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Maintaining Oral Health in the Nursing Facility

January 1, 2004
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A service of growing importance, as more residents retain at least partial dentition BY LINDA LESLIE, RDH, AND KARLA GIRTS, BSDH, RDH
Maintaining Oral Health in the Nursing Facility
Many residents these days maintain partial, if not full, dentition, and good oral care remains important

BY LINDA LESLIE, RDH, AND KARLA GIRTS, BSDH, RDH At birth, one of the first ministrations a newborn receives is an oral swab. A clean mouth is no less important for the elderly or other long-term care residents than it is for newborns-promoting oral health is important to maintaining general health even in old age. Quality of life suffers when oral disease is present because of the resulting pain, speech limitations, reduced sense of taste, increased chewing complications, low self-esteem, and reduced socialization. Moreover, the Surgeon General's 2000 report on oral health in America noted that the development of systemic disease is strongly associated with an overabundance of bacteria and inflammation in the oral cavity. Chronic oral infections have been linked to diabetes, heart disease, respiratory pneumonia, and the general degradation of the immune system. At present, MDS Sections K (Oral/Nutritional Status) and L (Oral/Dental Status) require an oral health assessment, including a decision on whether a resident is able to perform his/her own oral hygiene regimen without assistance. If not, a care plan must be developed to have it done by someone on the care team.

Although trained to assist and/or monitor a resident's oral hygiene and dedicated to providing good care, aides are not always comfortable with this service because a poorly kept mouth can be intimidating and, frankly, repulsive. Consequently, oral care, while being addressed, is not necessarily being provided correctly or confidently in the nursing home.

Fortunately, practical assistance is available. By enlisting the services of a registered dental hygienist (RDH) as an oral health liaison (OHL), a facility can improve the outcomes from this very important health habit.

The OHL's Role
Many states have developed and adopted guidelines for providing dental care to nursing home residents. Many of the guidelines suggest that an RDH be designated as the OHL to a nursing home, whether in a full- or part-time capacity. It is safe to say, though, in this era of limited resources, that unless an on-site dental hygienist is required by state licensing boards, this position will most likely be passed over. But it is equally important to note that providing dental services in the long-term care milieu is beneficial to residents and appreciated by their families, and reflects well on the facility.

These services can help make up for an important gap in third-party reimbursement. Medicare does not cover routine dental care, and coverage is optional for individual state Medicaid programs. In states where dental care is reimbursed, Medicaid covers the cost of an annual cleaning; unfortunately, the reimbursement is so low that many dentists don't want to get involved. Some states do cover this service, however, when provided by an RDH.

Although OHLs are not state-mandated throughout the country, a growing number of facilities are enlisting the services of these oral health practitioners, if not on staff, at least on a contract basis. Some hygienists provide services to a number of client facilities, which is an attractive alternative for facilities with budgetary concerns. Some even have offices set up inside their vans and carry dental equipment that would not be available at the facility.

At in-services, an OHL can instruct staff on how to adapt dental care equipment (toothbrushes, flosses, interdental brushes, and the like) so it is easier for residents to care for themselves. An OHL's first goal is to see that staff and residents are trained in the basics of daily mouth care and that they make it a routine standard of care. Beyond providing oral health education, OHLs are trained to recognize and address problems they discover during a dental hygiene examination. For example, if there is an infection or severe decay, an OHL will facilitate scheduling an appointment with a dentist or advise the nursing staff to do so. They can also expedite attention to dental emergencies, if necessary.

Equipment Needed
A dedicated dental treatment room is an expensive proposition for a facility-some nursing homes do have them-but a program can be launched with a few simple items and adaptations. First, a dental chair is not always necessary; most exams can be done in wheelchairs or gerichairs. The basic tools necessary for an evaluation and screening include a mouth mirror, an explorer (pick), and a probe to evaluate the teeth and gums. To clean teeth, OHLs have their own portable equipment. The facility may have other devices, such as sterilization and suction machines that can be used by the hygienist.

Treating the Elderly
Registered dental hygienists interested in providing care as OHLs in long-term care settings should take continuing education courses that focus on geriatric care. Not all residents are easy to treat. An OHL must consider the individual and customize his or her approach to reduce anxiety and emotional trauma. Working with the elderly is similar to working with children (except they are 70 years older!). Both groups exhibit similar behavior (e.g., "I don't want to!"). It might not be possible to get every piece of plaque off teeth, but OHLs strive to do the best they can. Any oral health care is better than no care at all.