The nursing home's view of oral care

The mouth, while the center of our world, is not the center of theirs.

Remember the first time you put your hands in a patient's mouth? Not a family member or fellow student's mouth, but someone you only knew for a few minutes. Were you afraid? Did the following list of potential problems cross your mind:

  • Patient not opening their mouth
  • Patient refusing to let you do your job
  • Patient biting the prophy angle or instrument
  • Patient refusing to rinse
  • Patient kicking or hitting you
  • Patient spitting on you
  • Patient biting you

Do you remember when you realized how much needed to be done in a prophy appointment? Did you panic and wonder how on earth you were going to fit all that into a 60-, 50-, 40-, or 30-minute appointment? What did you end up eliminating from your treatment plan? Would you ever consider leaving calculus behind in order to get an oral cancer screening done?

Now, what if you had to work on a number of patients, say, over 10? Replace the title of patient or client with "resident." You are responsible for all forms of personal hygiene for this group of residents. These areas include dressing, eating, washing the entire body, feeding, potty events, rolling patients over, helping them from bed to wheelchair and back numerous times a day, as well as getting them to appointments and keeping progress notes on all that has occurred during the day.

You also are in charge of giving them medications, getting them to their favorite TV show, talking to them, doing pedicures and manicures, styling hair, changing wound dressings, arguing with them when they're grumpy, crying with them when they're lonely, and listening to the same story over and over, even though it's getting difficult to understand due to illness, stroke, tubing, or fatigue.

Do this for a solid eight to 10 hours a day, and eliminate prestige, orderliness, gratitude, and a good back when performing these duties. That's the life of a certified nursing assistant (CNA) and even a nurse in a long-term care facility. Oops, I forgot to list oral care. No wonder they give us the evil eye when we bring it up!

Studies over the years show the dental industry that care-givers in long-term care facilities don't do oral care for numerous reasons, most of them listed above. The mouth, while the center of our world, is not the center of theirs. Until recently, most residents had very few teeth. Removing the denture and giving it the once over in the sink with running water and a brush wasn't that big a deal. Some residents did not even wear dentures. They ate a soft diet and got along nicely. We know that's just not true today. Residents have more teeth, and, consequently, more problems.

This is not a phenomenon noticed by hygienists in the United States only. Many studies have been done in other countries with similar results. Japan, the United Kingdom, Sweden, Switzerland, and Canada are just a few of the countries that share this scenario.

CNAs are educated people. Over 90 percent have completed a CNA course and, while educated, only 14 percent had more than a one-hour lecture on oral health. They take very good care of people that need specialized help. They care for the entire body, directly.

A study from Geneva looked at facility managers, care-givers, and physicians. The data supported the educational level of the care-givers. One interesting fact was that the few care-givers who had a minimal education reported fewer problems with oral care. The Geneva care-givers wanted more oral hygiene education, which is similar to other research findings. Here's more:

  • 33 percent of the physicians indicated that they did a systematic exam of the mouth on new residents
  • 39 percent checked the mouth when symptoms presented
  • 50 percent of the physicians thought of the mouth as a source of pathology
  • 22 percent stated it was not part of their profession
  • 17 percent said that the oral cavity was primarily an integrated part of the body
  • 78 percent agreed that a course on oral health of the residents might be relevant to their medical practice
  • About half the physicians thought a private dentist in the vicinity was the best option for dental care
  • 65 percent of nurses thought the best way to deliver dental treatment was a dentist with mobile equipment
  • Less than half of the nurses, assistant nurses, and qualified aides thought that dentists or hygienists should provide daily oral care
  • 36 percent of the managers did not answer the question about frequency of dental visits of their residents
  • 23 percent reported one dental visit per year per resident
  • 15 percent of the managers reported having a program for oral hygiene instruction
  • 40 percent of the managers reported having a room available for dental care on site

Japanese care-givers have this to say about the oral care aspect of their jobs:

  • Only 11 percent found oral care to be a burden
  • Only 8 percent wanted to discontinue oral care
  • Only 23 percent perform systematic oral care
  • 80 percent want equipment to simplify oral care
  • 85 percent want to use additional oral-care methods
  • A whopping 99 percent consider oral care to be important

So, what's the problem? Why do dental-care providers see patients with all types of dental problems stemming from lack of oral hygiene measures?

A study of nurses' dental assessments in Minnesota nursing homes helps shed a little light on the question. Although the population they deal with is at extremely high risk for dental problems, the assessment instrument (check sheet) that the nurses used to detect dental and oral problems identified very few. The authors wondered if the instrument was even functioning.

There is a false sense of security on the care-givers' part. They think they are doing well.

It's clear from the literature that care-givers in long-term care facilities care about the oral-health status of the residents. Even during their busy day, they know that oral care is important. The biggest drawback for them is the fact that they do not have willing participants like we do. The residents don't come to them, lay down, and open wide. The providers fear getting bitten, getting spat on, or worse. I think we have to respect that. We also have to respect what they think will help them achieve this common goal. Nebraska Directors of Nursing said the following:

  • Oral health in-services by dental personnel is helpful (An in-service is an on-site 30-45 minute presentation on a technique or solution to a problem)
  • Dental personnel evaluating existing oral hygiene protocols is helpful

On the other hand:

  • Distributing oral-health educational materials is not helpful
  • Assigning a nursing-staff person or CNA as an "oral health specialist" within the facility is seen as not helpful

If, in the future, an opportunity for educating staff members in long-term care presents itself, the studies say that they will happily receive us. These studies also show that the higher the dental IQ of the staff members, the more apt they are to provide this service to the resident. It might be helpful if a dental hygienist would teach the section on oral care to student CNAs and nurses. Learning oral care properly in school increases the importance of the procedure. A mandatory in-service training during a lunch break at work doesn't get the same attention.

I remember one of my instructors telling our class that we weren't just "tooth-pickers." We were educators. At the time, I thought she meant educating our patients. Now I know that she was referring to an interdisciplinary approach of educating for the betterment of all patients.

Shirley Gutkowski, RDH, BSDH, has been a full time practicing dental hygienist in Madison, Wis., since 1986. Ms. Gutkowski is published in print and on Internet sites, and speaks to groups through Cross Links Presentations. She can be contacted at dentwrite@aol.com.

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