10/17/11

ST. CHARLES, MO. – A campaign against dental problems in a nursing facility doesn’t have to be a battle. A new program of oral care shows that when it is personalized and staff are trained and empowered, the result can be residents who smile more and feel better.

Philip Sloane, MD, of the University of North Carolina at Chapel Hill School of Medicine and his team described the program, "Mouth Care Without a Battle," at the Pioneer Network national conference. The key to quality oral care, he said, is a program that individualizes mouth care according to the resident’s specific needs, preferences, fears, and situation. This involves training staff who are willing to take the time and make the effort to learn how to provide such care.

Courtesy University of North Carolina at Chapel Hill and Horizon Productions In the "Oral Care without a Battle" project, caregivers--such as the one pictured here--learn to provide quality, stress-free dental care.

Mouth Care Without a Battle is a 6-week program that addresses ways to prepare a patient, sanitize surfaces and supplies, and clean the mouth properly. Caregivers also are taught to look for signs of dental or other mouth problems, such as swelling, redness, bleeding, or sores. The program includes the use of a chlorhexidine gluconate rinse, a prescription product designed to fight gum disease such as gingivitis, for 6 weeks. The program’s goals, Dr. Sloane reminded, are to make the oral care easy and comfortable for the resident and easy and rewarding for the caregiver.

The team decided that a limited, dedicated team would be best at accomplishing the goals. Therefore, as part of a pilot, the team chose to train two certified nursing assistants as full-time mouth aids. These individuals had to be willing to undergo extensive training and remain committed to the program.

While the CNAs are the key players, the training modules include materials and information for staff beyond caregivers. In all, the program consists of four modules addressing the basics of oral care, the challenges of providing mouth care for residents with dementia, information for nurse supervisors, and an overview for others interested in quality care.

The Team Opens Up

Aides involved in the pilot shared their experiences with the audience. One aide said, "One of the residents didn’t like to do anything she couldn’t do herself. I asked if I could check her mouth. Then I asked if I could brush her teeth. I took it one step at a time, and it worked. Now she’s more alert and not as grouchy. Having her teeth brushed was a big deal. It makes her feel a lot better."

Another aide said she volunteered without hesitation: "I thought, ‘How hard is it to brush teeth?’ " In fact, it was difficult. "At first, I got hit, spit at, and yelled at."

The aide soon learned to use her powers of observation and her knowledge about residents to make the job easier. "I had one patient with a brain injury, and it was hard to get him to open his mouth. I noticed how fascinated he was by a balloon in the room. So I got the balloon for him. He got so excited, he opened his mouth, and I went in." Eventually, this patient began to brush his own teeth.

Explaining her approach to residents, the aide emphasized the importance of being polite and respectful. "I always knock on the door and ask permission to enter the room," she said. "I introduce myself, and I tell them what I’m going to do every step of the way."

The value of denture care often is underestimated, said dental hygienist Patricia Poole, RDH, of the University of North Carolina at Chapel Hill. "Dentures need daily care. Staff should never use toothpaste to clean dentures, and they should make sure that products used are American Dental Association approved for dentures."

She stressed that it is important to remove dentures regularly. "If you don’t, patients can get fungal infections, and it can affect the way dentures fit." She added, "Ideally, dentures should be removed and stored appropriately overnight. If the resident resists or refuses, Ms. Poole said, "find a 4- to 6-hour space during the day when the dentures can be removed."

Dry mouth is a huge problem in the elderly population, she noted. "Over 500 medications, including antihypertensives and antidepressants, can cause dry mouth. If patients have dry mouth, they don’t eat or talk."

Winning the Nonbattle

"It’s all about relationships and knowing the patient," said team member Ann Louise Barrick, PhD, a psychologist based in Butner, N.C. "It is important to focus on the person rather than the task."

When there is a behavioral issue affecting oral care, said Dr. Barrick, "you have to step back and ask why. Maybe the person has pain or can’t hear. Maybe he or she is anxious or afraid. You need a toolbox of lots of strategies."

Oral care is hard, Dr. Barrick admitted. "You can bribe residents to bathe with a cookie or a chocolate bar. You can engage them in conversation. You can’t do this with oral care. It’s more challenging to find ways to distract people." You need to find the right time and way to provide the oral care. When you do this, it can be a nice experience." The team showed a video in which the caregiver sang softly to the resident while attending to her mouth. The gentle approach clearly had a positive effect on the resident, and both she and the caregiver seemed to be enjoying the encounter.

It is important to emphasize the benefits of oral care, said Dr. Sloane, partly because staff may not realize how important it is. "One researcher found in talking to CNAs that mouth care was one of the first things they didn’t do when they were short on time," said Dr. Sloan.

"The medical director can be aware of and point out the health benefits, such as improving nutritional intake and diabetic control," he said.CfA

Senior contributing writer Joanne Kaldy is a freelance writer in Harrisburg, Pa., and a communications consultant for AMDA and other organizations.