If daily oral care is to be improved in long-term care facilities, better education and training is needed for the nursing assistants who provide this care (Viger, 2019; Sifuentes & Lapane, 2020). Teaching in small groups and bedside coaching would likely be more effective than the traditional “lecture” dental professionals often give to the nursing staff on the importance of oral health. Internal oral health programs presented by a dentist or a dental hygienist, focused upon oral health care in nursing homes and presented to nurses, nurse’s assistants, and members of the administration in small groups, can emphasize the importance of oral health. These programs can also provide information about efficient means by which the nursing home staff can provide oral health care to those patients who cannot provide for themselves (Weintraub, et al., 2018). The strategies that may enhance cooperation during provision of oral hygiene care include: ● Making sure that the room is quiet, with as few people present as possible. ● Introducing yourself and explaining what you are about to do. ● Approaching at eye level and maintaining eye contact. ● Avoiding baby talk, sometimes referred to as “elderspeak.” ● Smiling, praising, and offering frequent encouragement. ● Using a gentle touch and soft toothbrush. ● Distracting the resident by giving him or her a favorite object to hold, talking about something he or she loves, or singing. (American Dental Association, 2021a). Nursing home residents should be encouraged to be as independent as possible in providing their own daily oral care. Pantomime and gestures may be helpful in getting the resident to understand what to do. Implicit memory or unconscious memory is memory created early in childhood and includes tasks learned at that time, such as toothbrushing. Implicit memory may be preserved in older adults with dementia. Placing a toothbrush in the hand of the resident and gently moving the toothbrush toward his or her mouth, or placing a hand over the resident’s hand and then moving the toothbrush over his or her teeth, may cue implicit memory and help the resident remember how to brush his or her teeth (Alzheimer’s Association, 2020). Dental professionals themselves may need training in how to enhance cooperation when providing care for long-term care residents. These strategies include using gestures and pantomime, displaying pleasant facial features (smiling), limiting the use of pronouns (elderspeak), moving slowly around the patient, positioning oneself at or below the patient’s eye level, and providing a quiet environment for the oral examination. Dental professionals should also be aware of modifications regarding diagnosis and treatment planning for those with dementia. For example, diagnosis of dental problems and assessment of dental pain may be more difficult in a patient with dementia. A cognitively intact patient may present with sensitivity to hot and cold, a dull ache, or sensitivity to percussion, while a patient with dementia may not be able to communicate these symptoms. The astute dental professional will look for signs of dental pain in the behavior of the patient. Signs of dental pain in a patient with dementia include:
Incurred Medical Expense. Nursing home residents may use the money that they would have spent to pay the nursing home for their monthly bill to instead pay their dental bill (considered an incurred medical expense). To compensate the nursing home for the lost revenue, Medicaid increases the amount they pay the nursing home for the month of the incurred expense. Often older adults are admitted to a nursing home with neglected oral hygiene and high rates of oral disease. In the days and weeks leading up to placement in a nursing facility, an older adult may have suffered a serious illness or chronic disability that compromised his or her ability to provide oral self-care or to seek professional dental services. Sometimes older adults are admitted to a nursing home from a hospital stay where the nursing and medical staffs have been focused on acute care. In addition, sponge- tipped oral swabs (spongettes) are often utilized instead of toothbrushes in hospitals for oral hygiene care. Spongettes are ineffective in removing plaque from the teeth as the lack of rigidity is not conducive to a consistent and firm application of pressure. The material itself is conducive to the retention of debris and bacteria. Another concern is that the foam head of this device can become detached and become a choking hazard (Otukoya & Doshi, 2018; Narain & Felipe, 2017). Once older adults are residing in a nursing home, they may not be able to perform their own oral hygiene care. There is a large and increasing number of nursing home patients with varying degrees of dementia, which can challenge the patient’s ability to perform even the most basic of oral hygiene functions or permit a staff member to provide these functions for them (Konstantopoulou, et al., 2020). In addition, most nursing home residents have functional limitations. Nearly three-quarters of nursing home residents have difficulty performing activities of daily living. Many nursing home patients may be unable to maintain a daily oral hygiene regimen with the staff of most nursing homes minimally trained to perform this service (Barbe, et al., 2019). The ability to brush and floss their teeth and/or to maintain cleanliness of partial or complete dentures is essential for the optimal oral and systemic health of these patients. However, with minimal staffing and heavy workloads the ability to provide these services on a routine basis for nursing home patients is often minimized or neglected. The staff may not appreciate the role and interrelationship between oral health and systemic well-being even though oral neglected oral health can cause adverse systemic consequences, can cause pain and swelling of odontogenic origin and can have an adverse effect upon social relationships because of altered speech and facial aesthetics (Konstantopoulou, et al., 2020). Several authors have suggested reasons why helping with daily oral hygiene is such a challenge for nursing staff in long-term care facilities (Sifuentes & Lapane, 2020; Lowe & Rossopoulos, 2018). These include: ● A general lack of knowledge of the importance of oral health to systemic health. ● Higher priority given to other duties by nursing assistants, nurse supervisors, and facility administrators. ● Lack of a perceived need by patients, family, administrators, and staff. ● Insufficient workforce staff to provide daily oral hygiene. ● Disgust for oral care by the nursing assistant providing the oral care. ● Nursing assistants’ lack of knowledge in handling care resistance.
● Restlessness or aggression. ● Pulling at the face or mouth. ● Chewing the lip, tongue, or hands. ● Grinding the teeth. ● Disinterest in eating. (Alzheimer’s Society, 2020; Beck, 2022)
● Fear of being bitten. ● High turnover of staff.
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