The Invisible Population: Dental hygienists providing care in a skilled nursing facility is something Florence would approve of

March 13, 2015
Dental hygienists providing care in a skilled nursing facility is something Florence would approve of

Dental hygienists providing care in a skilled nursing facility is something Florence would approve of

BYCarol Roszel, RDH, BSDH, CHT

"I think one's feelings waste themselves in words; they ought all to be distilled into actions which bring results." - Florence Nightingale

Dental hygiene social media sites recently have been aflutter with concerns over the poor oral health of the elderly population in skilled nursing facilities (SNF). Most of the social media comments point fingers at the nursing and support staff of the SNF, stating that they should improve the oral care for the residents.

Should nurses and support staff be in charge of oral care? Doesn't it make more sense for hygienists, who spend their entire career providing oral prevention, to be in charge? Dental hygiene was created because this is an area that needs special attention and care.

In 2000, the Centers for Disease Control and Prevention (CDC) proclaimed: "Elderly nursing home residents have extensive oral disease and poor oral hygiene and suffer the worst oral health of any population." Subsequent to this proclamation, the CDC has still done nothing to help rectify the situation. What are dental hygienists actively doing differently than the CDC? It is easy to make the oral health issues of our elders someone else's responsibility. Yet, as Florence Nightingale said so long ago - and still holds true today - actions bring results.

Educational Differences

In the ever-changing health-care arena, nurses and nursing assistants are overworked, understaffed, and underpaid, having little time and expertise to provide - let alone consider - adequate oral care. Nurses and aides are already inundated with a multitude of necessary duties. The first and most surprising point that I learned is that their educational background does not prepare them to properly perform oral care for any patient. Nursing students get minimal education in oral care. Their dental education consists of how to swab a patient's mouth when it's appropriate.


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The norm for many nursing assistants is on-the-job training from others with little oral care background. Becoming a certified nursing assistant requires formal training. Yet instruction in patient care focuses on how to properly dress, bathe, and feed a patient. They are also taught to take vital signs and provide catheter care. These skills are practiced during a clinical externship at a local hospital or nursing home with a licensed health-care professional supervising the externship. This is to ensure that each student has the knowledge and skills required for certification.

Nothing is mentioned in the educational curriculum about oral health, periodontal disease, or systemic effects of oral bacteria increasing the chance of developing aspiration pneumonia, heart disease, or diabetes. So how can dental hygienists chastise the staff of an SNF for not completing tasks when information regarding the task is not taught in their training? It is our responsibility and obligation as dental hygienists to care for our patients even when they are in their elderly years. It is also our responsibility to educate and assist other health-care professionals in providing appropriate oral care for their patients. It's been a few years since I've graduated from dental hygiene school, yet I do not remember an age limit for care we provide.

"I attribute this to my success: I never gave or accepted any excuses." - Florence Nightingale

Actions with Words

Having my 88-year-old mother with moderately severe dementia in an SNF for the last two and a half years has brought me to the frontline of the need for change. In January 2014, I met Angie Stone, RDH, BS, who shared with me her family story and passion of working with the elderly and her viable solution. Angie started HyLife, LLC (hylifellc.com) - a network of compassionate dental hygienists who are also certified caregivers (americancaregiverassociation.org). We provide brushing and interproximal cleaning on a weekly basis, not as hygienists but as caregivers, to dependent adults. Residents use xylitol, a naturally occurring sweetener taken three times throughout the day to supplement our weekly visit. This is accomplished by the nursing staff dispensing xylitol to the residents three times per day as ordered by the physician. The staff is also given simple, appropriate oral health actions to assist between our visits.

I started my mom on this regimen in January 2014. For my mom, this has been more than just fresher breath. Mom, a former dental assistant and wife of a dentist for 55 years, still has a full complement of teeth. The combination of the xylitol in addition to my reminding and assisting her with brushing and flossing has improved her beginning gingivitis infection.

She also has not had a urinary tract infection since being on the xylitol. The year before using xylitol, she had eight infections. My mom remains healthy, except for her cognitive deficiencies. During her last quarterly care plan review, I noted this improvement to her care team and explained the clinical research and the benefits we offer at HyLife. The administration has been extremely encouraged and delighted with the opportunity to offer this oral health option to the rest of the residents in their facility.

Florence Would Approve

This oral care model is not a perfect situation; most elders would prefer to take care of their own oral health, but considering their physical, mental, and comorbid conditions, this is a workable solution. Our elders deserve optimal oral and physical health and HyLife is making it happen. We are taking small but firm steps in providing necessary oral care. Of greatest importance, we are preventing elders from "dying of dirty teeth." If Florence were alive today, she would stand side by side with any of us as we challenge our coworkers, fellow health-care providers, and legislators to be part of the solution and not the problem. She would applaud our efforts to provide the best care possible for our patients and educate those who care for them on a daily basis.

"Were there none who were discontented with what they have, the world would never reach anything better." - Florence Nightingale

It is still our responsibility to care for these patients. Ideally, every patient should be able to walk into a dental office, sit down, and "open wide" until the day they die. However, the ideal world does not exist. We have taught, cajoled, and encouraged our patients to "brush and floss so their teeth will last a lifetime." Why would we stop seeing them when they need us most?

These are the loyal patients who have supported us over the years and kept their six-month recare appointments, remained in the practice for all of their restorative work, and became long-term patients. In their time of need, their elder years, are we to let their teeth decay and allow their oral infections to complicate their death?

Try to get a general dentist to do a house call to a nursing facility. It is problematic to get dental care in long-term care or skilled nursing facilities. Our elders become the invisible population. Many people ignore our elders, avoid visiting or caring for them because "they're difficult or slow." In reality, it's out of fear that we too may be in that position someday, sooner than we think.

Hygienists are very much like Florence Nightingale. We want to make a difference. We are people in a specialized preventive profession, filled with compassion, kindness, and the insatiable yearning to help others. We're edgy, pushing the boundaries of our practice acts, office policies, and personal routines. We are life-long learners and think outside the box. We constantly ask why do we do that? Or, what if we ...? We multitask, organize, and seek efficiency. When a particular patient's trouble hits our hearts, we attack a problem with the passion and devotion of a pit bull.

So what we should be asking is, "What would Flo do?" More importantly, "What can I do and how do I want to be treated in my elder years?" RDH

Carol Roszel, RDH, BSDH, received her education at Loyola University. She has spent a majority of her career in various settings of clinical hygiene and is an Oraspa therapist. Carol has been an oral care specialist with HyLife, LLC, since 2014 and continues her passion in writing and speaking. She can be contacted at [email protected]