Dental Cleanings in Long Term Care

[missjennmb]

I'm back again with more student questions. :) I hope it does not bother anyone. Still at my clinical in the LTC facility. My observations are that many of the patients have a lot of plaque and just plain nasties on their teeth and tongues (forgive my lack of technical terminology). There is a mixture of white buildup and mucous coating teeth, and oral mucosa, as well as darker colors about 1/3rd of the way up the teeth from the gumlines. This is the case on about 3 of the 8 that I have cared for (pretty much those who have tubes). We cannot use a toothbrush because they are all NPO once they get their g-tubes and not all of them even want to open their mouths, but the toothettes are just not getting all of it off. I'm also admittedly afraid they are going to swallow the foam of the toothette, either from falling apart or the patient clamping down (although that could just be my inexperience).

I assumed that the dentist would do a professional cleaning every 6 months, just as we are supposed to do ourselves, but when I asked last clinical, I was told that is not the case. The dentist makes rounds every monday but does not do any cleanings ever. Is that normal? How does plaque build up get removed without a dentist's tools? Or do they just give up on it at that point? Some of our residents have a lot of years ahead of them, and they must get cavities and gingivitis without more extensive cleanings than a toothette right? Perhaps I should read on it more, but we really just skimmed over oral care.

The way that my clinical is run, we don't interact with the nurses at all, or even our instructor. We have a selected "charge nurse" every week who we take our questions/comments/concerns/needs to, and she is the liason between us and the teacher and between us and the staff. I find I have learned more in the few instances where I have been able to view an actual CNA/LPN/RN have really helped me a hundred times more than the hands on I have,, but unfortunately, thats not really much of an option at our school.

Just wondering what your observations/input/thoughts are on oral care in LTC both on a daily basis and from a visit from the dentist? Are there ways that you can remove germs and bacteria from the mouth of an NPO patient (we're only allowed to use water on a toothette and it has to be completely squeezed out and it does not seem to be working very well for me).

Thank you all for your input. Your input on my last question was very enlightening to me. I am DEFINITELY not trying to judge anyone working in LTC. I know they have a huge workload here. I just want to know how *I* should approach this issue, both as a student now helping out, and down the road, when I am a nurse (and hopefully will still have the opportunity to help take care of my residents/patients atleast some of the time)

[achot chavi]

In my LTC facility, we do oral care 1x a shift on residents, 2x a shift for tube feeding. I work day shift 6-2 and for the tube feeders we use toothbrushes. That is how we were instructed in CNA class. We either roll them to their side and brush, use a towel underneath to drain and a washcloth to wipe up any excess fluid. Or we sit them up, lean them forward and proceed. We use toothettes afterwards that are dry to also soak up any excess fluid. Then we use wet ones wrung out for a final cleaning. I find that odd that it varies since we were taught this in class unless careplans say otherwise.

ok, you obviously know what youre doing- wish I had more like you in my facility- I have to be a watchdog for this very basic care- I know it takes time and energy and isn't fun, Of course we provide gloves and basins but till I instill it in every staff member the importance of oral care- I could scream-

Keep up the great work!!

[Dental Hygienist]

I don't know a whole lot about long term care but I can tell you what the problem is here, it's money.

Plaque like you've described (which is actually calculus or tartar) will need professional removal.

Medicare does offer some nominal reimbursement in some cases...but it is really a pittance and very time consuming to follow up on getting paid this money. You have to remember that dental professionals are not in the habit of billing medicare on a regular basis so are not hip to all the tricks and methods of getting paid quickly. And this would be for a small amount of claims at an even smaller rate of reimbursement.

For instance a dental cleaning in private practice may cost $75-85. Medicare may re-imburse at $35-40 (I doubt it's even that high)...when you consider that a dental hygienist typically earns $30-40 an hour and a dentist earns upwards of $75 an hour it is tough to find dental professionals willing to take on this kind of work...not to mention that it would actually be MORE difficult and time consuming to do a cleaning on a long term care resident than on a private practice patient...without the proper equipment combined with the fact that the patient can be uncooperative and probably their teeth are in worse shape than "typical" dental patients...a cleaning procedure that might take 45 minutes in private practice can easily take 90 minutes or longer and will be reimbursed at half the price...so that is like getting paid 25% of your normal wages.

It's sad but true...I'm not saying it's right, it's just the way it is. Until there is decent reimbursement from medicare, then long term care residents will continue to be ignored by dental professionals unless their family pays out of pocket.

Second problem is even if family is willing to pay out of pocket only a few states allow a dental hygienist to work independently in these situations. Very few dentists are willing to do the work of hygienists and if they are willing, they'll want a higher fee (with good reason).

I'm sorry at the state of oral health care in our underserved populations in this country...but I'm so happy that you are aware and doing what you can.

If you cannot obtain the appropriate dental care for your patients, the next best thing is daily plaque removal with toothbrush (and floss? if possible) and a daily topical fluoride source such as toothpaste, rinse etc.

Thanks for caring!

[achot chavi]

Money is always the problem- ingenuity and caring tries to counterbalance that!