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)

[racing-mom4, BSN, RN]

Plaque like you have described will not wash off with water on a damp sponge. It needs to be scraped off by a dentist. Unfortunatly you will see lots of nasty teeth in your future---seems as if going to the dentist is not even close to the top of the list of caring for elderly anymore.

You can ask your teacher how you go about setting up for the dentist to come and actually do a cleaning. I know the nursing home by Grandmother is in we sign a paper/permission slip of sorts for the dentist to visit every 6 months for general cleanings.

Bless you for noticiing this problem---I could NOT IMAGINE having icky teeth each day. I am sure even the damp sponge is heaven for those folks. Mouth care is in my opinion so important and unfortunatly so over looked.

[CoffeeRTC, BSN, RN]

Getting a dentist to come in and one that would be able to work on bed bound pts is most of the battle. Then you have to deal with actually getting the residents to be cooperative with dental care....that is another huge hurdle.

I would love to hear how other places deal with this too.

[caliotter3]

I am glad that you have noticed this and are concerned. The LTC facilities that I worked at never addressed dental care or dental hygiene for that matter. As a CNA, I was never instructed to do oral care. I did the best I could and discussed this with a supervisor who couldn't give me an answer for the problem.

[bookwormom]

I guess part of the question is, who is going to pay for routine dental care. I don't think Medicare pays for this, nor Medicaid. I agree that mouth care is a big problem. I also suspect that some people who cannot express themselves may be experiencing dental pain. I don't think anyone has a good handle on how to do really good daily mouth care for residents who are at risk of aspirating and who can't cooperate at all.

[big-chicken]

My sister suffered from Multiple Sclerosis and was a resident in a LTC facility for 20 years before her death in 2000. She too had very poor oral care. I don't think the care providers brushed her teeth, ever.

Near the end, she had problems swallowing which got progressively worse until she could no longer swallow even water. She became very dehydrated after this point and eventually she failed to thrive. Cleaning her teeth was not possible or safe at this point, but it certainly was when her health was better. Oral care was one of those things that got low/no priorty and it simply wasn't done. My parents used to brush her teeth when they visited but as was stated in a previous note, it really required a dental hygeinist to remove plaque once it adheres to teeth.

This is one of those sad realities of being in LTC. It definately needs to change.

big-chicken

[beachgirl17]

Hi Scorpiostudent, I am a registered dental hygienist (and very soon-to-be RN), so I thought I would give my . Racing-4mom is correct that what you are describing will not come off with a toothbrush or toothette. Regular plaque can be removed with a toothbrush and floss, once it is hardened it is called calculus (also known as tartar) and needs a professional cleaning with dental instruments. I am not too famailiar with LTC facilities, but I would imagine it would be difficult to arrange adequate dental care. You are doing the best job you can for them by either brushing or using a toothette (in my opinion brush is better, but I understand that is not always possible). It may be a good idea to find out about the visiting dentist and if cleanings are available to the patients. Dentists do do cleanings, however, it is often the role of dental hygienists. I am sure many dental hygienists would do cleanings in a LTC facility, however it is difficult to "make-do" without proper equipment when you are not actually in a dental office. Plus, in many states dental hygienists cannot perform care without a dentist on site with them or at least having seen the patient prior and diagnosing them with a need for a cleaning. It truly depends on the state you live and the practice act of the dental hygienist and dentist. Also, bookworm mentioned money and I am sure that is a huge problem. I am not too sure on the guidelines of Medicare anymore..but I think that it may only pay for an x-ray and extraction in certain situations, but like I said, I am not sure on all of that. I think the best hope for many of these people is to have caring families with money who then take them to the dentist, but as we all know...this doesn't happen often.

Hope I shed some light on the subject. Good luck in school!

[RNfaster]

See http://www.vac-acc.gc.ca/clients/sub.cfm?source=health/dental - "Mouth bacteria can be drawn into your lungs when you breathe and cause a serious type of pneumonia. This is a concern for those in nursing homes because many people in nursing care die of pneumonia. Oral disease can increase the risk of pneumonia by three to six times. This risk continues to increase in combination with other factors such as poor overall health, swallowing problems, dry mouth and feeding dependency."

[PsychNurseWannaBe, BSN, RN]

We use Healthdrive. They have dentists, podiatrist, audiologist (in some areas) and vision. Medicare and Medicaid reimbursement does exist... but it is based on medical necessity. Then the resident pays the rest. They come to our facility on a set schedule and will do emergency visits that cost the resident extra. I just started helping residents set up their appointments....so I don't know all the details. But we have a brochure that explains the cost up front to the resident.

http://www.healthdrive.com/facilities.htm

[NotFlo]

Yup, we have healthdrive too. The hygenist comes every six months per a schedule and cleans everyone's teeth (everyone that doesn't see an outside dentist with their family, etc.) Some people are covered and some do have to pay for this service out of pocket.

It takes several days and can be quite an ordeal. It is a major deal to get some of the more confused people to comply. I was overjoyed last time when the whole process was finally complete for another six months.

The dentist also comes in to see people with dental problems on an as-needed basis. Whatever he or she can't do at the bedside is referred to a dentist that takes medicaid...this dentist is in a clinic over and hour away and has a long wait so it can take them awhile to get problems repaired.

I totally agree that oral care if very often totally neglected and it sucks.

[fuzzywuzzy, CNA]

As a CNA working 2nd shift, oral hygiene never came up once during my orientation. The girl who trained me just doesn't do it, I guess. If someone has dentures I clean them myself. I set the others up with their toothbrushes and basins, but some refuse to do it.

They all have candy stashes that their families bring in, which doesn't help!

[noc4senuf]

We use a company that send a dentist, hygenist and chiar side assistant out into the nursing homes. They come into our facility twice per month along with all of their equipment (it truly looks like a dentist office when they are set up). They perform all services just as you and I would get when we go to the dentist.

They process there own billing and the only thing we need to do is provide them the face sheets and the schedule. We also use a service that provides monthly podiatrist, audiologist, and vision. This company also does their own billing. I don't have the paperwork here in front of me but, MA pays for some and i believe others is Med B and private pay.