Loretta Seidl is fulfilling one of her life-long dreams: helping seniors maintain good oral health for a lifetime.
Mary Martha Stevens, RDH, PhD
Ken Dychtwald, PhD, points out in his provocative book, Age Wave, "Throughout most of recorded human history, only one in 10 people could expect to live to the age of 65. Today, nearly 80 percent of Americans will live to be past that age." This is good news for the mass of baby boomers who will move into their forties and fifties throughout the next decade. By the turn of the century, the Census Bureau projects that there will be 35 million Americans over the age of 65. Dychtwald warns us, however, that this will be a challenge for our gerontophobic society. His book clearly outlines the fears, prejudices, misconceptions, and myths we hold about growing old.
From an oral-health perspective, most dental professionals have not begun to look at the oral-health needs of the elderly. However, one exception is hygienist Loretta J. "Letty" Seidl. She recently has been able to fulfill one of her life-long dreams: helping seniors maintain good oral health for a lifetime.
"I`ve loved and respected seniors ever since I was a child," says Seidl. "My parents taught me to respect my grandparents. I was taught to be quiet and listen to what my grandparents had to say because they had information and knowledge that I needed to know."
Seidl, currently program developer for Johnson County Health and Human Services and Aging in Olathe, Kan., became a dental hygienist after working as a dental assistant for 13 years. She found that working with older patients as an assistant and hygienist was extremely rewarding. "In time, I realized that our older patients were my favorite patients. They wanted to talk and share their experiences with me. I became aware that this was probably the only time they had someone to converse with during the day. Progressively, my understanding grew of how important it was for us, as dental professionals, to take time to be with them. The wealth of knowledge they had could not be gleaned from other patients," says Seidl. "As I became more and more attracted to working with our senior population, I realized that this needed to be my life`s work."
Seidl had this opportunity in 1985, when she began working on a master of health-science degree at Wichita State University. As a graduate-teaching assistant in the department of dental hygiene, there were many opportunities to provide staff development for long-term-care facilities. "Luckily, I usually was the only one who was interested in doing this," says Seidl. "I would teach the nursing-home staff the importance of maintaining good oral hygiene for the residents.
After she explained how oral hygiene would help the frail residents eat better, she said staff members began making the connection between the residents` oral health and their overall health. Unfortunately, the staff was not always enthusiastic about performing daily oral-hygiene procedures. They confided to her that residents` mouths had not been cleaned because proper oral-hygiene training had not been provided.
Seidl taught nursing-home aides simple procedures, including how to:
- Prevent chipping a denture by placing a towel in the sink before cleaning it.
- Wet and soften a toothbrush before placing a small amount of toothpaste on the toothbrush before brushing residents` teeth.
- Help residents maintain independence by encouraging them to brush their own teeth, which might involve handing them their toothbrush and toothpaste.
- Use toothettes in the mouths of residents who won`t or can`t brush.
- Remind residents to rinse their mouths after meals and before retiring in the evening.
Although these tasks might seem elementary, Seidl explains that they frequently were overlooked.
While earning her master`s degree, Seidl designed an internship program at the St. Joseph`s Adult Day-Care Center in Wichita. Adult day-care centers were relatively new at the time, which made the experience more exciting. The centers provide stimulation and professional care for seniors who might otherwise be placed in nursing homes. It also relieves caregivers from the constant attention that can accompany their role.
The center gave Seidl the opportunity to interact with physical therapists, occupational therapists, social workers, nurses, and gerontologists. "Each morning, we would review the clients` charts, noting any changes that might have occurred over the weekend or the night. I participated in recreational activities like bingo and ball exercises. Sometimes, I read the morning newspaper to clients. But I always helped feed clients when snacks or lunch was served. One day, we even made butter," smiles Seidl. "After several months, I presented a hygiene program to clients and their caregivers that focused on the importance of daily oral care. It was the first time oral health had been addressed at the center."
Although Seidl subsequently taught dental hygiene at Wichita State University for several years, her day-care experiences were inspiring enough to change her professional outlook. When the opportunity presented itself, Seidl moved to northeast Kansas to work as director of community services at the Douglas County Senior Center in Lawrence. "In this capacity, I worked directly with seniors who still were in their homes, helping them with a variety of services," says Seidl. "These services ranged from tax preparation to placement in subsidized housing." As editor of a 20-page newsletter that was distributed to Douglas County residents, Seidl wrote articles on preventive dentistry, which proved to be enlightening for readers.
In her current position, Seidl designs and implements programs that allow seniors to remain independent and healthy in their homes. The major thrust of the programs is to provide accurate and pertinent information on how to make better financial and medical decisions - decisions that can direct the course of their independence. "I love my job because I know I`m helping seniors stay in their homes a lot longer than they might otherwise be able to do. They can age in place, which means they don`t have to move out of their homes as they age."
But the real magic in Seidl`s life happened when she was able to combine both of her loves into one project.
"I had always wanted to provide hygiene care to seniors in long-term-care facilities," says Seidl. "So, I volunteered to feed nursing-home residents at the adjoining Johnson County Nursing Center. When the center hired a new administrator, I approached him with a plan to establish a hygiene program for the center`s residents. Chuck Nigro, the new director, was elated."
Seidl spent one-half day per week administering hygiene care to the residents under the general supervision of an area dentist. After 18 months of preparation, a comprehensive Oral Hygiene Program (OHP) for nursing-home residents was established utilizing the talents of hygiene students at Johnson County Community College.
"When designing a program of this nature, it was vitally important to involve those individuals who were responsible for the care of the residents. The staff dentist and I met with the director of nursing and her staff, the case managers, and anyone else who was directly involved with patient care," adds Seidl. The dentist would screen the residents and refer them to the program.
Initially, hygiene students spent the first 10 minutes reviewing records and getting to know residents before performing any procedure. "For example, if we found that a resident was taking antidepressants or antihypertensives, we weren`t surprised to find xerostomia," says Seidl.
Seidl taught hygiene students to:
- Review the resident`s health history and admission`s record.
- Perform a comprehensive oral assessment.
- Remove plaque and debris from the resident`s teeth and oral cavity.
- Clean dentures.
- Spend time getting to know and enjoy the resident.
These services were provided to residents who were unable to provide care for themselves. When residents were able to clean their own mouths and dentures, the students would assist and monitor for the desired results.
Nursing-home staff members were asked to participate in the program, which fostered continuity and long-term maintenance of the program`s goals. Seidl explains that involvement ranged from placing toothpaste on a toothbrush and encouraging residents to brush to directly performing daily hygiene care on physically compromised residents.
"Residents who had arthritis were unable to brush their teeth in the morning because their hands weren`t limber enough to hold a toothbrush," says Seidl. "They wanted to brush in the evening when they had more flexibility. It is vitally important to always ask the residents when they want to clean their mouths. Involving the residents as much as possible is essential."
Recording the patient`s progress and the name of the assisting staff member in the resident`s chart also was paramount to the process. "That way," says Seidl, "when the resident`s oral hygiene markedly improved, the staff member was congratulated. It also provided a red flag when additional staff training was needed." But most of the time, Seidl feels, that it gave her an opportunity to praise the staff member for a job well done. Successful staff members then were asked to assist other staff members with these procedures. "People love to be teachers," she says.
Seidl feels it is vitally important for dental hygienists in private practice to know how to work effectively with seniors. "Since seniors will continue to make up a large percentage of their patient load, they will be faced with some of the same challenges that are commonly found in nursing homes. For example, more patients with hearing and vision losses, as well as arthritis, will be walking in the door on a regular basis. Hygienists need to be ready and willing to work with those seniors who live with mental and physical challenges every day."
If you want to learn more about how to work with seniors, check your local or regional continuing-education offerings. Seidl highly recommends the University of Minnesota`s Mini-Residency in Nursing Home Care for the Dental Team, an intensive, one-week residency program that focuses on how to work with the elderly and long-term-care populations.
Many dental and dental-hygiene schools offer other options. Seidl also participated in a nine-month, geriatric-fellowship program sponsored by the University of Missouri-KC School of Dentistry. "If dental hygienists want to make a positive impact on our senior population, they should volunteer to provide staff training at a long-term-care facility in their home town. And, if this experience is intimidating at first, volunteer to help nursing-home residents in any way that you can. Even today, one of my greatest joys comes from volunteering to feed the nursing center`s residents who have dementia."
Seidl wants to dismiss the myths that most people have about working with our senior population. "The greatest misconception is that seniors are cranky people who want to be left alone. They`re not cranky; they just may not feel well. Seniors love to be with people. When pets (trained to be with seniors) are brought into the center, the residents really come to life; especially when a dog enters a room and lays his head on a resident`s lap. Even though the resident may not have felt like talking to anyone that day, you can be sure he`ll talk to that animal."
Chuck Nigro`s response about the benefits of the nursing center`s OHP, is warm: "When your mouth is clean, it makes you feel better. It would be great if this type of care could be provided in all nursing homes, but there`s such a struggle going on right now for government-payment sources for nursing-home care."
Nigro feels strongly that the OHP would not have gotten off the ground in his facility, had it not been for Seidl`s passion for working with the frail elderly and her desire to make a difference. "Letty saw the need. Without Letty, this program would have been a lot harder to develop. She has created an innovative program that, hopefully, will encourage hygiene students to volunteer in long-term-care facilities after graduation."
If funding for staff hygienists in nursing homes is not forthcoming in the near future, Nigro hopes hygienists will "really push to make things better in nursing homes by giving of themselves on a volunteer basis."
Seidl`s passion for the elderly is obvious. "We need to be patient with seniors. We need to take time to be with them. Don`t rush them when they come into the dental office. Hold their hands, look into their eyes, and listen to their stories. They have so much wisdom to share."
Mary Martha Stevens, RDH, PhD, is an RDH consulting editor. For many years, she was manager of health and wellness for Puritan-Bennett Corp. Currently, she is clinical associate professor, UMKC School of Dentistry. She can be contacted by e-mail at [email protected].
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Every morning, Joy Patchin (left) volunteers to work at the Johnson County Health and Human Services reception desk. She knows the importance of brushing more than her dentures. She`s learned that brushing the soft tissues inside her mouth and cleaning her tongue are equally important. In the photograph, she hugs "Letty" Seidl. Photo by Bob Steckmest.
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Lynda Frost, BSN, MS, (right) one of the younger residents in the nursing center, does an excellent job of brushing her teeth even though she is confined to a wheelchair and unable to use the left side of her body. She is one of the few residents who uses dental floss everyday. In March, an anesthesiology library at Truman Medical Center in Kansas City was dedicated in Frost`s honor for her years of service and expertise as a clinical instructor in the hospital`s School of Nurse Anesthesia.
Educators encourage involvement
Valerie Blanco Johnson received a bachelor`s in dental hygiene and a master`s in dental public health from the University of Iowa. When I asked her to identify the greatest challenge dental professionals face today in dealing with the oral-health needs of our senior population, she laughed. "I don`t exactly know how to word this, but the challenge is trying to convince others that there is a challenge to be met. There seems to be very little importance placed on the issue because we`re not with seniors everyday. We`re not seeing the problems first hand. The biggest challenge is trying to get people to understand that this populations` oral-health needs are important, and they should be addressed now!
"For example, xerostomia, or dry mouth, is a major problem for seniors because of all the medications they are taking. But, quite frankly," emphasizes Johnson, "the biggest problem is the lack of daily oral-hygiene care. This is compounded by the fact that, as we age, the musculatures of the mouth do not allow for normal cleansing of food from vestibules in the mouth. What`s really needed is for seniors to have their mouths cleaned regularly, especially after their meals."
"Dental hygienists need to have more of a presence in the community," said Johnson. "We need to get involved with how health care is designed. Let`s remind decision-makers that the oral-health care for seniors needs to be integrated with their primary medical care."
As an assistant professor in the department of periodontics at the University of Missouri-Kansas City School of Dentistry, Johnson practices what she preaches to her students and fellow hygienists in the community. She developed a special task force to address the oral-health needs of seniors in Kansas. Promoting Oral Health for Elderly Kansans (POHEK), has gathered volunteers from nursing-home organizations, state agencies, dental schools, dental-hygiene schools, as well as representatives from the Kansas dental hygienists` and dental associations. "First, we targeted nursing homes," explained Johnson. "Besides educating dental professionals on the needs of this population, we have spent time helping nursing homes identify issues as basic as how to provide daily oral-hygiene care to their residents."
POHEK offers a special award each year, the Best Care Practices Award, that recognizes institutions that have taken steps to improve the oral health of their residents. "We also write articles for newsletters and try to have a presence at whatever conferences we can afford to attend even though the group has no funding source," adds Johnson.
"Hygienists need to step outside of their comfort zones. We all have a tendency to want to stay in our daily routine in the dental office because it can be uncomfortable to go into a setting we are not familiar with. But, we need to step outside and get involved and share what knowledge we do have with those who help others."
Dr. James Mixson worked for a number of years in the U.S. public-health service before taking a faculty appointment at the University of Missouri-KC, School of Dentistry in 1985. However, it wasn`t until four years later that he became involved in working with the elderly. At that time, he had the opportunity to participate in a two-year geriatric dentistry fellowship program at the University of Kentucky. "We worked with patients in nursing homes and learned about general issues affecting seniors. In addition to financial and retirement issues, we dealt with a whole variety of geriatric topics that emphasized treating functionally dependent patients."
After incorporating this knowledge into the dental-school curriculum, Dr. Mixson began working with Baptist Medical Center`s outpatient geriatric clinic. In this setting, he teaches dental and dental-hygiene students how to work with nursing-home residents who are transported to the clinic for dental care.
"These older adults, often because they`re on multiple medications, typically exhibit xerostomia. They`re a lot more susceptible to periodontal disease, dental disease, and plaque accumulation. Without saliva, they`re really at risk for all sorts of problems," says Dr. Mixson.
"If xerostomia is a problem for seniors, often they will need to have their teeth cleaned three or four times a year," says Dr. Mixson. He and Johnson agree that fluoride rinses and toothpastes, as well as saliva substitutes are helpful to some extent, but sipping water throughout the day and rinsing after meals often provides the best results.
"Keeping seniors hydrated is very important," adds Dr. Mixson.
"Over the last 10 years, I`ve seen a greater awareness, interest, and concern among dental professionals for the oral health of our seniors. But to be honest, sometimes I feel overwhelmed by the amount of oral disease I see out there. It`s almost a crisis situation in our society," says Dr. Mixson. "If Medicare paid hygienists to work with rehab departments in nursing homes, preventive oral care could be provided to residents on a daily basis."
- Mary Martha Stevens
Medication classes known to cause xerostomia
> Antihypertensives > Anticholinergies
> Antidepressants > Antihistamines
> Decongestants
> Antiparkinsonians
> Antipsychotics
> Diuretics
