One of the very first skills taught to children in the early years of life is how to brush their teeth. Small children, who are often sensitive to the physical sensation of it, don’t always take it in stride. However, it soon becomes routine in childhood and automatic in adulthood, with the daily ritual of brushing and flossing done twice or more continuing into the future. In later years of life, they may be brushing fewer of their original teeth, or none at all. 

For the elderly entering long term and post-acute care (LT/PAC) facilities, the charge of brushing and flossing carries on, usually with the help of a certified nurse assistant (CNA).

While moving into an LT/PAC center may mark a new beginning, there is hardly anything new about a resident’s teeth. They may reflect the resident’s physical abilities, medications, and undiagnosed oral or other medical conditions. Taking oral hygiene a step further, to knowing the hidden signs of these conditions and how they appear, can make a difference to the resident’s oral and overall health.

Undiagnosed Outcomes

Often, oral conditions in the elderly are largely unknown. “Some of the most common oral health issues in the elderly population include undiagnosed and untreated periodontal disease, undiagnosed and untreated dental caries, difficulty with swallowing due to dry mouth, and undiagnosed and untreated dental infections,” says Sal Selvaggio, DDS, who had a private practice in general dentistry for 36 years in the District of Columbia. 

During his tenure as a dentist, Selvaggio treated a number of long-term patients who also became long term care (LTC) patients. Undiagnosed periodontal disease, many times unseen, can lead to a large number of problems, he says.

“It has sometimes been called an intra oral bedsore,” he says. “For example, if a patient in an LTC center has a bedsore, it is considered a real problem that can lead to many bad outcomes. Because periodontal disease is not readily visible, a large area of undiagnosed inflammation can cause multiple problems.”

Those problems include oral infections and the increase in circulating inflammatory factors that can have an effect on multiple organs and pre-existing diseases.

Oral Trouble Triggers Body Trouble

Poor oral health can also affect other health conditions in the body, says Selvaggio. These include an exacerbation of diabetes; aspiration pneumonia; possible contributing factors to stroke, heart disease, and dementia; and poor nutrition causing weight loss.

According to the Centers for Disease Control and Prevention (CDC), oral diseases and conditions are common among older Americans who grew up without the community water fluoridation and other fluoride products. Those with the poorest oral health are those who have economic disadvantages, lack insurance, and are members of racial and ethnic minorities. Individuals with disabilities also have an increased risk of poor oral health, CDC says. 

Medications also add to the complexity. Selvaggio says a number of commonly taken medications can affect the oral health of older adults. “These include blood pressure medications and antianxiety medications,” he says. “A big problem is the side effect of causing dry mouth, or xerostomia, for people taking these medications. This can cause an alarming increase in caries, swallowing difficulties (dysphagia), aspiration pneumonia, bad breath, and discomfort.”

Education on the Frontlines

So what does it take for caregivers, particularly CNAs on the frontline who are helping residents brush their teeth, to recognize the signs of a potential breakdown in oral health? The answer is education. 

The Carlos Rosario Training Center in the District of Columbia trains about 50 students per year for CNA certification. The center also helps with job placement, with about half of graduates going into hospitals and the other half working in care centers, including LT/PAC centers. 

Thanks to a partnership with the District of Columbia Dental Society Foundation, oral health care is a big part of the curriculum, says Laurel Anderson, coordinator of the program. 

While oral care is taught along with other activities of daily living in the curriculum, students take a deeper dive into it. “In the curriculum, we typically don’t get into the challenges of oral care in the elderly, and that’s where Dr. Selvaggio comes in,” says Anderson.

The goal of the in-depth portion of the program, taught by Selvaggio, is to educate the students in the biology of oral health, the relationship of microbes to infection, and the relationship of poor oral health to general health. 

After touching on these key areas, students are shown examples of healthy and unhealthy mouths so that they can understand what is normal and what is not when attending their patients.

The last two parts of the training include an overview of dental appliances students may come across as CNAs and how to provide oral care to patients with various abilities to self care.

Seeing the Difference

“Someone who’s not had that deeper dive is able to perform oral care, but they’re not able to recognize issues when they arise,” says Anderson, “and be able to report them.” 

The students in their curriculum are taught how to clean dentures, for example, and that’s where the curriculum leaves it. “But recognizing any issues with the dentures—like if they are chipped, cracked, or not fitting correctly, if those things come up, the deeper dive helps the students recognize that,” she says.

The in-depth training is given to the students to not only recognize the red flags of failing oral health, but to help them to act on it when needed. “The aim is to empower the students to be able to alert the medical staff when needed on dental issues,” says Selvaggio.

Ongoing Education Play​s a Role

CNAs receive oral care training on the job twice a year and as needed at Forest Hills of D.C., a private, nonprofit, full-service retirement community. Creative and compassionate care techniques are the focus, says Janice Johnson, RN, nurse educator/infection preventionist at Forest Hills. 

Johnson says the idea for the onsite training began two years ago when she conducted a dining class in which the importance of oral hygiene was emphasized. “Research shows that if you provide oral hygiene prior to the meal, it will stimulate their appetite,” she says. “This also helps prevent weight loss.”

Partnering with a local dentist to gather research, Johnson incorporates it into the training. “Some techniques include approach [residents] from the front, make eye contact, and use verbal cueing and a hand over hand approach, where you’re putting your hand over their hand to demonstrate,” she says. She tells staff that if they use these approaches, they will get better outcomes and the resident will not be as resistant.

Medications also play a role in the state of residents’ oral health. “They have reduced salivary glands so their mouths are dryer,” Johnson says. “They take a lot of medications that affect their taste buds.”

The Right Approa​ch

At Forest Side, the provider’s assisted living location providing care to people with Alzheimer’s or other dementia, Johnson says the key to proper oral care is knowing which residents have what type and stage of dementia so that staff use the right approaches. “Those residents exhibit very specific behaviors with the type of dementia they have,” she says. “Staff have to know all that so that they know how to approach them.”

Residents with Alzheimer’s disease, for example, may have hallucinations. Another resident with a different type of dementia may not hallucinate but may be combative. 

“The staff have a good baseline knowledge of dementia and the specifics of it,” she says.

Johnson says if residents are experiencing issues with eating or weight loss, she will review their medications to find the cause and then will do individualized training that is specific for each resident.

Keeping Up ​Routine

All residents receive routine dental care in the center’s dental suite, says Johnson. The dentist comes at least once a month and provides routine dental care for all residents there and whatever is needed—extractions or dentures, for example. A former director of nursing, Johnson says it has been a few years since more dentists started to accept Medicaid, and that has helped. 

What also helps, she says, is the center’s restorative nursing program, which aims to keep residents from declining functionally. “We have some residents that are on bathing and grooming—restorative nursing,” says Johnson. “Twice a day, six days a week, they are instructed on how to bathe or how to groom, which includes brushing your teeth, combing your hair, and so on.”

The regular training helps keep oral care at the top of mind for staff. “They are trained to look for anything abnormal in the mouth, or pain or bleeding or any type of discharge,” she says. “Immediately they will notify the charge nurse, who will call the dentist and get a dental consult. And that resident will see the dentist on their next visit.”