Tough work, Good reward

Jan. 1, 2000
Ensuring adequate oral health in a long-term care facility usually means volunteering and spending that fictional income on more training. The benefits of caring for the elderly, however, are plentiful.

Ensuring adequate oral health in a long-term care facility usually means volunteering and spending that fictional income on more training. The benefits of caring for the elderly, however, are plentiful.

Cathleen Terhune Alty, RDH

Do you love dental hygiene so much that you`d practice for free? Before you laugh at the seemingly preposterous question, consider the needs of individuals who live in a long-term care facility. Although all ages can be represented in a facility`s population, most are elderly and in desperate need of basic dental care. You could supplement that ho-hum, business-as-usual office experience and volunteer for a position that puts you in charge of planning the care for hundreds of patients. Few other practice settings offer dental hygienists the incredible challenge and satisfaction that a long-term care facility can offer.

The need for oral health care is great. Reports estimate that the number of nursing home residents will increase to 2.4 million by 2005. In the past, many elderly people had full dentures, but many now have full or partial dentitions. Statistics say that 30 percent of 65- to 74-year olds were edentulous in 1986. It is estimated that only 10 percent of this age group will be edentulous in 2024.

Barbara J. Smith, RDH, a clinical dental hygienist at VA Hospital in Ann Arbor, Mich., identifies several issues for dental hygienists to consider when reaching out to the patients in long-term care facilities.

"Keep in mind that a person residing in a long term care facility will not be getting better and will have chronic disease that requires extensive supportive care," Smith said. "Most are elderly and have multiple physical diseases that accompany old age."

A former assistant director of Oral Health Services for Older Adults at the University of Minnesota - a graduate training program for geriatric dentistry - Smith added that the need may be great but the workers are few. "There is a lack of people who are qualified and interested in providing care," she said. "Many hygienists have a keen interest in geriatric dentistry because they see the need. But there is a need for training in dentistry for geriatrics that is over and above what they initially received in school, even for dentists."

Dr. Ronald L. Ettinger, who is with the department of prosthodontics and The Dows Institute for Dental Research at the University of Iowa, said, "Dental hygienists have a major role in the care of aging adults, particularly in hospitals and long-term care facilities. But to do that, there is a need for more than just the skills they have now, particularly in the areas of oral medicine and pharmacology."

It will probably take a bit of effort on the hygienist`s part to even secure a volunteer position in a long-term care facility. You probably won`t see a nursing home with a "dental hygienist wanted" sign in the window. "Jobs don`t exist like this in nursing homes," Smith said. "You have to make a job for yourself in a facility."

Chances are good that it won`t be a paid position, either. Even though these residents have extensive oral health needs, there are little or no funds to pay for it. "Financial barriers are a problem," Smith said. "Many residents have exhausted their financial resources and are dependent on medical assistance, such as Medicaid. A small percentage of dental care is paid for by medical assistance, but some states have no provisions for adult dental benefits. A hygienist who wants to do this should see it as a community service."

Many aspects of practice that we are accustomed to will be different in a nursing home. "We are most comfortable with patients coming to us, but in a long-term care facility, we come to them," Smith said. "Dental professionals often don`t have a firm grasp of the medical issues that these patients face. There may be several medical problems layered with several different drug therapies. Any or all may affect dental health."

Smith said the most useful function of the hygienist in the long-term care facility is as more of an administrator than solely as a clinician. Hygienists are familiar with a clinical environment, where they partner with patients, assessing patient needs, cleaning teeth, and providing one-on-one patient education. She feels that the key to working in a nursing home is to work with the individuals who provide the day-to-day care.

"It`s a poor use of a dental hygienist to do the daily hygiene care of these patients. Instead, the hygienist should evaluate the needs of the patient and then ask, `How can I help the nurses aides do what this patient needs?` Rather than one-on-one education with the patient, you have a larger audience to educate because patients are dependent on others to help them."

Besides providing assessments and training, a hygienist could organize a system that monitors and directs daily care for each patient, working with the facility`s administration to ensure that proper care is rendered. "A dental hygienist who is organized, detail-oriented, and creative could develop some very effective systems to help meet these extensive oral health needs. Realistically, these patients need comprehensive oral health care supported by a team. A hygienist would be an important part of this team."

State practice acts can be a barrier, preventing hygienists from directly working with a nursing home facility. Instead, they legally must work with a dentist, hopefully one who shares the interest.

Whether working in a long-term care facility or as part of an oral health care team, the two significant components that are needed for care to actually occur are:

- A good relationship with the facility`s administration.

- Communication skills tailored for the elderly.

First, you need good support from the administration at the long-term care facility. "Administration usually is comprised of the administrator of the facility and the director of nursing," Smith said. "The administrator is responsible for the overall functioning of the facility, including the budget, and the director of nursing is responsible for the nursing functions. Their interests overlap, although they are two separate jobs. If these two people are on your side, they can make anything you want to do work. If they are not 100 percent behind you, it won`t work. So it`s important to get their complete support."

Getting their support comes from first understanding the nature of their business. Smith said that a pitfall is that dental professionals don`t often spend enough time studying the nursing home industry. "It`s easy for us to come in and say, `You should be doing this or that,` without realizing there are many things that these people are responsible for. There are the finances, the level of care required, plus they are tremendously regulated by federal and state laws. Dentistry is one small piece of a larger puzzle, regardless of how dental professionals see it."

A second critical element is communication. "As a provider of clinical services, we often forget that the long-term care facility is home to these patients," Smith said. "This is where these people live. As a part of living, they engage in multiple activities, such as bathing, activities, hair appointments, physical therapy, etc. We carry on our appointment schedule mentally as we enter in the long-term care facility, forgetting that a person could be involved in another activity when we arrive."

We also need good communication systems set up between the administration and our work in the facility. "They need to know what we are doing, and we need to understand what they are doing. It is helpful to have a liaison between the nursing home and the dental team to help facilitate patient care. You must remember you are interacting with the facility, as well as the individual. You must also communicate with the family and the physician. You need to identify all these people and consider how to reach them."

Dental jargon can interrupt good communication, according to Smith. "We need to speak in a way that nursing home personnel will understand. Even the dental record needs to be written so nondental personnel can read it and understand what was done. Instead of a prophylaxis or prophy, it should also be written as a cleaning; an `MOD,` may need to be also written as a `filling.` The medical and dental records must be compatible."

Smith thinks a very hygiene-specific computer program that would track delivery of preventive care would be ideal, but no program of this type as yet exists. But just as portable dental equipment didn`t exist a few years ago, demand often brings needed products to the marketplace.

Demand for more geriatric training and hygienists who are free to practice in alternative settings such as nursing homes may bring these to reality as well.

It all starts with concern for a population that is underserved and dental professionals who are willing to sacrifice some income for something much more rewarding: The knowledge that they really made a difference in another person`s life. I think we`re up to the challenge.

Cathleen Terhune Alty, RDH, is a frequent contributor to RDH who is based in Clarkston, Michigan.

Where`s the toothpaste? is a San Francisco company that specializes in providing information and resources for people who need help in obtaining training for a career. The company offers the following insights into nursing aides, who likely know where the toothpaste is kept for facility residents.

- "[Nursing aides] answer patients` call bells, deliver messages, serve meals, make beds, and help patients eat, dress, and bathe. Aides may also provide skin care to patients, take temperatures, pulse, respiration, and blood pressure, and help patients get in and out of bed and walk."

- "Nursing aides employed in nursing homes are often the principal caregivers, having far more contact with residents than other members of the staff."

- "Most full-time aides work about 40 hours a week, but, becuase patients need care 24 hours a day, some aides work evenings, nights, weekends, and holidays ... Aides spend many hours standing and walking, and they often face heavy workloads."

- "Nursing aides often have unpleasant duties: They empty bed pans and change soiled bed linens. The patients they care for may be disoriented, irritable, or uncooperative ... While their work can be emotionally demanding, many aides gain satisfaction from assisting those in need."

- "Nursing aides held about 1,312,000 jobs in 1996 ... about one-half of all nursing aides worked in nursing homes and about one-fourth worked in hospitals."

- "In many cases, neither a high school diploma nor previous work experience is necessary for a job as a nursing aide ... Nursing homes often hire unexperienced workers who must complete a minimum of 75 hours of mandatory training and pass a competency evaluation program within four months of employment. Aides who complete the program are placed on the state registry of nursing aides."

- "Applicants should be healthy, tactful, patient, understanding, emotionally stable, dependable, and have a desire to help people. They should also be able to work as part of a team, have good communication skills, and be willing to perform repetitive, routine tasks."

The entire profile of nursing aides can be viewed by logging onto the company`s Web site, which is the same as its name -

How does toothpaste work?

If you`re planning to train caregivers, here are some tips from Kathy Olson, RDH, who has taught in-service programs at extended care facilities throughout Illinois for the past 12 years:

- Understand your audience. Caregivers usually work hard for minimum wage and do not have a high level of education. Tailor your presentation accordingly.

- Make your presentation as interesting as possible. If you simply read a list of facts, don`t expect interest and enthusiasm from your listeners. Audience involvement and participation often are helpful.

- Don`t get bogged down in details. Keep it simple and brief. Focus on a few critical points.

- Help staff to see that oral care is a critical part of total patient care.

- Be assertive and present your material confidently. You are the expert with this audience!

- Use visual aids whenever possible, but don`t overload your presentation with them.