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Good oral hygiene has a positive impact on the overall health of nursing home and other post-acute and long-term care residents, but like many other functions it has taken a back seat during the pandemic. But this issue shouldn’t and doesn’t have to fall off the radar.
The challenges of providing mouth care are real, but there is cause for optimism. “We know that good, consistent mouth care has a positive effect on infections and overall health of the mouth. We’ve tested the delivery of mouth care in very restrictive research settings. It’s doable and makes a difference,” said Rita Jablonski, PhD, CRNP, FGSA, FAAN, professor of nursing at the University of Alabama at Birmingham. “The nursing assistants know this is important, even under challenging circumstances.”
One resource that has helped is Mouth Care Without a Battle (http://www.mouthcarewithoutabattle.org/), a standardized program that teaches mouth care in health care settings, provides instruction on individualized techniques and products for mouth care, and trains caregivers to provide care to residents who are resistant and in special situations. This is an evidence-based approach to person-centered daily mouth care for people with cognitive and physical impairments. It combines best practices in oral hygiene with proven techniques to overcome resistance to care. For instance, it teaches the “jiggle sweep” technique to remove plaque from the teeth, the use of interdental brushes to clean between teeth, the benefits of nonalcoholic rinses instead of toothpaste for residents with swallowing difficulties, the method for steadying a loose tooth during cleaning, the importance of not using toothpaste to clean dentures, and techniques to encourage residents to open their mouth when they are resistant.
COVID-19 and Oral Care
“We can’t stop giving people the care they need because of the pandemic, and this includes mouth care,” said Sheryl Zimmerman, PhD, coeditor in chief of JAMDA. “If a person doesn’t have COVID and you have the proper PPE [personal protective equipment], you can safely do mouth care; and with the right training and protocols, you can do this effectively.” In many ways, the pandemic has enhanced the importance of mouth care, added Philip Sloane, MD, MPH, coeditor-in-chief of JAMDA, “Mouth care really is about infection control and prevention.” Both Dr. Zimmerman and Dr. Sloane were part of the team that developed the Mouth Care Without a Battle program.
Dr. Jablonski noted, “I have a dentist on my team who separates mouth care activities into low versus high aerosolized spray care. Higher aerosolized care means a face shield and N95 mask.” She added, “We are fortunate to have plenty of PPE, but it’s essential to teach staff how to put this equipment on and [take it] off properly and in what order.” Although PPE is essential to preventing infection transmission and keeping everyone safe, it’s not without its challenges when it comes to mouth care. Dr. Jablonski said, “People with dementia can’t see the aide’s face or read nonverbal cues. The mask is out of their reality, and that can trigger behaviors.”
The pandemic has been stressful for everyone, said Patty Van Dyke, RN, BSN, staff development coordinator at Glenaire CCRC in Cary, NC, so it’s important to remind staff that mouth care doesn’t take much time and that it has significant benefits. “If they can make it something fun, they can get it done quickly, and the resident will feel better.”
Training Champs to Take Charge
“We need champions at the nursing facility level and nursing assistants who are trained,” said Dr. Sloane. It’s important not to assume that staff know how to provide quality mouth care. He pointed out, “We looked at what was documented and in the MDS [Minimum Data Set], and what we saw with the residents. There was little connection between what was documented and what we observed. We saw that the staff wasn’t trained about things like denture care.” He stressed that “these are good people practicing quality care,” but mouth care is often ignored or not done properly.
Dr. Sloane said, “In our trials we had facilities identify a nursing assistant to be an oral care aide. They received training, some additional responsibilities, and a small pay raise. They worked more or less full-time in this role, and they spent a bit of time helping and mentoring others.” He added, “They loved their job, and they gained a new skill set.” In fact, Dr. Zimmerman said, “We have had 0% turnover in those champions. They appreciated what they were able to accomplish.”
When facilities implement a mouth care program, said Dr. Sloane, the results are “eye opening.” He explained, “It takes a concerted effort over time, but they see that people feel better and it’s better for their health.” He stressed, “Mouth care has to be right up there with mobility, skin care, diet, and other issues.” Leadership has to provide guidance on what the priorities are, he said, and this should be one of them.
The Enlightenment of Training
Mouth Care Without a Battle provides training via DVD and online platforms, which enables team members to train on their own time. This is especially useful during a pandemic, when in-person meetings and travel are out of the question.
“We are trying tele-training,” said Dr. Jablonski in discussing the Managing Oral Hygiene Using Threat Reduction Strategies (MOUTh) intervention, which she helped develop (J Gerontol Nurs 2016;42:15–23).“The staff is open to it, and it would be convenient if they could just grab a tablet when they have time for training or have questions we can help them with.”
Dr. Zimmerman noted, “Training and competencies are a hugely important aspect of raising any service to a higher level, and this is certainly true of mouth care.” She added, “That is what we have tried to do with this program — provide training, supervision, and peer support.”
Overhauling dementia education and integrating oral care with it is important, agreed Dr. Jablonski. “I approach training grounded in neurobiology. I help caregivers know what to do when the patient won’t open his or her mouth.” She stressed that in addition to caregivers, registered nurses should receive some training so that they can provide support and help with problem-solving.
“We do competency training every year with the staff,” said Ms. Van Dyke. “People come and go, and even if you don’t have much turnover, you have to train new people and refresh others.” She added, “We have people practice by brushing their own teeth, paying attention to how it feels, and thinking about how it may feel to someone else, particularly someone with dementia.” She added, “People forget sometimes that this is really an intimate thing.”
Dementia and Dental Care
For residents with dementia, said Dr. Jablonski, “Refusals are the biggest problem. They won’t open their mouth or let you provide oral care.” She has a few basic suggestions, such as providing the care in the bathroom, a location residents generally associate with toothbrushing and oral care, using a hand-over-hand technique to keep from being hit or slapped away, and employing a two-toothbrush approach so that if the resident “chomps” on something, it’s a toothbrush rather than a hand or finger. These techniques and others are covered in MOUTh training, and Mouth Care Without a Battle addresses some of these kinds of challenges and solutions in its training videos and materials as well.
Knowing the resident can make a tremendous difference in how receptive the person is to mouth care. “When you know the resident well, you don’t have to start at ground zero every time,” said Dr. Jablonski. She added that it also helps to know about the residents’ value systems. She explained, “We had one resident who resisted going in the bathroom so we could brush her teeth. Her daughter told us that she used to always wear lipstick, but they started giving her lip balm because she couldn’t apply [lipstick] right and would get it on her face. So I would say to her, ‘You have lipstick on your teeth. Let’s go to the bathroom and clean that off.’ It worked, and we didn’t have trouble with her after that.”
Smile Like You Mean It
In the end, said Dr. Sloane, “When oral care is a priority, residents feel better, look better, eat better, and socialize better. It’s a winning proposition that takes some work and investment of time, training, and labor, but the outcomes make everyone smile.