Annals of Long Term Care

Key words: Long-term care, malnutrition, oral health, periodontal disease.

In the past few decades, oral health has become a national priority in the United States. In May 2000, the US Surgeon General issued a significant report titled Oral Health in America, which provided an evidence-based argument for the importance of optimal oral care, specifically how diseases and conditions that affect the face, mouth, and teeth are connected to overall health and well-being in all age groups.¹ The Surgeon General’s report advocated for a revision to the medical curriculum so that it includes a dental care component. Despite advances in this area of care, poor oral health among long-term care (LTC) residents remains pervasive, as there continue to be numerous barriers to providing care in this population. Meeting these challenges should be a priority since approximately 75% of baby boomers are expected to reside in LTC facilities, a majority of whom will have their natural teeth intact.² At an LTC facility based in Kentucky, we sought to overcome some of these barriers by designing and implementing a comprehensive oral health staff training program. In this report, we describe our pilot program, which yielded positive results. A brief review of the serious health issues associated with poor oral care is also given, underscoring the need for other LTC facilities to work toward implementing similar staff education programs. Resources for doing so are provided at the end of this report.

Evidence of Poor Oral Care Leading to Other Health Problems

Addressing poor oral health among LTC residents is imperative because it may cause more than mouth pain. Untreated dental decay, broken teeth, inflamed gingival tissues, and problems with dentures can impair a person’s ability to eat, potentially affecting his or her nutritional status. According to a 2012 systematic review by Belgian investigators, there is tentative evidence of an independent association between oral health status and malnutrition in LTC residents.³ The investigators advise caution in assuming a direct link between the two conditions, as there is no gold standard to define and assess malnutrition and oral health status. However, a cross-sectional Finnish study involving more than 2000 institutionalized frail elders found that malnutrition was strongly related to both poor oral status and oral health problems,⁴ such as chewing and swallowing difficulties, mouth pain, and xerostomia (ie, dry mouth), which is a common side effect of many medications.

There are strong correlations between poor oral health and life-threatening systemic diseases and conditions. Many studies indicate a positive relationship between the provision of oral care and a reduction in aspiration pneumonia, an inflammation of the lungs due to breathing in foreign material (eg, food).^5-8 Complications from aspiration pneumonia, which include hypotension and bacteremia, can be fatal. A 2006 systematic review by Azarpazhooh and Leake⁹ found fair evidence of an association between pneumonia and oral health (odds ratio, 1.2-9.6, depending on oral health indicators). In the study, improved oral hygiene, including professional oral care, significantly reduced the incidence of or progression of respiratory diseases among high-risk elders residing in nursing homes or being cared for in intensive care units (relative risk reduction, 34%-83%).

Periodontal disease has also been known to interfere with glycemic control in diabetic individuals, potentially leading to kidney disease, myocardial disease, and peripheral neuropathy and retinopathy. This is particularly disconcerting because approximately 25% of LTC residents have diabetes, a majority of who have type 2 diabetes mellitus.¹⁰ Based on data from a longitudinal study, Taylor and colleagues¹¹ reported that persons with type 2 diabetes and severe periodontitis are six times more likely to experience worsening glycemic control over time, compared with their counterparts without periodontitis.

A number of cardiovascular conditions have also been associated with poor oral health, specifically with periodontal disease.^12-16 Some research suggests that periodontal disease may be a risk factor for atherosclerosis, leading to coronary artery disease and stroke; the presence of oral bacteria has been documented in atherosclerotic plaques.¹⁵ The observational studies only support a strong link between periodontal disease and atherosclerosis,^11,14,15 but large prospective studies have failed to find an association between the two after adjusting for risk factors, indicating that this is an area where further studies are needed.¹⁷

In addition, some studies point to a potential association between poor oral health and dementia and cognitive decline.^18-20 A study comparing systemic exposure to periodontal pathogens (assessed by Porphyromonas gingivalis-specific serum immunoglobulin G, a serological marker of periodontitis), and cognitive test outcomes in adults 60 years of age and older found that periodontitis is associated with delayed verbal recall and impaired subtraction skills.¹⁸ Other studies have found a correlation between loss of teeth and dementia.^19,20 In a longitudinal study of dental records from adults aged 75 to 98 years, study participants with the fewest teeth had the highest risk dementia, and the prevalence of dementia was also greatest in this population.²⁰

Barriers to Providing Oral Healthcare in LTC Settings

The problem of poor oral health among nursing home residents is multifactorial.²¹ One of the greatest facilitators to good oral health is simply ensuring daily oral hygiene; however, this seemingly simple task can pose a challenge in the LTC setting. Many LTC residents have difficulty brushing their own teeth due to poor manual dexterity, limited mobility, vision problems, or cognitive impairment. A study by Frenkel and colleagues²² found that 72% to 94% of LTC residents have difficulty providing their own oral hygiene care or cleaning their own dentures, yet residents often receive little or no help with these practices. In one study, only 5% of residents in LTC facilities who requested assistance with oral hygiene ever received help.²³ It also appears that when help is provided, best practices are often not employed. In an observational study of actual daily oral care provided by certified nursing assistants (CNAs) to elderly residents who required assistance, Coleman and Watson²⁴ reported that adherence to standards was low; teeth were brushed and rinsed with water in only 16% of resident observations, and when help was given, the staff brushed the teeth on average for 16.2 seconds, instead of the 2 minutes that is commonly recommended by dentists. Furthermore, the investigators cited a disturbing lack of appropriate infection control, with none of the CNAs wearing clean gloves to provide oral care and some not even changing gloves after cleaning the perineal area or changing soiled garments.²⁴

In various surveys and questionnaires, nursing assistants have cited a range of challenges to providing oral hygiene care to LTC residents, including lack of time²⁵ and care-resistant behaviors in residents.²⁶ Some nursing assistants reported a lack of education on providing daily oral hygiene for LTC residents and a lack of accountability for providing this care, instead deferring this responsibility to the residents’ regular dentist.²⁷ Lack of standardized practice or routine appears to be an issue. A Swedish study found that the quality of oral healthcare was given to patients depending on several factors, but a questionnaire indicated oral health as a “low priority” of their daily activities.²⁸

Many of the aforementioned studies indicate a pressing need for staff education and training in oral healthcare. Recognizing that oral health is an underrecognized but significant area of care in LTC settings, staff at an LTC facility in Kentucky worked on a collaborative project with our dental team from the University of Kentucky College of Dentistry to address these barriers to care and provide residents with necessary oral care. Following our description of this program, we provide direction to free online resources so that other LTC providers may design and implement their own program.

Pilot Program

In Kentucky, 80% of institutionalized elders have fair to poor oral health, according to the results of a statewide survey.²⁹ The aim of our project was to develop and implement a unique oral health training program for CNAs working in LTC settings that would ultimately improve the oral health and overall health of residents. In our model, one CNA was specially trained to be the facility’s oral health specialist, becoming responsible for the daily oral hygiene of the residents and having minimal other care responsibilities. The specialist then carried out a standardized care plan, which was developed by our dental team and informed by a literature review of best practices in oral hygiene. The intent of this approach was to overcome the key barriers reported by staff in the medical literature, including a lack of time and of accountability. The Figure outlines each step of our pilot program.

The first step was to identify a local LTC facility with which to test our program, ensuring that the facility’s leadership was on board with having one of their nursing assistants trained in oral healthcare. The dental team then met with the director of nursing, an administrator, and a social worker at the facility to create a feasible written plan, outlining the logistics of the location and time needed to train an assistant. These conversations helped to forge a true partnership between institutions and departments.                  

When a realistic plan for training the nursing assistant was put into place, the dental team developed the curriculum. The curriculum was based on a literature review to determine best practices and elements of successful oral health training programs in LTC facilities. Evidence-based recommendations were incorporated into the curriculum, including the following: engaging the leadership of the facility to ensure support²²; providing information on the importance of a healthy mouth, focusing on the links between oral and systemic health³⁰; providing detailed “how-to” instructions for using basic oral hygiene tools and for implementing appropriate infection-control measures²¹; and providing strategies for managing care-resistant behaviors.²⁶ Specifically, we utilized guidelines from the American Dental Association and a self-study course developed by the Southern Association of Institutional Dentists.³¹ We also consulted various academic nursing papers for evidence-based protocols of oral healthcare,^32,33 as well as additional recommendations for communication and behavior strategies.³⁴

The next step in the process was to create four interactive and self-instructional slideshow presentations (ie, PowerPoint) and videos, which were developed by the dental team in collaboration with a multimedia expert, a medical illustrator, and an instructional designer. These lessons were titled as follows: The Importance of Daily Oral Care; Guidelines for Daily Oral Care; Checking for Problems; and Residents Requiring Special Care. In addition, Quiz Your Knowledge questions were interspersed throughout the curriculum to highlight the most important take-home messages. Written materials were developed, including a template for creating individualized daily oral hygiene plans for residents, forms for documenting daily provision of oral care, and a Request for Dental Consult referral form. We also laminated color-coded flash cards that could be kept at the nurse’s station and carried to the bedside as reminders of supplies, procedures, and safety precautions for providing oral care. All of these materials were developed with the intention of being easy to access and easy to understand by nursing assistants in LTC facilities nationwide. We needed to develop a curriculum that was self-instructional because in many facilities, we expected that dental professionals are not always available to deliver the presentation or work one-on-one with staff.

After the training materials were developed, a CNA who had been employed at the facility for more than 20 years volunteered to undergo the training and become the facility’s oral health specialist. In addition to watching all four slideshow presentations, a dental hygienist, who was paid in part by grant funding, provided hands-on demonstrations with oral hygiene tools. Continuous coaching was also provided at the bedside by a dental hygienist. The dental team communicated with the nursing assistant on a weekly basis, encouraging her to provide verbal feedback regarding any challenges, concerns, and successes.