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Engaging with nursing homes

April 2, 2018
Kyle Isaacs, RDH, advocates for dental hygienists to provide preventive dental therapy for institutionalized elderly patients.
The experience can be sobering, but you can make
inroads with caring for patients who need your touch

By Kyle Isaacs, RDHEP, BHS

I used to cringe at the idea of going into a nursing home, observing people lying in bed or sitting all day in a wheelchair with their heads drooping down onto their chests, saliva dripping slowly from their mouths. A multitude of feelings would hit me as soon as I walked through the front door—disgust, sorrow, recoil, and determination—a determination to not end up in one of these places and a resolve to do something to increase the quality of the resident’s lives.

I might not be able to change the fact that they are living there, but I can make a difference in their oral health one person and one facility at a time, and so can you. Don’t let state practice acts stop you. Get creative because there is more you can do than just providing direct care, at least that is until the laws change.

I have heard from many dental hygienists who are frustrated and bored with working in traditional dental offices, and many expressing interest in helping people in long-term care facilities. Oral care in these facilities is either not happening or, at best, is poor, even though intentions may be good. Based on my experience, I find that administrators, nurses, and social service directors on the whole have no idea about what is behind the lips of their residents. They are not looking in the mouth and think that, if a resident does not complain, all is good!

Slowly, I am educating those in charge as well as certified nursing assistants about the importance of oral health as well as the unhealthy status of residents’ mouths. You can do this too! It might not be easy to get started. It might be slow getting facilities on board, but we need to start somewhere if we are to make a difference.

Have you had the opportunity to look into the mouth of a resident living in a long-term care or skilled nursing facility (SNF)? What about a person with special needs who is unable to go to a dental office or someone who is homebound?

It is my goal to have at least one dental hygienist on staff providing education and direct dental hygiene services in every facility in the United States. These are our parents, grandparents, brothers, sisters, and friends who need our care.

When I worked in private practice, I had seen only a small number of special needs and dementia patients. I was shocked the first time I saw the lack of oral care in a long-term care facility and was quick to judge (at least in my mind) about why oral care was not happening. It was far worse than I ever expected, even with people who have money. I quickly learned that people in facilities are not getting the oral care they need as care providers are overworked, underpaid, and many do not feel comfortable providing oral care.

Of course, there are those patients/residents who are not cooperative, making oral hygiene difficult. But the majority of these residents do not have the skills anymore to effectively clean their mouths and those who try usually do not do a thorough job. Finding a way to educate staff without them feeling like you are judging them can go a long way in building strong relationships with care providers and these relationships build trust and open up good lines of communication. I knew that I had to find a balance between educating and appreciating so as not to create animosity.

Make Friends, Not Enemies

If you have not visited a nursing home, memory care facility, rehab, or assisted living facility, I recommend you do. I have never seen one with a dental operatory, but they all have hair salons. In no way am I denying that looking good makes you feel good, but the importance of oral health is understated. Hygienists can start by contacting the facilities and asking to speak with the administrator, director of nursing, or social services director.

Ask if you can write a short blog about oral health to go into their newsletter that goes home to family members. When I started doing this, I immediately was contacted by a resident who had questions about dry mouth remedies.

Ask if you can come to the facility and provide an in-service training. This is a great way to help the staff and administrators understand the importance of oral health. This could be done in a variety of ways. You could put together a survey to find out what the care providers are doing now to provide oral care, and how they feel about doing it. You could use that information to help you formulate a presentation with PowerPoint slides that includes information about the oral systemic link, periodontal disease, and caries as a start.

Most facilities where I have presented have allotted less than an hour. I have had some that only gave me 20 minutes. In those situations, decide what are the most important items that you want the staff to learn? My presentation includes information about how to work with people who have dementia as well as those with an intellectual or developmental disability. But not all of the facilities have these types of patients. So instead of talking about a group of patients that does not pertain to them, it is helpful to ask ahead of time.

When I do a presentation, I always tell the care providers that I am available and happy to show them how to provide oral care. Before the presentation, I always thank them for all they do. This can go a long way for building good relationships without animosity; the relationships that will help gain the support needed to get the assistance necessary to provide dental hygiene services.

Beyond the minimal

Compounding the situation in the skilled nursing facilities are the minimal state and federal guidelines regarding dental care. The guidelines are as follows:

• Resident’s Rights 483.10 (c)(8) (i)(E)—Residents of SNFs have the right to supplies including: a toothbrush, floss, toothpaste, denture adhesive, and denture cleaner.1

• Resident Assessment standard 483.20 (b)(1)(xi)—A new resident must have a dental assessment and dental diagnosis within 14 days of admission.1 Assessments must be done at a minimum of every 12 months or if there is a detected decline in their physical condition and then it has to be done within 14 days of notice of said decline.1

• Administration standard 483.75 (h)(1)—Facilities are also required to contract with a dentist under the most likely to provide oral assessments.1

• 483.55—Facilities are required to help residents get 24-hour emergency dental care and make appointments, arrange transportation to a dental office, and refer residents who have lost or broken dentures.1

Even with these guidelines, I often wonder if the assessments are being done and, if so, what treatment is being performed for oral disease. After seeing the mouths of the residents in the SNFs, I cannot fathom that much, if any, dental treatment has taken place. I don’t know what is happening, but aside from much needed preventive dental hygiene services, even these minimum standards do not appear to be happening. Some states have guidelines that go above the federal ones.

Are you ready to show the world that the more than 1.3 million people living in SNFs need our care? Who is up for the challenge? It is my goal to have at least one dental hygienist on staff providing education and direct dental hygiene services in every facility in the United States. These are our parents, grandparents, brothers, sisters, and friends who need our care.

Many states have changed their practice acts to make it easier for dental hygienists to provide dental hygiene preventive care for those unable to access care. This is a huge game-changer for everyone—patients and dental hygienists. Even with the changes in practice acts, it is no easy feat to start seeing these patients and providing care. There can be many hurdles getting there such as figuring out who the power of attorney is for some patients, how to get paid, and to get your foot in the door. With good reason, care providers at facilities are often overworked and underpaid. They do not have extra time to talk with us.

I know it can feel daunting trying to get a handle on the state of the oral health of residents in SNFs. But if we do not do anything, the health care costs, poor health outcomes, and poor quality of life will continue to worsen. Each time one of us can go into a facility and educate, regardless of providing treatment, this is one step closer to providing care and, while doing so, building much needed relationships so that we can collaborate and do what is best for the many people living in these places. How can you help if you can’t provide direct dental hygiene services? Getting your foot in the door is the first step in helping to educate patients, care providers, administrators, and families on the importance of good daily oral hygiene and professional dental hygiene services.

Maybe you would like to do assessments and provide care but cannot due to your state’s practice act. Don’t despair. Maybe a dentist would be willing to go with you once a month or even quarterly. Your presence in doing this and providing in-service training will begin to bridge the gap between the medical and dental communities.

I helped start a pilot project increasing access to care and all of the facilities (14 in total) were so excited to have us come and take care of their residents. I am working on getting the local media to do a story on our pilot project and how we are getting preventive oral care to people who have not had it for many years. I know it can be easy to talk yourself out of trying for fear that you will get a door closed in your face. This just means it is time to try a different tactic. Be persistent. New ideas and change can take time, and it can take several times emailing, calling, and showing up before you get an audience

I am so grateful that I get to make an impact on the lives of those living in these facilities. I try hard not to judge even though I have assessed countless residents with multiple broken teeth, teeth broken to the gum line, unimaginable periodontal disease with many teeth hanging on by sheer will, rampant decay, and mouths laden with biofilm and food debris that has probably not moved for years. It is so much easier to judge than not, but, when we do, the progress we have made will be stifled and gaining trust and acceptance will be that much tougher.

Finding a way to delicately explain the situation can be difficult. For me what has helped is to take photos and/or show the administrator or nurse directly in a resident’s mouth often not the first time I am there, but after a few visits and the staff knows me. Every time I have done this, there are shocked responses. I also have heard, “Wow, but they never complained!” Obviously, no one is looking!

Instead of complaining, instead of giving up, let’s do whatever we can to educate and share our expertise with long-term care facilities so that our loved ones and those who do not have anyone to care for them can get daily oral care and professional dental hygiene services regularly. We need to start opening those doors to better health and dignity. Are you ready for the challenge? Let’s start to lay the groundwork; the rewards are so worth the hard work.

Kyle Isaacs, RDHEP, BHS, lives near Corvallis, Oregon, where she provides school-based sealants in Benton County. She also owns a company, Miles 2 Smiles LLC, and provides dental hygiene care in churches, private homes, and schools. She is a professional educator for WaterPik and a clinical representative for Young. She is a member of the American Dental Hygienists’ Association and serves on the board of trustees for the Oregon Dental Hygienists’ Association. She loves to volunteer and comes from a family with many dental professionals. She has been a dental hygienist for 35 years. She is a 2017 recipient of the Sunstar/RDH Award of Distinction.


1. University of Minnesota School of Public Health. 2011. NH Regulations Plus. Dental Services. http://www.hpm.umn.edu/nhregsplus/NH%20Regs%20by%20Topic/Topic%20Dental%20Services.html#descriptionfed.