Suffering in silence

How expanded dental hygiene practice and SDF could radically improve outcomes for older Americans

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We live in an exciting time. Although it is slow by some people’s standards, the scope of practice for dental hygienists is expanding across the nation. Not only will this open up more career options for hygienists—it will also bring dental care to those in need and result in better health outcomes.

This is especially true for those over 65, as the need for nursing-home care will almost double. In 2010, 1.3 million people used these services, and it is estimated that 2.3 million will in 2030.1 This means that there will be a huge number of people who are unable to go to a dental office. Imagine an ideal world in which a dental hygienist is on staff in every facility to screen patients, provide preventive services, and apply silver diamine fluoride (SDF). This would be a huge step in making an impact on the overall health outcomes and quality of life for the older population.

The first time I went to a nursing home to provide dental hygiene care for a resident, I was glad I had my mask on to hide the look on my face. I quickly learned that the lack of oral care was the norm, and that no one in the facility knew about the advanced disease and devastation that lurked in the residents’ mouths because no one was looking for it.

As the population of people over 65 rapidly increases (98 million projected for 2060, twice that of 2006), the need for paid long-term care will grow exponentially, and with that the need for preventive oral hygiene services.2 Not only will there be more seniors than ever before, but many will have disabilities that make oral care difficult. In the 2017 Profile of Older Americans, 35% of those over the age of 65 had some sort of disability that made it more difficult for them to take care of their activities of daily living, meaning they were reliant on others to care for them.2

And what about chronic disease? As people age, the incidence of chronic disease rises, as does polypharmacy. More medications can lead to hyposalivation, a diminished sense of taste, and an increase in the consumption of simple carbs, a recipe for disaster. When our patients are no longer able to care for themselves, who will clean their teeth? I can tell you that, for the most part, the nursing assistants and nurses are not comfortable providing this care. They have had little to no training, and they generally do not know what to look for, often waiting for residents to complain.

For many people, especially those who have dementia, are on hospice, or are bedbound, going to a dental office for treatment is not realistic. I often hear from facility staff that the patient I just assessed, who has rampant dental disease, has not complained of pain or discomfort. Although there is very little research on the subject, a person with dementia has difficulty communicating pain. Waiting for them to do so usually means extensive destruction has already taken place.3

I have had patients who refused to leave their memory care facilities, and others who were taken to the dental office only to refuse to go in, and still others who were in the chair but were uncooperative. Many never leave their beds, need two people to be transferred to a dental chair, or require a Hoyer lift. All of these circumstances prohibit treatment in a dental office. To make matters worse, there are very few mobile dentists or dentists willing to provide treatment in a facility or in a person’s home.

Even for our older patients who can still come into the dental office, extensive and expensive procedures are not always realistic. Recurrent root caries is common, and many older patients have a lot of dental work and compromised crown margins. Paying for dental care is a barrier for many seniors, as they live on a limited income and have no dental insurance; Medicare does not pay for any dental services. According to the 2017 Profile of Older Americans survey, in 2016 the median income for seniors was $31,618 for men and $18,380 for women, making it even more difficult for seniors to get dental care.21907 Rd Hisa P02 Copy

I think you can see the picture I have painted. There are so many factors to tip the scale toward disease. To make matters worse, people with dementia or who have had a stroke are more likely to “pocket” food and have dysphagia, both increasing the possibility of oral disease and aspiration pneumonia. Dysphagia (i.e., difficulty swallowing) is common in older people who live in long-term care facilities (LTCFs); in fact, it affects up to 68% of the elderly who live in a nursing home and 45% of those people who have dementia and are in an LTCF. 4 Dysphagia also affects as many as 64% of patients after they have a stroke.4

Nutrition is often compromised, and dehydration is common.4 When people experience dysphagia, often they will be provided with thickened liquids for meals. The thickened liquids are made with modified food starch or maltodextrin, which are refined starches that break down quickly in the mouth. Because of the nutritional deficiencies, many patients with dysphagia are given “nutritional shakes.” We are talking about premade shakes that have a lot of sugar. We all know what happens when sugary beverages are consumed on a regular basis.

It can be tough to enact dietary changes in LTCFs or get the staff on board with daily oral care. Even dental offices that have nursing home patients coming to them for their oral care still have a tough time getting oral hygiene recommendations enacted at the facility. Many of my patients have a very long list of medications, some of which are prescribed to counteract the side effects of other medications. It can be so frustrating trying to do the best for these patients. Who knows if the prescription fluoride and xylitol you recommend is being used? All of these circumstances often lead to quick and devastating destruction in the mouth—believe me, I have seen it firsthand.

The availability of silver diamine fluoride (SDF) in the United States in 2015 for dentinal hypersensitivity has given us another option to help these patients. Yes, it works great for desensitizing and it is used off-label, just like fluoride varnish. Although there have not been a lot of studies on older adults and permanent teeth, SDF has been shown to help control caries, stop the initiation of lesions on roots, and has in a few studies shown promise for reducing biofilm adherence on teeth in the elderly population.5-7

A systematic review of 895 older adults compared an annual application of SDF to quarterly applications of 1% chlorhexidine and sodium fluoride varnish, and a control over three years. All three of the test groups were better at decreasing the incidence of new carious lesions, and with time, better results were seen with SDF.7 Promising news!

When SDF was first approved by the FDA and available in the United States, some early recommendations suggested rinsing, drying with air after application, and light curing. Those practices are no longer recommended. Apply for up to one minute if possible. Patients with dementia might not allow that; do what you can. Sometimes my dementia patients won’t open much, if at all, and I can only apply on buccal surfaces.

After applying, you can blot excess liquid with gauze and let it be or you can cover it with fluoride varnish. Evaluate two to four weeks after initial application if possible, and then, for high-risk patients such as those living in facilities, check at three-month intervals, and alternate applying SDF and varnish. Reapplication may be necessary for caries arrest, and continual monitoring is important. This is just a brief overview of how to apply SDF, and because it is a new therapy in the US, clinical practices can change quickly. Please consult continuing eduction materials for more information.

SDF is not a cure, and good oral hygiene and nutritional counseling are still important. Until we can get a hygienist on staff in each LTCF, the oral hygiene of the residents will continue to be less than ideal, with heavy biofilm and materia alba throughout.

According to Mei et al., SDF was shown to inhibit biofilm by decreasing the formation of glucan, which is integral to the growth and adherence of biofilm. This action is thought to result from the combination of the silver and the high concentration of fluoride content in the SDF.5 Knight et al. conducted a small in vitro study looking at SDF and its effect on biofilm; they found that SDF with and without potassium iodide decreased biofilm formation after extracted third molars were exposed to Streptococcus mutans.6 They also found that there was less calcium and phosphate loss in the SDF group.6 Just think how this will benefit the oral health of the residents of LCTFs . . . less biofilm and less decalcification, one more piece of the puzzle in preventing oral disease.

We know that prescription 5,000-ppm sodium fluoride has been shown to be effective in preventing new carious lesions, but when a resident of an LTCF is reliant on others to use these gels and pastes, there is no guarantee that it will be used effectively. The cost of the 5,000-ppm sodium fluoride paste is more expensive than one application of SDF applied biannually. A three-year study done in 2010 showed that annual applications of SDF on roots of healthy older adults was found to result in fewer new root caries than quarterly applications of 1% chlorhexidine and 5% sodium fluoride varnish.8

As the older population rapidly increases, their oral needs will rise exponentially and the use of SDF in LTCFs as well as in dental offices will be even more necessary. lt will not cure disease, but can help make a vast impact on helping to control and prevent caries. Once we are able to educate the public, LTCFs, and the medical profession on the importance of oral health, and change practice acts to allow hygienists to bring care to those unable to access it, will we be able to make greater strides in reaching the older population early enough to prevent the ravages of poor and no oral care. Not only will this help our loved ones have healthier mouths, better nutrition, and increase better overall health outcomes, but it will also help them have a better quality of life.

References

1. Mather M. Fact Sheet: Aging in the United States. Population Reference Bureau website. https://www.prb.org/aging-unitedstates-fact-sheet/. Published January 13, 2016.

2. Administration on Aging. 2017 Profile of Older Americans. https://acl.gov/sites/default/files/Aging%20and%20Disability%20in%20America/2017OlderAmericansProfile.pdf. Published April 2018.

3. Ciolek C. Recognizing Pain in People with Dementia. https://www.phca.org/wp-content/uploads/2018/06/Recognizing-Pain-in-People-with-Dementia-for-handouts.pdf.

4. Sura L, Madhavan A, Carnaby G, Crary MA. Dysphagia in the elderly: management and nutritional considerations. Clin Interv Aging. 2012;7:287-298. doi:10.2147/CIA.S23404.

5. Mei ML, Li QL, Chu CH, Lo EC, Samaranayake LP. Antibacterial effects of silver diamine fluoride on multi-species cariogenic biofilm on caries. Ann Clin Microbiol Antimicrob. 2013;12:4. doi:10.1186/1476-0711-12-4.

6. Knight GM, McIntyre JM, Craig GG, Mulyani, Zilm PS, Gully NJ. Inability to form a biofilm of Streptococcus mutans on silver fluoride- and potassium iodide-treated demineralized dentin. Quintessence Int. 2009;40(2):155-161.

7. Oliveira BH, Cunha-Cruz J, Rajendra A, Niederman R. Controlling caries in exposed root surfaces with silver diamine fluoride: A systematic review with meta-analysis. J Am Dent Assoc. 2018;149(8):671-679.e1. doi:10.1016/j.adaj.2018.03.028.

8. Tan HP, Lo EC, Dyson JE, Luo Y, Corbet EF. A randomized trial on root caries prevention in elders. J Dent Res. 2010;89(10):1086-1090. doi:10.1177/0022034510375825.

Kyle Isaacs, BHS, RDHEP, is an expanded-practice dental hygienist working in a variety of settings. She is passionate about serving the underserved, mentoring other dental hygienists, and volunteering. She is an American Dental Hygienists’ Association member and serves on the board of the Oregon Dental Hygienists’ Association. She is a recipient of the 2017 Sunstar/RDH Award of Distinction and the 2018 Hu-Friedy/ADHA Master Clinician Award. She can be reached at kjulin@gmail.com or milestwosmiles.com.