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With the new year upon us, many of us make resolutions to improve our health and well-being. Popular resolutions include exercising more, eating healthier, losing weight, and taking better care of our oral health by regularly brushing for two minutes twice a day, flossing, and visiting the dentist and dental hygienist. Personally I have struggled to maintain many of my new year resolutions, but I have been fastidious about caring for my teeth and gums since I was a young adult.
I suppose that five years of orthodontics to correct my very crooked smile and a family history plagued by gum disease and tooth loss motivated me to optimize my oral care routines. My personal history of oral health complexities and the obstacles I encountered in accessing routine dental care during the COVID-19 pandemic have made me think a lot about the current state of oral care in post-acute and long-term care (PALTC)— specifically, about the barriers and facilitators that can hinder or help our patients support their oral health.
Oral Health in PALTC
The state of oral health care in some PALTC settings in the United States is dismal: 80% to 85% of patients do not receive adequate oral care (J Am Geriatr Soc 2006;54:138–143; J Am Geriatr Soc 2017;65:2516–2521). In fact, poor oral care is an international problem: Canadian (J Clin Nurs 2015;24:2815–2825) and Norwegian (Gerodontology 2012;29:e748–755) studies have demonstrated that 50% to 60% of PALTC residents receive inadequate oral care and 19% of patients skip oral care entirely. I was unable to find more recent national data to describe the current state of oral health among US nursing home residents, and a recent article seems to confirm my suspicion that none currently exists (J Nurse Home Res Sci 2020;6:1–5).
Poor oral care among PALTC patients is associated with respiratory infections, pain, decreased oral intake, decreased quality of life, morbidity, and mortality. As practitioners in PALTC, we have seen firsthand that individuals living with dementia exhibit cognitive, functional, and behavioral symptoms that lead to poor oral health. Additionally, gum disease and tooth loss have also been associated with an increased likelihood of cognitive decline and dementia (J Am Med Dir Assoc 2021;22:2039–2045), likely due to the long-term impact of inflammatory cytokines (N Am J Med Sci 2015;7:241–246).
Interestingly, among my close family members the two with the worst periodontal disease as adults were also the only ones to later have dementia. These anecdotal data have motivated me to take good care of my own teeth and gums.
Regulatory Guidance for Oral Care and Dental Services
The National Institutes of Health issued an updated report in 2021 on oral health across the life span that acknowledged that older adults living in PALTC settings are at significant risk for poor oral health. The NIH recommended that interprofessional caregiving teams coordinate interventions and programs to improve the oral care of patients (“Section 3b: Oral Health Across the Lifespan: Older Adults,” National Institutes of Health, National Institute of Dental and Craniofacial Research, https://bit.ly/3VhjuAF).
So I was surprised to find that the current regulatory guidance from the recently updated Appendix PP of the State Operations Manual (revision Oct. 22, 2022, available from https://bit.ly/3VoqMml) does not provide any new regulations or guidance on oral care and dental services for PALTC. According to §483.55, nursing homes are required to:
Perform an oral health assessment of a patient on admission and periodically as needed.
Arrange for patients to have access to preventative and emergency dental care.
Make dental service appointments for residents who request them.
Arrange transportation to dental service appointments.
Assist in the application for reimbursement for dental care.
Have a policy about the replacement or repair of dentures.
Refer patients with damaged or lost dentures for repair or replacement within three days.
However, PALTC facilities are not required to provide routine dental care services unless the services are covered under Medicaid. During my 28 years working in PALTC, I have never seen a facility cited for dental services.
Barriers to Oral Health in PALTC
The barriers to adequate oral health care in PALTC are numerous.
Financial barriers to dental services are significant: most PALTC patients lack dental insurance and do not possess the financial resources to pay for dental services.
Chronic medical conditions, cognitive decline, functional disability, and xerostomia, which is frequently aggravated by polypharmacy, also place older adults living in PALTC communities at greater risk for poor oral health.
Patients may also refuse or exhibit resistive behaviors when nursing or dental staff attempt to assess their mouths or provide routine oral hygiene and dental treatments.
Other barriers to good oral care that nursing staff report include a lack of supplies, minimal training/education on how to provide effective oral care, and a lack of time (Geriatr Nurs 2021;42:799–805).
I know a few dental hygienists who have expressed an interest in providing preventive dental services to PALTC patients, but they cannot bill for their services unless a dentist is also onsite at the facility at the same time.
The COVID-19 pandemic created new barriers for maintaining oral health. In the first several months of the pandemic, most dental offices were closed, and contracted onsite or mobile dentistry services were not given access to PALTC settings. As dental practices were permitted to reopen, priority was given to emergency dental care; appointments for routine cleanings and on-site visits were hard to come by (Dent Clin N Am 2022;66:181–194).
During the pandemic, supply chain issues and family visitor restrictions also created shortages of oral care supplies, although we were all a bit more focused on finding masks, toilet paper, and antibacterial wipes. Most importantly, severe staffing shortages and the risks to direct care staff associated with providing oral care to patients also resulted in decreased provision of oral care in PALTC settings.
Promoting Better Oral Care
Although the barriers may appear insurmountable, there are things we can do to promote better oral health for individuals living in PALTC settings.
Facilitate interprofessional collaborative education and training for practitioners and direct care providers in assessing the oral cavity and strategies for providing adequate oral care. Pragmatic interventions and training programs such as the Mouth Care Without a Battle Training Program and DVD (https://bit.ly/3Ul1Drb), Smiles for Life: A National Oral Health Curriculum (https://www.smilesforlifeoralhealth.org/), and the MOTIVATE Program (Maine’s Oral Team-Based Initiative: Vital Access to Education at https://bit.ly/3ioAtSZ) are evidenced-based interventions and curricula that can be used to improve oral health outcomes.
Use role model strategies by the direct care staff to cue and encourage residents to brush their teeth. I am regularly amazed that even individuals with severe dementia often can summon their old “muscle memory” to brush their own teeth with cueing, so long as they can hold a toothbrush. For those individuals who can no longer hold a toothbrush, hand-under-hand techniques can help them achieve the range of motion and feel involved in the process.
Get creative with location. Although it may be helpful for some patients to engage in oral care in their bathrooms, be flexible about the location of providing oral care. Individuals with dementia may feel anxious in a small bathroom, and those with limited mobility may be fine seated in a chair with the dental care supplies brought to them.
Locate dental care service partners who can meet your patients’ needs. Mobile dentists and dental hygienists are increasingly available, and dental telehealth services can help assess whether an in-person dental visit is needed. If you have a dental school or dental hygienist program nearby in your community, contact them about their dental trainees participating in special needs dental services.
Dr. Galik is editor in chief of Caring for the Ages. The views the editor expresses are her own and not necessarily those of the Society or any other entity. Dr. Galik is a nurse practitioner in LTC- and community-based settings through a clinical practice with Sheppard Pratt Health System. She is a professor at the University of Maryland School of Nursing, where she teaches in the Adult-Gerontology Primary Care Nurse Practitioner Program and conducts research to improve care practices for older adults with ementia and their caregivers in long-term care. She may be reached at[email protected].
In this episode, Dr. Karl Steinberg and Dr. Elizabeth Galik discuss our January-February issue, including the use of alcohol in long-term care communities, misconceptions about nurse practitioners and physician assistants in long-term care, dental hygiene in older adults, and how facilitating better sleep might help prevent cognitive decline.