Overcoming Oral Hygiene Challenges in the Nursing Home

      Incorporating a well-structured, daily oral hygiene program has a beneficial impact on nursing home residents as well as the entire health care team. But the question is how to logistically accomplish, develop, and implement such a program?
      In many nursing homes, up to 80% of residents do not receive daily oral care (J Am Geriatr Soc 2006;54:138–143), despite the fact that 84% of residents have difficulty brushing their own teeth due to cognitive and/or physical limitations. In general, oral health care is not adequately considered in most personal hygiene protocols for the elderly in long-term care facilities (“Geriatric Oral Medicine,” in Burket’s Oral Medicine, 12th ed. [Hamilton, ON: BC Decker, 2014, 653–668]).
      The task of brushing teeth twice daily for each resident does take a lot of time. In addition, providing consistent oral hygiene care for geriatric residents with dementia in long-term care facilities poses special challenges. These residents’ decreased cognition, sequencing abilities, and communication as well as increased behavioral resistance can affect the standard of oral care provided by staff. The resistant behaviors can potentially escalate to the point of staff injury — residents with severe dementia may strike or even bite staff.
      In the face of such challenges, educating the front-line staff on the rationale and techniques of good oral hygiene helps them to understand both the process and the benefits for the residents. At the Georgia War Veterans Nursing Home in Augusta, our team has developed comprehensive staff training and a structured program of daily, routine oral care conducted by the nursing staff for the support and maintenance of our residents’ oral health.

      Oral Health Assessment

      First and foremost, oral health assessments must be timed routinely and in a systematic fashion. During the comprehensive medical admission evaluation, our residents undergo a full oral needs assessment and examination. This includes examining all prostheses, nutritional changes (including weight loss), mastication and swallowing issues, mucosal disease, periodontal issues, pain, salivation, and caries. The resident should be examined with and without prostheses in place to look for fit, mucosal lesions, and ease of prosthetic removal and insertion.
      Assessment of systemic factors is next, and it incorporates medical problems, medications, and communication with previous health care providers as needed. Part of the overall team evaluation is testing the resident’s functional and mental capacity, with specific attention to communication and their skill level in performing oral self-care as assessed by both the occupational therapist and physician.
      This initial comprehensive geriatric evaluation is followed by a dental professional’s admission evaluation, with periodic reviews every 6 to 12 months thereafter. If the resident develops new oral health signs or symptoms in the interim periods, in-house medical evaluation and treatment ensue, with referral to the dentist as needed.

      Challenges to Brushing

      By developing an organized system-wide approach to oral care a facility may overcome the challenges to regular brushing. The main objectives of such an approach are to increase resident participation in oral care and enhance interdisciplinary oral hygiene involvement — all while optimizing the overall health and quality of life of our residents.
      Our Oral Care Staff Training Toolkit consists of an interactive PowerPoint presentation, hands-on training, and a staff attitudes/knowledge questionnaire. Nursing staff and certified nursing assistants are trained in identifying the residents’ ability to participate in tooth brushing, with a goal of improving the residents’ independence and easing their resistance toward staff during routine oral care.
      Older residents may have trouble with oral self-care for a variety of reasons. In the face of cognitive deficits, tooth brushing can become a seemingly complicated, even overwhelming task. Techniques to overcome these difficulties include verbal cueing, distraction, and a hand-over-hand technique.
      To begin, residents may find staff approaching from behind or in front of them to be unnerving, so approaching the resident from the side can be more calming. The caregiver may begin the oral hygiene process, then help or guide the resident to complete the task. Engaging the resident in pleasant talk or even singing may increase participation. Also, a hand-over-hand technique helps to improve sensory awareness and allows residents to feel that they are performing the task along with the caregiver. Standby assistance for some of the steps, such as paste application or replacing the cap, may be needed due to a resident’s sensory defensiveness or oral sensitivity, cognitive decline, or behavioral changes.
      Teaching these specific techniques of tooth brushing should help the staff approach residents with confidence, compassion, and efficiency.
      In addition to cognitive deficits, there may be physical limitations. If a resident’s hand dexterity is altered due to arthritis, contractures, strokes, or tremors, adaptive handle modifications may be required. The team’s occupational therapist can structure an appropriate tooth-brush handle modification. For instance, some shaped or large-handled adaptive changes such as tennis balls can help improve the resident’s grip quality and control. Adding a heavier handle may also be beneficial for residents with tremors.
      If the systematic to-and-fro motion of manual brushing becomes difficult, an electric brush may help. For residents who are unable to expectorate, swallow, or manage secretions, a suction toothbrush can be used — these soft-bristled, hollow-handled brushes are designed to fit directly onto a standard suction machine apparatus.

      Management Goals

      The goals of oral management should be to optimize the residents’ oral hygiene in the daily care setting and also with periodic professional oral health care visits. For residents with progressive dementia in particular, treatment may become more challenging and inherently more problem-based, and the role of the caregiver becomes critical for performing daily oral care, enhancing communication, and overcoming the challenges.
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      A comprehensive assessment of oral health is required first to mount a successful oral hygiene program in PA/LTC.
      Oral health care is not adequately considered in most nursing home protocols on personal hygiene. Addressing these issues with a well-developed, interdisciplinary team and an oral care program diminishes morbidity and mortality, enhances the overall quality of life and independence of older adults, and certainly makes caregiver involvement with dementia residents much more effective.
      Dr. Gulati serves as the medical director at Georgia War Veterans Nursing Home, Augusta, GA. She is coauthor of the first geriatrics chapter in Burket’s Oral Medicine and has hosted an active dental care program at the facility during her 17-year tenure.
      Laura Ross Cordaro is the director of occupational therapy at Georgia War Veterans Nursing Home, Augusta, GA. She has extensive experience from pediatrics to geriatrics on the life spectrum and received the 2016 Occupational Therapist of the Year Award from the Georgia Occupational Therapy Association.