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 Effective Oral Health Care Requires Effective Collaboration

A dentist offers his perspective on improving dental care for residents  in long term care settings.

 

Health care experts are increasingly affirming the importance of oral health as an essential component of overall health. The need for quality-based mouth care does not diminish as a person becomes older, chronically ill, or placed within long term care settings.
 
Indeed, these individuals experience a disproportionate and debilitating amount of oral disease, which places them at higher medical risk; diminishes their quality of life; and, unless effectively addressed, may add significantly to the cost of care.

Plaque Key Culprit In Oral Health Problems

Inadequate daily oral hygiene will lead to a buildup of plaque (biofilms) in the mouth and is primarily responsible for the development of dental cavities, gum disease, and most other oral-related problems.
 lower, plaque covered teeth
Elders, in general, have an increased likelihood of developing oral health problems caused by poor oral hygiene, and older adults living in long term care settings are particularly vulnerable. Many nursing home residents have diminished oral hygiene due to deficits associated with their cognitive status, stroke, arthritis, vision, and other problems.
 
In addition, they may have mouth dryness associated with their medications, their diet may be comprised of soft and sticky foods, and their remaining teeth may be poorly aligned, leading to food impaction.
 
Unmet dental needs can be quite substantial in long term care residents. For example, in a recent Massachusetts study, nearly 60 percent of nursing home residents had untreated dental cavities, compared with 35 percent of community-dwelling elderly, and 34 percent of these residents had major or urgent needs associated with these cavities.
 
Other studies have documented a high level of poor oral health found in nursing home residents:
■ More than 40 percent had periodontal disease;
■ Up to three-quarters aged 65 and older had lost some or all teeth;
■ More than 50 percent of those over age 75 were edentulous (completely toothless); and
■ Eighty percent of those who had lost all teeth had dentures, but nearly one in five did not use them.
 
impact of tooth loss on nutritionThe consequences of dental infections from cavities or gum disease can be quite significant. Dental infections may lead to severe pain, as well as systemic health problems such as bacteremia, sinusitis, cellulitis, brain abscess, and/or airway collapse.

Cavities and gum disease are responsible for the loss of natural teeth and can lead to chewing problems, which can impact nutritional health.

Poor nutritional status has been shown to increase the length of hospitalizations, elevate infection rates, and even increase dependence in activities of daily living.

Studies Find Barriers

Studies looking at barriers influencing dental care in long term care facilities have identified several key issues that may inhibit satisfactory dental care. Nursing home administrators, unit charge nurses, and dentists have agreed that patient financial constraints, as well as lack of interest by the resident or by the resident’s family, are quite problematic.
 
It is interesting to note, however, that administrators and unit charge nurses were generally more likely than dentists to cite unwillingness of dentists to see the resident at the dental office, as well as the nursing home, and nursing staff time constraints as significant barriers.
 
On the other hand, dentists were more likely to attribute residents’ oral health problems to the apathy of nursing home administrators and staff, in addition to the lack of suitable portable equipment and inadequate space.
 
These findings underscore the need for appropriate dialogue and, ultimately, the need to enhance teamwork between dental care providers and nursing home personnel. In some ways, these differing perceptions are like those of the three blind men trying to describe the elephant: Each may be correct from their individual perspective, but a more accurate picture only emerges when all three views are combined.
 
In a white paper entitled, “Improving Dental and Oral Care Services for Nursing Facility Residents,” by the TRECS Institute (www.thetrecsinstitute.org/downloads/DentalCare.pdf), key factors were identified behind the poor response to addressing dental and oral health needs, as follows:
■ A pervasive lack of knowledge of the importance of dental and oral health care on the part of residents, their families, and the nursing facilities’ staff;
■ Difficulties faced by some residents in providing self-care due to physical limitations, despite the desire to maintain good oral health and the desire to remain independent;
■ Providing good daily oral care to residents with dementia and/or behavioral problems can be extremely difficult for staff in spite of good intentions and efforts;
■ Ageism prejudices are overtly evident among staff, families, and even the residents themselves; and
■ A lack of or severely limited reimbursement for professional dental services results in significant access problems.
 
Oral health is essential for the general health and well-being of nursing home residents. The challenges of meeting their diverse and sometimes complicated dental needs can be imposing, but it is very important to quality of care and quality of life for these individuals.
 
The team of multidisciplinary care providers essential to address the constellation of medical, psychosocial, emotional, financial, and spiritual needs of the long term care resident must place greater priority and emphasis on the significant oral health concerns of this population.
 
Dedicated collaborative efforts between nursing facility professionals and dental practitioners can be very helpful in better meeting the oral health needs of residents in long term care
settings.
 
Douglas Berkey, DMD, MPH, MS, professor, University of Colorado; dental director, InnovAge Greater Colorado PACE; member, National Elder Care Advisory Committee, American Dental Association. Berkey can be reached at douglas.berkey@ucdenver.edu or at (303) 907-5336.
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