols have to be active, but little has been researched or published regarding the best ways to actively infuse these protocols into long-term care. The protocols also need to be delivered concurrently with strategies for managing care-resistant behaviors.

Please tell us more about the research you have been doing on care-resistant behavior in residents with dementia, and how this research applies to oral care.

My team is currently testing behavioral interventions to use with persons who have dementia and who resist mouth care. The interventions were culled from the dental and nursing literature, but we were the first to make the connection between these practices, the neurobiology of threat response, and how the neurobiology is altered with dementias.^5,6 The techniques include accessing implicit memory, which we do by providing care in front of a sink. Many nursing assistants, in the interest of time, will attempt to brush teeth or perform mouth care while the resident is sitting on the toilet. We also floss using interdentate sticks. Other techniques include the use of gestures and pantomime, short yet respectful commands, and judicious yet gentle touch. Caregivers should avoid using “elderspeak.” Additionally, care providers can employ hand-over-hand, chaining, and bridging techniques. Chaining involves the care provider initiating an activity, like brushing, and then engaging the elder to take over and complete the activity. It is much better tolerated than simply doing the activity for the resident. Bridging is a technique where you have the individual hold an object related to the activity. I tend to use the two together. When brushing teeth, I start with chaining, and if the elder pushes my hand away but does not engage in the activity, I switch to bridging. I hand her another toothbrush while I continue to brush.

The research team’s initial hypothesis was that these techniques would diminish care-resistant behavior. Preliminary results are showing this is not the case, but the experimental teams are able to provide mouth care more often, and more completely, than the control teams. When we examine the types of recorded care-resistant behaviors, the elders are exhibiting less severe ones. The mouth care providers (who are predominantly nursing students) are finding that they become more comfortable using the behavioral techniques over time and are more confident with handling care-resistant behavior. Some have shared, anecdotally, that they are using the same behavioral techniques with other activities of daily living and with other cognitively-impaired populations. One student, for example, told us that she was successfully using the threat-reduction techniques while working with patients who had sustained brain injuries.

Our 30-minute video, which incorporates evidence-based oral hygiene and strategies to reduce care-resistant behavior, can be found on the University of Alabama School of Nursing’s Research Portfolio website at https://bit.ly/Care-Resistant-Study.

Salivary disorders in the aging population are usually caused by systemic diseases, and more than 500 medications can contribute to dry mouth (ie, xerostomia). Because older adults frequently use one or more of these medications, they are at higher risk of experiencing xerostomia. Dry mouth is not only bothersome, but also makes elderly residents more vulnerable to tooth decay, mouth sores, and oral infections. What treatments can nurses give to residents at the bedside to treat xerostomia?

Provide and offer drinking water or sugar-free fluids throughout the waking hours. This is very important with residents who are immobile. It is not enough to have a pitcher of water at the bedside; pour and offer a glass every time you interact with a resident. This is the cheapest and most effective way to address dry mouth. Consistent oral hygiene also reduces xerostomia. There are products out there too. The use of gum containing xylitol has been shown to improve saliva production and also to reduce tooth decay. Commercially available mouth care products, including toothpastes, mouth rinses, and gels, have shown efficacy in persons with xerostomia in the oncology literature.

Stomatitis (eg, canker sores, cold sores, and mouth irritation) is also common in older persons and may affect their ability to eat and sleep. What kinds of products, techniques, and resources can nurses use to treat stomatitis?

Prevention is the key. Poor-fitting dentures and failure to remove dentures overnight contribute to gingival lesions. Nurses should be examining dentures for fit and for any rough spots or chips that may be irritating the gums or palate. The stomatitis may also be due to a candida infection, which will warrant evaluation by primary care provider or dentist. Oral antifungals will address the candida, and a mouth rinse with analgesic agents can help with the burning. For cold sores and canker sores, application of an over-the-counter analgesic gel or cream is fine. Any lesion, however, should be evaluated to determine if it is benign or malignant. The Smiles for Life Curriculum has a wonderful module about geriatric oral health, with excellent pictures that illustrate different types of oral lesions. This resource can be accessed at bit.ly/SmilesLifeCurriculum. Licensed nurses and other professionals can also receive free continuing education credits for viewing the modules.

What is the role and responsibility of family caregivers for ensuring good oral health for their loved one?

Ideally, family members should maintain the same dental care for the resident after he or she enters long-term care. Some facilities have a dentist on site, but this is rare. Family members can keep the resident’s preferred mouth care products available in the room or bathroom, and make sure everything is clearly marked with the resident’s name. If unused supplies are noted, they should bring this to the attention of the nurse manager. Family members may know ways to get the resident to accept mouth care and share these methods with the nursing home staff. Family members can also provide mouth care. One useful strategy is to brush teeth together with the resident. The resident is less likely to resist if someone else is also brushing.

Family members should note the fit, or lack thereof, of dentures. I have seen nursing home residents use the same set of dentures for 20 years! Over time, the shape of the gums change and dentures need to be refitted. Simply using more adhesive is not a good idea. Sometimes, previously accepted mouth care items, such as electric toothbrushes, may no longer be tolerated as the dementia progresses. If this occurs, switch to a soft non-electric toothbrush.

In the past few years, there has been some controversy over the use of products containing chlorhexidine for oral hygiene. For example, a literature review by Autio-Gold⁷ concluded that there is a lack of clinical evidence to support the use of chlorhexidine rinses for preventing tooth decay. What role, if any, could this agent have in long-term care?

Mouth rinses containing chlorhexidine have been shown to reduce bacteria in the mouth. These rinses are being integrated into oral hygiene protocols of hospitals, especially for persons on mechanical ventilators. However, chlorhexidine is not a substitute for the mechanical removal of plaque. If it is used long term, it does stain teeth. Some researchers have advocated its use in nursing homes.⁸ The logistical issue with chlorhexidine is that it is a prescribed substance and only licensed nurses may dispense it to the residents. I think it may have a place in the oral hygiene arsenal as an adjuvant to brushing, but I am concerned that it could be abused as a substitute for brushing. 

References

1.  Abe S, Ishihara K, Adachi M, Okuda K. Tongue-coating as risk indicator for aspiration pneumonia in edentate elderly. Arch Gerontol Geriatr. 2008;47(2):267-275.

2.  Pace CC, McCullough GH. The association between oral microorgansims and aspiration pneumonia in the institutionalized elderly: review and recommendations. Dysphagia. 2010;25(4):307-322.

3.  Sjogren P, Nilsson E, Forsell M, Johansson O, Hoogstraate J. A systematic review of the preventive effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes: effect estimates and methodological quality of randomized controlled trials. J Am Geriatr Soc. 2008;56(11):2124-2130.

4.  van der Maarel-Wierink CD, Vanobbergen JN, Bronkhorst EM, Schols JM, de Baat C. Oral health care and aspiration pneumonia in frail older people: a systematic literature review. Gerodontology. 2013;30(1):3-9.

5.  Jablonski RA, Therrien B, Kolanowski A. No more fighting and biting during mouth care: applying the theoretical constructs of threat perception to clinical practice. Res Theory Nurs Pract. 2011;25(3):163-175.

6.  Jablonski RA, Therrien B, Mahoney EK, Kolanowski A, Gabello M, Brock A. An intervention to reduce care-resistant behavior in persons with dementia during oral hygiene: a pilot study. Spec Care Dentist. 2011;31(3):77-87.

7.  Autio-Gold J. The role of chlorhexidine in caries prevention. Operative Dentistry. 2008;33(6):710-716.

8.  Sloane PD, Zimmerman S, Chen X, Barrick AL, Poole P, Reed D, et al. Effect of a person-centered mouth care intervention on care processes and outcomes in three nursing homes. J Am Geriatr Soc. 2013;61(7):1158-1163.