Examining Oral Health in Nursing Home Residents and Overcoming Mouth Care–Resistive Behaviors
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Pages 21 - 26
Rita A. Jablonski, PhD, RN, CRNP
Nursing home residents are a group with significant health disparities in the area of oral health. Poor oral health can place nursing home residents at risk for developing pneumonia, exhibiting poor glycemic control if already diabetic, and increasing cardiovascular disease. The majority of nursing home residents arrive with some or all of their dentition but without the resources to continue preventive dental care—Medicare does not reimburse for routine dental care and Medicaid either does not reimburse for this service or reimburses so poorly, few providers will accept it. The onus of mouth care falls on nursing assistants; many admit to failing to provide mouth care because of mouth care–resistive behaviors. Clinicians in nursing homes can model specific methods to reduce mouth care–resistive behaviors (for example, bridging, priming, and avoiding elderspeak) and share these techniques with the nursing assistants responsible for providing mouth care. (Annals of Long-Term Care: Clinical Care and Aging 2010;18:21-26)
In the United States, nearly 2 million older adults reside in 16,100 nursing homes (NHs).1,2 The majority of these elderly individuals require assistance with activities of daily living (ADL),3 and nursing assistants (NAs) are the predominant providers of this care.4 The National Institute of Dental and Craniofacial Research (NIDCR) recognizes these NH residents as a group with significant health disparities in the area of oral health.5 The existence of acute and chronic diseases may create a negative spiral in which the diseases are worsened by the presence of poor oral health, which deteriorates as their medical problems progress.6 The oral health status of NH residents has been described as “deplorable.”7 There are emerging connections between poor oral health and poor systemic health. The number of residents retaining their natural teeth exacerbates the problem of poor oral care in NH. In the early 1980s, 54% of persons age 65 years or older had some natural teeth; by 2002, the percentage had increased to 70%.5 The purpose of this review is to describe the oral health of elderly NH residents, the effect of mouth care–resistive behaviors on the oral health of these residents, and specific interventions to reduce mouth care–resistive behavior.
General Description of the NH Population
The current NH population is frail and functionally dependent. Ninety-one percent of NH residents are 65 years of age or older, and 46% are 85 years of age or older.3,8 Eighty-three percent require assistance with three or more ADL.9,10 The three most common ADL requiring assistance were bathing or showering (96%), dressing (87%), and eating (45%).3 Oral care was not specifically mentioned in any ADL category, but one could conservatively estimate that the 45% who required assistance with eating would most likely require assistance with mouth care. Self-care is further compromised by cognitive impairment; 70% of NH residents exhibit some form of cognitive impairment regardless of diagnoses.9
Oral Health Affects Systemic Health
Nearly one-third of all older adults experience xerostomia, or dry mouth, due to hyposalivation.11 Xerostomia causes mouth discomfort, interferes with chewing and swallowing, and supports plaque formation.11 Furthermore, saliva has antibacterial properties; diminished saliva production results in increased bacteria in the mouth.
1. The National Nursing Home Survey: 1999 Summary. Department of Health and Human Services. Centers for Disease Control and Prevention website. http://www.cdc.gov/nchs/data/series/sr_13/sr13_152.pdf. Accessed May 29, 2009.
2. Gabrel CS. National Nursing Home Survey: Nursing Home Facilities. National Center for Health Statistics. Centers for Disease Control and Prevention Website. www.cdc.gov/nchs/data/ad/ad311.pdf. Page last reviewed April 23, 2009. Accessed May 29, 2009.
3. Gabrel CS. Characteristics of elderly nursing home current residents and discharges: Data from the 1997 National Nursing Home Survey. National Center for Health Statistics. Centers for Disease Control and Prevention Website. www.cdc.gov/nchs/data/ad/ad312.pdf. Accessed May 29, 2009.
4. Gabrel CS. An overview of nursing home facilities: Data from the 1997 National Nursing Home Survey. National Center for Health Statistics. Centers for Disease Control and Prevention Website. www.cdc.gov.nchs/data/ad/ad280.pdf. Accessed May 29,2009.
5. A plan to eliminate craniofacial, oral, and dental health disparities. Revised 2002. The National Institute of Dental and Craniofacial Research Website. www.nidcr.nih.gov/NR/rdonlyres/54B65018-D3FE-4459-86DD-AAA0AD51C82B/0/hd.... Accessed May 29, 2009.
6. Oral health in America: A report of the Surgeon General. Office of the Surgeon General Website. http://www.surgeongeneral.gov/library/reports/oralhealth/ Acessed May 29, 2009.
7. Cohen-Mansfield J, Lipson S. The underdetection of pain of dental etiology in persons with dementia. Am J Alzheimers Dis Other Demen 2002;17(4):249-253.
8. Gabrel CS, Jones A. The National Nursing Home Survey: 1997 Summary. Vital Health Stat 13 2000;(147):1-121.
9. Krauss NA, Altman BM. Characteristics of Nursing Home Residents, 1996. Rockville, MD: U. S. Department of Health & Human Services, Public Health Service, Agency for Health Care Policy and Research; 1998.
10. Rhoades JA, Krauss NA. Chartbook #3: Nursing Home Trends, 1987 and 1996. Agency for Healthcare Policy and Research Website. www.meps.ahrq.gov/mepsweb/data_files/publications/cb3/cb3.shtml. Accessed May 29, 2009.
11. Gupta A, Epstein JB, Sroussi H. Hyposalivation in elderly patients. J Can Dent Assoc 2006;72(9):841-846.
12. Matear DW, Locker D, Stephens M, Lawrence HP. Associations between xerostomia and health status indicators in the elderly. J R Soc Promot Health 2006;126(2):79-85.
13. Shay K, Ship JA. The importance of oral health in the older patient. J Am Geriatr Soc 1995;43(12):1414-1422.
14. Ettinger RL. Review: Xerostomia: A symptom which acts like a disease. Age Ageing 1996;25:409-412.
15. Rauen MS, Moreira EA, Calvo MC, Lobo AS. Oral condition and its relationship to nutritional status in the institutionalized elderly population. J Am Diet Assoc 2006;106(7):1112-1114.
16. Poulsen I, Rahm Hallberg I, Schroll M. Nutritional status and associated factors on geriatric admission. J Nutr Health Aging 2006;10(2):84-90.
17. Langmore SE, Skarupski KA, Park PS, Fries BE. Predictors of aspiration pneumonia in nursing home residents. Dysphagia 2002;17:298-307.
18. Adachi M, Ishihara K, Abe S, Okuda K. Professional oral health care by dental hygienists reduced respiratory infections in elderly persons requiring nursing care. Int J Dent Hyg 2007;5(2):69-74.
19. Medina-Walpole AM, Katz PR. Nursing home-acquired pneumonia. J Am Geriatr Soc 1999;47(8):1005-1015.
20. Mehr DR. Nursing-home-acquired pneumonia: How and where to treat? J Am Board Fam Pract 1997;10(2):168-170.
21. Muder RR. Pneumonia in residents of long-term care facilities: Epidemiology, etiology, management, and prevention. Am J Med 1998;105(4):319-330.
22. Mylotte JM. Nursing home-acquired pneumonia. Clin Infect Dis 2002;35(10):1205-1211. Published Online: October 28, 2002.
23. Scannapieco FA, Mylotte JM. Relationships between periodontal disease and bacterial pneumonia. J Periodontol 1996;67(10 suppl):1114-1122.
24. Yoneyama T, Yoshida M, Ohrui T, et al; Oral Care Working Group. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc 2002;50(3):430-433.
25. Yoshino A, Ebihara T, Ebihara S, et al. Daily oral care and risk factors for pneumonia among elderly nursing home patients. JAMA 2001;286(18):2235-2236.
26. Langmore SE, Terpenning MS, Schork A, et al. Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia 1998;13:69-81.
27. Terpenning MS, Taylor GW, Lopatin DE, et al. Aspiration pneumonia: Dental and oral risk factors in an older veteran population. J Am Geriatr Soc 2001;49:557-563.
28. Scannapieco FA, Ho AW. Potential associations between chronic respiratory disease and periodontal disease: Analysis of National Health and Nutrition Examination Survey III. J Periodontol 2001;72(1):50-56.
29. Scannapieco FA, Stewart EM, Mylotte JM. Colonization of dental plaque by respiratory pathogens in medical intensive care patients. Crit Care Med 1992;20(6):740-745.
30. Terpenning M. Geriatric oral health and pneumonia risk. Clin Infect Dis 2005;40(12):1807-1810. Published Online: May 10, 2005.
31. Bakhshandeh S, Murtomaa H, Mofid R, et al. Periodontal treatment needs of diabetic adults. J Clin Periodontol 2007;34(1):53-57.
32. Tsai C, Hayes C, Taylor GW. Glycemic control of type 2 diabetes and severe periodontal disease in the U.S. adult population. Community Dent Oral Epidemiol 2002;30(3):182-192.
33. Furukawa T, Wakai K, Yamanouchi K, et al. Associations of periodontal damage and tooth loss with atherogenic factors among patients with type 2 diabetes mellitus. Intern Med 2007;46(7):1359-1364. Published Online: September 3, 2007.
34. Promsudthi A, Pimapansri S, Deerochanawong C, Kanchanavasita W. The effect of periodontal therapy on uncontolled type 2 diabetes mellitus in older subjects. Oral Dis 2005;11:293-298.
35. Tabrizi F, Buhlin K, Gustafsson A, Klinge B. Oral health of monozygotic twins with and without coronary heart disease: A pilot study. J Clin Periodontol 2007;34(3):220-225. Published Online: January 25, 2007.
36. Desvarieux M, Demmer RT, Rundek T, et al; Oral Infections and Vascular Disease Epidemiology Study (INVEST). Relationship between periodontal disease, tooth loss, and carotid artery plaque: The Oral Infections and Vascular Disease Epidemiology Study (INVEST). Stroke 2003:34(9):2120-2125. Published Online: July 31, 2003.
37. Desvarieux M, Demmer RT, Rundek T, et al. Periodontal microbiota and carotid intima-media thickness: The Oral Infections and Vascular Disease Epidemiology Study (INVEST). Circulation 2005;111(5):576-582.
38. Kurihara N, Inoue Y, Iwai T, et al. Oral bacteria are a possible risk factor for valvular incompetence in primary varicose veins. Eur J Vasc Endovasc Surg 2007;34:102-106. Published Online: May 2, 2007.
39. Janket SJ, Qvarnström M, Meurman JH, et al. Asymptotic dental score and prevalent coronary heart disease. Circulation 2004;109(9):1095-1100. Published Online: February 16, 2004.
40. Bretz WA, Weyant RJ, Corby PM, et al. Systemic inflammatory markers, peridontal diseases, and periodontal infections in an elderly population. J Am Geriatr Soc 2005;53:1532-1537.
41. Dey AN. Characteristics of elderly nursing home residents: Data from the 1995 National Nursing Home Survey. Adv Data 1997;(289):1-8.
42. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital Health Stat 11 2007(248):1-92.
43. Manski RJ, Brown E. Dental use, expenses, private dental coverage, and changes, 1996 and 2004. Agency for Healthcare Research and Quality Website. www.meps.ahrq.gov/mepsweb/dta_files/publications/cb17/cb17.pdf. Accessed May 29, 2009.
44. Jablonski RA, Munro CL, Grap MJ, Elswick RK. The role of biobehavioral, environmental, and social forces on oral health disparities in frail and functionally dependent nursing home elders. Biol Res Nurs 2005;7(1):75-82.
45. Bagramian RA, Heller RP. Dental health assessment of a population of nursing home residents. J Gerondontol 1977;32(2):168-174.
46. Murray PE, Ede-Nichols D, Garcia-Godoy F. Oral health in Florida nursing homes. Int J Dent Hyg 2006;4(4):198-203.
47. Reed R, Broder HL, Jenkins G, et al. Oral health promotion among older persons and their care providers in a nursing home facility. Gerodontology 2006;23(2):73-78.
48. Shay K. Dental management considerations for institutionalized geriatric patients. J Prosthet Dent 1994;72:510-516.
49. MacEntee MI, Weiss R, Waxler-Morrison NE, Morrison BJ. Factors influencing oral health in long-term care facilities. Community Dent Oral Epidemiol 1987;15(6):314-316.
50. Dolan TA, Atchison KA. Implications of access, utilization and need for oral health care by the non-institiutionalized and institituionalized elderly on the dental delivery system. J Dent Educ 1993;57(12):876-887.
51. Shareff HL, Strauss RP. Behavioral influences on the feasibility of outpatient dental care for nursing home residents. Spec Care Dentist 1985;5(6):270-273.
52. Kiyak HA, Grayston MN, Crinean CL. Oral health problems and needs of nursing home residents. Community Dent Oral Epidemiol 1993;21:49-52.
53. Coleman P, Watson NM. Oral care provided by certified nursing assistants in nursing homes. J Am Geriatr Soc 2006;54(1):138-143.
54. Chalmers JM, Levy SM, Buckwalter KC, et al. Factors influencing nurses’ aides’ provision of oral care for nursing facility residents. Spec Care Dentist 1996;16(2):71-79.
55. Mahoney EK, Hurley AC, Volicer L, et al. Development and testing of the Resistiveness to Care Scale. Res Nurs Health 1999;22(1):27-38.
56. Kambhu PP, Levy SM. Oral hygiene care levels in Iowa intermediate care facilities. Spec Care Dentist 1993;13(5):209-214.
57. Adams R. Qualified nurses lack adequate knowledge related to oral health, resulting in inadequate oral care of patients on medical wards. J Adv Nurs 1996;24:552-560.
58. Pyle MA, Jasinevicius TR, Sawyer DR, Madsen J. Nursing home executive directors’ perception of oral care in long-term care facilities. Spec Care Dentist 2005;25(2):111-117.
59. Algase DL, Beck C, Kolanowski A, et al. Need-driven dementia-compromised behavior: An alternative view of disruptive behavior. Am J Alzheimers Dis Other Demen 1996;11(6):10-19.
60. Kolanowski AM, Whall AL. Toward holistic theory-based intervention for dementia behavior. Holist Nurs Pract 2000;14(2):67-76.
61. Whall A. Developing needed interventions from the Need-Driven Dementia-Compromised Behavior Model. J Gerontol Nurs 2002;28(10):5.
62. Volicer L, Bass EA, Luther SL. Agitation and resistiveness to care are two separate behavioral syndromes of dementia. J Am Med Dir Assoc 2007;8:527-532. Published Online: September 17, 2007.
63. Williams KN, Herman R, Gajewski B, Wilson K. Elderspeak communication: Impact on dementia care. Am J Alzheimers Dis Other Demen 2009;24(1):11-20. Published Online: June 30, 2008.
64. Cunningham J, Williams KN. A case study of resistiveness to care and elderspeak. Res Theory Nurs Pract 2007;21(1):45-56.
65. Kayser-Jones J, Bird WF, Redford M, et al. Strategies for conducting dental examinations among cognitively impaired nursing home residents. Spec Care Dentist 1996;16:46-52.
66. Chalmers JM. Behavior management and communication strategies for dental professionals when caring for patients with dementia. Spec Care Dentist 2000;20(4):147-154.
67. Harrison BE, Son GR, Kim J, Whall AL. Preserved implicit memory in dementia: A potential model for care. Am J Alzheimers Dis Other Demen 2007;22(4):286-293.
68. Son GR, Therrien B, Whall A. Implicit memory and familiarity among elders with dementia. J Nurs Scholarsh 2002;34(3):263-267.