ADVERTISEMENT
Meeting Oral Health Challenges in Long-Term Care Facilities
Key words: Long-term care, malnutrition, oral health, periodontal disease.
____________________________________________________________________________________________________________________________________________________
In the past few decades, oral health has become a national priority in the United States. In May 2000, the US Surgeon General issued a significant report titled Oral Health in America, which provided an evidence-based argument for the importance of optimal oral care, specifically how diseases and conditions that affect the face, mouth, and teeth are connected to overall health and well-being in all age groups.1 The Surgeon General’s report advocated for a revision to the medical curriculum so that it includes a dental care component. Despite advances in this area of care, poor oral health among long-term care (LTC) residents remains pervasive, as there continue to be numerous barriers to providing care in this population. Meeting these challenges should be a priority since approximately 75% of baby boomers are expected to reside in LTC facilities, a majority of whom will have their natural teeth intact.2 At an LTC facility based in Kentucky, we sought to overcome some of these barriers by designing and implementing a comprehensive oral health staff training program. In this report, we describe our pilot program, which yielded positive results. A brief review of the serious health issues associated with poor oral care is also given, underscoring the need for other LTC facilities to work toward implementing similar staff education programs. Resources for doing so are provided at the end of this report.
Evidence of Poor Oral Care Leading to Other Health Problems
Addressing poor oral health among LTC residents is imperative because it may cause more than mouth pain. Untreated dental decay, broken teeth, inflamed gingival tissues, and problems with dentures can impair a person’s ability to eat, potentially affecting his or her nutritional status. According to a 2012 systematic review by Belgian investigators, there is tentative evidence of an independent association between oral health status and malnutrition in LTC residents.3 The investigators advise caution in assuming a direct link between the two conditions, as there is no gold standard to define and assess malnutrition and oral health status. However, a cross-sectional Finnish study involving more than 2000 institutionalized frail elders found that malnutrition was strongly related to both poor oral status and oral health problems,4 such as chewing and swallowing difficulties, mouth pain, and xerostomia (ie, dry mouth), which is a common side effect of many medications.
There are strong correlations between poor oral health and life-threatening systemic diseases and conditions. Many studies indicate a positive relationship between the provision of oral care and a reduction in aspiration pneumonia, an inflammation of the lungs due to breathing in foreign material (eg, food).5-8 Complications from aspiration pneumonia, which include hypotension and bacteremia, can be fatal. A 2006 systematic review by Azarpazhooh and Leake9 found fair evidence of an association between pneumonia and oral health (odds ratio, 1.2-9.6, depending on oral health indicators). In the study, improved oral hygiene, including professional oral care, significantly reduced the incidence of or progression of respiratory diseases among high-risk elders residing in nursing homes or being cared for in intensive care units (relative risk reduction, 34%-83%).
Periodontal disease has also been known to interfere with glycemic control in diabetic individuals, potentially leading to kidney disease, myocardial disease, and peripheral neuropathy and retinopathy. This is particularly disconcerting because approximately 25% of LTC residents have diabetes, a majority of who have type 2 diabetes mellitus.10 Based on data from a longitudinal study, Taylor and colleagues11 reported that persons with type 2 diabetes and severe periodontitis are six times more likely to experience worsening glycemic control over time, compared with their counterparts without periodontitis.
A number of cardiovascular conditions have also been associated with poor oral health, specifically with periodontal disease.12-16 Some research suggests that periodontal disease may be a risk factor for atherosclerosis, leading to coronary artery disease and stroke; the presence of oral bacteria has been documented in atherosclerotic plaques.15 The observational studies only support a strong link between periodontal disease and atherosclerosis,11,14,15 but large prospective studies have failed to find an association between the two after adjusting for risk factors, indicating that this is an area where further studies are needed.17
In addition, some studies point to a potential association between poor oral health and dementia and cognitive decline.18-20 A study comparing systemic exposure to periodontal pathogens (assessed by Porphyromonas gingivalis-specific serum immunoglobulin G, a serological marker of periodontitis), and cognitive test outcomes in adults 60 years of age and older found that periodontitis is associated with delayed verbal recall and impaired subtraction skills.18 Other studies have found a correlation between loss of teeth and dementia.19,20 In a longitudinal study of dental records from adults aged 75 to 98 years, study participants with the fewest teeth had the highest risk dementia, and the prevalence of dementia was also greatest in this population.20
Barriers to Providing Oral Healthcare in LTC Settings
The problem of poor oral health among nursing home residents is multifactorial.21 One of the greatest facilitators to good oral health is simply ensuring daily oral hygiene; however, this seemingly simple task can pose a challenge in the LTC setting. Many LTC residents have difficulty brushing their own teeth due to poor manual dexterity, limited mobility, vision problems, or cognitive impairment. A study by Frenkel and colleagues22 found that 72% to 94% of LTC residents have difficulty providing their own oral hygiene care or cleaning their own dentures, yet residents often receive little or no help with these practices. In one study, only 5% of residents in LTC facilities who requested assistance with oral hygiene ever received help.23 It also appears that when help is provided, best practices are often not employed. In an observational study of actual daily oral care provided by certified nursing assistants (CNAs) to elderly residents who required assistance, Coleman and Watson24 reported that adherence to standards was low; teeth were brushed and rinsed with water in only 16% of resident observations, and when help was given, the staff brushed the teeth on average for 16.2 seconds, instead of the 2 minutes that is commonly recommended by dentists. Furthermore, the investigators cited a disturbing lack of appropriate infection control, with none of the CNAs wearing clean gloves to provide oral care and some not even changing gloves after cleaning the perineal area or changing soiled garments.24
In various surveys and questionnaires, nursing assistants have cited a range of challenges to providing oral hygiene care to LTC residents, including lack of time25 and care-resistant behaviors in residents.26 Some nursing assistants reported a lack of education on providing daily oral hygiene for LTC residents and a lack of accountability for providing this care, instead deferring this responsibility to the residents’ regular dentist.27 Lack of standardized practice or routine appears to be an issue. A Swedish study found that the quality of oral healthcare was given to patients depending on several factors, but a questionnaire indicated oral health as a “low priority” of their daily activities.28
Many of the aforementioned studies indicate a pressing need for staff education and training in oral healthcare. Recognizing that oral health is an underrecognized but significant area of care in LTC settings, staff at an LTC facility in Kentucky worked on a collaborative project with our dental team from the University of Kentucky College of Dentistry to address these barriers to care and provide residents with necessary oral care. Following our description of this program, we provide direction to free online resources so that other LTC providers may design and implement their own program.
Pilot Program
In Kentucky, 80% of institutionalized elders have fair to poor oral health, according to the results of a statewide survey.29 The aim of our project was to develop and implement a unique oral health training program for CNAs working in LTC settings that would ultimately improve the oral health and overall health of residents. In our model, one CNA was specially trained to be the facility’s oral health specialist, becoming responsible for the daily oral hygiene of the residents and having minimal other care responsibilities. The specialist then carried out a standardized care plan, which was developed by our dental team and informed by a literature review of best practices in oral hygiene. The intent of this approach was to overcome the key barriers reported by staff in the medical literature, including a lack of time and of accountability. The Figure outlines each step of our pilot program.
The first step was to identify a local LTC facility with which to test our program, ensuring that the facility’s leadership was on board with having one of their nursing assistants trained in oral healthcare. The dental team then met with the director of nursing, an administrator, and a social worker at the facility to create a feasible written plan, outlining the logistics of the location and time needed to train an assistant. These conversations helped to forge a true partnership between institutions and departments.
When a realistic plan for training the nursing assistant was put into place, the dental team developed the curriculum. The curriculum was based on a literature review to determine best practices and elements of successful oral health training programs in LTC facilities. Evidence-based recommendations were incorporated into the curriculum, including the following: engaging the leadership of the facility to ensure support22; providing information on the importance of a healthy mouth, focusing on the links between oral and systemic health30; providing detailed “how-to” instructions for using basic oral hygiene tools and for implementing appropriate infection-control measures21; and providing strategies for managing care-resistant behaviors.26 Specifically, we utilized guidelines from the American Dental Association and a self-study course developed by the Southern Association of Institutional Dentists.31 We also consulted various academic nursing papers for evidence-based protocols of oral healthcare,32,33 as well as additional recommendations for communication and behavior strategies.34
The next step in the process was to create four interactive and self-instructional slideshow presentations (ie, PowerPoint) and videos, which were developed by the dental team in collaboration with a multimedia expert, a medical illustrator, and an instructional designer. These lessons were titled as follows: The Importance of Daily Oral Care; Guidelines for Daily Oral Care; Checking for Problems; and Residents Requiring Special Care. In addition, Quiz Your Knowledge questions were interspersed throughout the curriculum to highlight the most important take-home messages. Written materials were developed, including a template for creating individualized daily oral hygiene plans for residents, forms for documenting daily provision of oral care, and a Request for Dental Consult referral form. We also laminated color-coded flash cards that could be kept at the nurse’s station and carried to the bedside as reminders of supplies, procedures, and safety precautions for providing oral care. All of these materials were developed with the intention of being easy to access and easy to understand by nursing assistants in LTC facilities nationwide. We needed to develop a curriculum that was self-instructional because in many facilities, we expected that dental professionals are not always available to deliver the presentation or work one-on-one with staff.
After the training materials were developed, a CNA who had been employed at the facility for more than 20 years volunteered to undergo the training and become the facility’s oral health specialist. In addition to watching all four slideshow presentations, a dental hygienist, who was paid in part by grant funding, provided hands-on demonstrations with oral hygiene tools. Continuous coaching was also provided at the bedside by a dental hygienist. The dental team communicated with the nursing assistant on a weekly basis, encouraging her to provide verbal feedback regarding any challenges, concerns, and successes.
(Continued on next page)
Program Challenges and Outcomes
The general response to our program was positive. The nursing assistant learned quickly and provided the oral care with few problems. The residents responded positively and appeared to enjoy the oral care, demonstrated by their requests to receive care from nursing assistants on other shifts.
As the program progressed, formative assessment resulted in several program modifications. The initial program had trained only one nursing assistant to become the oral health specialist. It was discovered that one person could not provide oral hygiene care to more than 100 residents who required care. Therefore, it became necessary to train other nursing assistants to provide this care. In addition, because the residents were asking nursing assistants on other shifts to provide oral care, we felt it was necessary to provide basic oral health training to all nursing staff. As a result, we created shorter versions of the presentations (a 12-minute video and 25-minute slideshow presentation) and provided this training to all nursing staff at the facility so that all caregivers would have a basic understanding of how to safely provide this care. But the initial assistant remained the facility’s go-to oral health specialist, as she could devote her time almost exclusively to providing oral care to residents.
Another challenge and important lesson learned was the need to carefully review each resident’s dietary restrictions, specifically those prohibiting thin liquids. For patients who could not have thin liquids, an oral hygiene protocol that included mouthwash, water, or toothpaste could have been a choking hazard. As these dietary restrictions tended to change daily, a protocol to ensure safety was created for patients who required special precautions. One way to address this safety concern is to advise nursing assistants to carefully check the care plan for restrictions or consult with the charge nurse to determine if any special precautions are needed before providing oral hygiene to residents. If the resident has any condition that requires alteration of the typical protocol, the nursing assistant may simply eliminate use of toothpaste and/or swishing with water or mouthwash and instead brush the teeth with a toothbrush slightly moistened with mouthwash or water. A list of conditions that require elimination of toothpaste, mouthwash, and water includes the following:
• Patient has dietary restrictions prohibiting thin liquids;
• Patient is unable to or refuses to expectorate, but instead holds liquids in the mouth or swallows;
• Patient is resistant to care; or
• Patient is comatose or delirious.
Resources for Implementation Across LTC Facilities
Perhaps the most important outcome of this project was the creation of tools that could be used by dental professionals, nursing home staff, and families of LTC residents in facilities nationwide. On the University of Kentucky Website, we have created a free online toolkit that provides training materials for nursing staff of LTC facilities, including an instructional YouTube video, voice-over slideshow presentations with animations for self-instruction, and a variety of written materials, such as task cards, documentation forms, and pre-test and post-test competencies for provision of oral care. The Website also provides resources for families, including what information they should provide to the LTC facility that can help the nursing staff provide the best oral care possible for their loved one. All of these resources are available at www.uky.edu/NursingHomeOralHealth.
Conclusion
There is an increasing amount of evidence supporting the adverse relationship between poor oral health and systemic illness in residents in LTC settings. For many years, oral health was viewed as an independent focus from overall health. However, contemporary healthcare culture is changing to reflect this growing interest. Education of healthcare professionals is key to solving the problem of poor oral health in nursing homes and other assisted living settings. Providing effective models of care and education for nurses and nursing assistants is necessary to ensure safe oral hygiene care for residents. We hope that the results of our pilot program serve as inspiration to other LTC facilities searching for ways to improve the oral care of their residents.
References
1. Office of the Surgeron General, US Department of Health and Human Services. A National Call to Action to Promote Oral Health. 2003. www.nidr.nih.gov/sgr/nationalcalltoaction.htm. Accessed August 13, 2012.
2. Haumschild MS, Haumschild RJ. The importance of oral health in long-term care. J Am Med Dir Assoc. 2009;10(9):667-671.
3. Van Lancker A, Verhaeghe S, Van Hecke A, Vanderwee K, Goossens J, Beeckman D. The association between malnutrition and oral health status in elderly in long-term care facilities: a systematic review. Int J Nurs Stud. Published online ahead of print April 27, 2012.
4. Soini H, Muurinen S, Routasalo P, et al. Oral and nutritional status—is the MNA a useful tool for dental clinics? J Nutr Health Aging. 2006;10(6):495-499.
5. Terpenning MS, Taylor GW, Lopatin DE, Kerr CK, Dominquez L, Loesche WJ. Aspiration pneumonia: dental and oral risk factors in an older veteran population. J Am Geriatr Soc. 2001;49(5):557-563.
6. Abe S, Ishihara K, Adachi M, Okuda K. Oral hygiene evaluation for effective oral care in preventing pneumonia in dentate elderly. Arch Gerontol Geriatr. 2006;43(1):53-64.
7. Yoneyama T, Yoshida M, Ohrui T, et al; Oral Care Working Group. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc. 2002;50(3):430-433.
8. Adachi M, Ishihara K, Abe S, Okuda K, Ishikawa T. Effect of professional oral health care on the elderly living in nursing homes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;94(2):191-195.
9. Azarpazhooh A, Leake JL. Systematic review of the association between respiratory diseases and oral health. J Periodontol. 2006;77(9):1465-1482.
10. Sinclair AJ, Gadsby R, Penfold S, Croxson SC, Bayer AJ. Prevalence of diabetes in care home residents. Diabetes Care. 2001;24(6):1066-1068.
11. Taylor GW, Burt BA, Becker MP. Severe periodontal disease and risk for poor glycemic control in patients with non-insulin dependent diabetes mellitus. J Periodontol. 1996;67(suppl 10):1085-1093.
12. Engebretson SP, Lamster IB, Mitchell SV, et al. Radiographic measures of chronic periodontitis and carotid artery. Stroke. 2005;36(3):561-566.
13. Glurich I, Grossi S, Albini B, et al. Systemic inflammation in cardiovascular and periodontal disease: comparitive study. Clin Diagn Lab Immunol. 2002;9(2):425-432.
14. Pussinen PJ, Nyyssonen K, Alfthan G, Salonen R, Laukkanen JA, Salonen JT. Serum antibody levels to Actinobacillus actinomycetemcomitans predict the risk for coronary heart disease. Arterioscler Thromb Vasc Biol. 2005;25(4):833-838.
15. Haraszthy VI, Zambon JJ, Trevisan M, Zeid M, Genco RJ. Identification of periodontal pathogens in atheromatous plaques. J Periodontol. 2000;71(10):1554-1560.
16. Grau AJ, Becher H, Ziegler CM, et al. Periodontal disease as a risk factor for ischemic stroke. Stroke. 2004;35(2):496-501.
17. Haynes WG, Stanford C. Periodontal disease and atherosclerosis: from dental to arterial plaque. Arterioscler Thromb Vasc Bio. 2003;23(8):1309-1311.
18. Noble JM, Borrell LN, Papapanou PN, Elkind MS, Scarmeas N, Wright CB. Periodontitis is associated with cognitive impairment among older adults: analysis of NHANES-III. J Neurol Neurosurg Psychiatry. 2009;80(11):1206-1211.
19. Gatz M, Mortimer JA, Fratiglioni L, et al. Potentially modifiable risk factors for dementia in identical twins. Alzheimers Dement. 2006;2(2):110-117.
20. Stein PS, Desrosiers M, Donegan SJ, Yepes JF, Kryscio RJ. Tooth loss, dementia and neuropathology in the Nun study. J Am Dent Assoc. 2007;138(10):1314-1322.
21. Helgeson MJ, Smith BJ, Johnsen M, Ebert C. Dental considerations for the frail elderly. Spec Care Dentist. 2002;22 (3 suppl):40S-55S.
22. Frenkel HF, Harvey I, Newcombe RG. Improving oral health in institutionalised elderly people by educating caregivers: A randomised controlled trial. Community Dent Oral Epidemiol. 2001;29(4):289-297.
23. Simons D, Brailsford S, Kidd EA, Beighton D. Relationship between oral hygiene practices and oral status in dentate elderly people living in residential homes. Community Dent Oral Epidemiol. 2001;29(6):464-470.
24. Coleman P, Watson NM. Oral care provided by certified nursing assistants in nursing homes. J Am Geriatr Soc. 2006;54(1):138-143.
25. Chalmers JM, Levy SM, Buckwalter KC, Ettinger RL, Kambhu PP. Factors influencing nurses’ aides’ provision of oral care for nursing facility residents. Spec Care Dentist. 1996;16(2):71-79.
26. Jablonski RA, Munro CL, Grap MJ, et al. Mouth care in nursing homes: knowledge, beliefs, and practices of nursing assistants. Geriatr Nurs. 2009;30:99-107.
27. Chung JP, Mojon P, Budtz-Jorgensen E. Dental care of elderly in nursing homes: perceptions of managers, nurses, and physicians. Spec Care Dentist. 2000;20(1):12-17.
28. Wärdh I, Hallberg LR, Berggren U, Andersson L, Sörensen S. Oral health care—a low priority in nursing. In-depth interviews with nursing staff. Scand J Caring Sci. 2000;14(2):137-142.
29. Henry RG. Final Report: Kentucky Elder Oral Health Survey 2005. Lexington, KY: Division of Dental Public Health, College of Dentistry, University of Kentucky, 2005. https://bit.ly/KentuckyOralHealthReport. Accessed August 31, 2012.
30. 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(2):68-71.
31. Southern Association of Institutional Dentists. Preventive dentistry for persons with severe disabilities. Module 11; 2001. www.saiddent.org/admin/images/61178500_1339447209.pdf. Accessed August 31, 2012.
32. Chalmers J, Johnson V, Tang JH, Titler MG. Evidence-based protocol: oral hygiene care for functionally dependent and cognitively impaired older adults.
J Gerontol Nurs. 2004;30(11):5-12.
33. Coleman P. Improving oral health care for the frail elderly: a review of widespread problems and best practices. Geriatr Nurs. 2002;23(4):189-197.
34. Chalmers JM. Behavior management and communication strategies for dental professionals when caring for patients with dementia. Spec Care Dentist. 2000;20(4):147-154.
Disclosures:
Funding for the collaborative project described in this article was provided by a grant from the Dental Trade Alliance Foundation. The authors report no other relevant financial relationships.
Address correspondence to:
Pamela Stein, DMD, MPH
Department of Oral Health Science
Division of Public Health Dentistry
University of Kentucky College of Dentistry
333 Waller Avenue, Suite 180
Lexington, KY 40504
pam.stein@uky.edu
