DENTAL CARE FOR ELDERLY RESIDENTS
abrégé
Sandra Bennett, BDS DDPH MSc
The Canadian Nurse / L'Infirmiere Canadienne, May 1996, 32-36

As the Canadian population ages and the absolute number of frail or medically compromised individuals grows,¹ we are likely to see an increased demand for dental care outside the traditional office practice.² The maintenance of a healthy dentition in the elderly is important not only for their quality of life, but also for their general health. For example, oral changes -- such as in the ability to chew food or in drug-induced xerostomia -- may contribute to nutritional problems in the elderly.³ Yet adequate dental care is often overlooked by people in charge of caring for the elderly.

Long-term care facilities, in particular, need to examine their oral health care programs. To ensure that the oral health needs of their patients are being met, these facilities must investigate which staff members are primarily responsible for the maintenance of residents' oral health care needs, what services they are currently performing, what level of expertise they have for these duties and what continuing dental education would enable these staff to perform their duties more effectively.

Recently, a study addressing these four concerns was conducted in the Hamilton-Wentworth and Brant County regions of Ontario. Following a literature review, a questionnaire was mailed to the directors of care of each of the 25 provincially regulated long-tern care facilities in the region. A reminder telephone call was made two weeks later to all facilities that had not returned a questionnaire.4 By the two-month deadline, 21 completed questicnnaires had been received. Although this is a high response rate (84%), the results should be viewed with caution because of the small sample size.

Dental services

Each director reviewed a list of dental services and indicated which services were currently provided in the facility. All facilities offered some dental care. Eighteen offered twice daily dental hygiene; two, once daily. Two facilities also offered modification of dental hygiene aids. Ten facilities did a periodic inspection of the mouths of consenting residents to check for infections or other abnormalities, and 12 offered denture identification. Seven facilities checked the 'other' column and variously cited the following dental services: assessment on admission and annually thereafter by the attending physician and referral to a dentist if required, a full-service dental clinic operating one morning each week, annual oral hygiene checks and a dental clinic, unspecified dental care as required, an on-call denturist and dentist service, semi-annual denture cleaning by Brant County Health Unit dental staff and regular visits by a denturist in conjunction with periodic inspection of the mouth for infections and abnormalities by a nurse and physician.

The directors were also asked whether the services of dental professionals were offered to residents. While two-thirds (n=14) of the responding facilities offered residents periodic examination by a dentist, only one-third (n=7) offered treatment by a dental team. Further investigation into follow-up and treatment is required to determine if residents' dental needs are being met through other means. Perhaps more importantly, only four of the facilities gave residents an initial dental assessment on admission, despite the documented recommendations of the Ontario Ministry of Health.

The Ontario Ministry of Health's Long-Term Care Facility Program Manual states, "New residents shall have an oral assessment on admission as part of the admission medical and nursing assessments .... A dental assessment, preventative services (scaling and cleaning, and an assessment to ensure that dentures are properly fitted) should be offered annually or as required by qualified dental personnel, on a fee-for-service basis."5 The lack of adherence to this recommendation is particularly surprising, given that 18 of the facilities reported that they found this document somewhat to extremely useful.

When presented with a list of services and asked to choose the ones they would like to provide regularly for their residents, the directors indicated a high level of interest in improving dental services. All wanted some form of dental service, and over half (n=11) would like their facility to provide twice daily oral hygiene. Many facilities would like to provide periodic inspection of the residents' mouths by a nurse or physician (n=13) or by a dentist (n=11). The most striking finding was that 18 (86%) of the responding facilities would like to provide treatment by a dental team. Yet in the margin beside the question, a number of respondents noted that they either did not know how to fund such a service or would only like to provide it if it were at no cost to residents.

In 10 of the responding facilities, nurses were listed as the staff type primarily responsible for maintaining the dental health of residents. Two directors did not answer this question, two listed multidisciplinary teams, two listed nursing assistants, and the other five each listed one of physician, occupational or physiotherapist, family members, the resident and health care aides.

Awareness of dental health

Whether long-tern care facility staff are aware of the implications of dental disease and infections on the residents' physical health depends on a number of factors, including the respective staff's training, the emphasis placed on dental care and disease in each facility, staff inservice and continuing education, and the staff's general knowledge.

In this study, 20 of the 21 responding directors said that, "yes," their staff were aware of the implications of dental disease and infections on the residents' physical health. All 21 directors believed that their staff were aware of the effects of good dental health and hygiene on the residents' quality of life (e.g. the residents' ability to speak, socialize and eat in front of others).

Six facilities provided staff dental inservice training annually or more often. The training included general mouth care with the activities of daily living (two facilities), an inaugural inservice by the visiting dentist on basic dental care (one facility) or a video on oral care and the importance of good mouth care (two facilities). The sixth facility was about to begin an annual inservice the month following the questionnaire completion. Training was primarily by lecture, although slide shows and videos were also used. The trainers variously included the director of care, the assistant director of care, a registered nurse, a dentist, a dental hygienist, the staff development coordinator and the local public health department.

When asked which staff groups would benefit from future dental inservice education, the directors most often chose nurses (20 facilities), nursing assistants (18) and health care aides (7). Eleven facilities would like to offer dental services once or twice a year, seven once a year, and three, three or more times a year. All facilities would like these sessions to be done inhouse. Two facilities commented that they would like to have training sessions on a rotating basis to ensure that all staff members have an opportunity to attend.

Most facilities (n=19) would like to have inservices on both denture cleaning and the cleaning of natural teeth. All facilities would like to have further education on the assessment of the mouth for abnormalities. From a dental standpoint, it would be a useful adjunct to professional dental services for appropriately trained facility staff to provide regular assessments for signs of oral abnormalities. Early interception and referral for appropriate dental care would ensure that residents maintain as healthy an oral environment as possible. Another positive finding in this category was that 18 of the facilities desired further education on the medications that can affect the health of the mouth and teeth, and 16 were interested in medication-induced dental disease. Equally welcome was the fact that 17 of the facilities indicated that they would like to have more information about the impact of dental health on the diet.

Many people who provide primary care to elderly individuals are acutely aware of the role of the mouth and teeth in maintaining an adequate intake of nutrition. The more information that can be disseminated at the facility level, the more likely all facility staff will understand the importance of maintaining preventive dental practices in the institutionalized elderly.

Only 10 facilities requested more information on infection control during dental procedures. it is feasible that nursing staff currently have an adequate background in infection control to deal comfortably with this issue. It would be useful to investigate whether the level of infection control knowledge is equally high among nursing aides and dietary staff.

Only one facility requested more information on the impact of dental health on the general state of health, confirming the fact that this connection is often overlooked.

A variety of preferred providers of dental inservice programs were indicated, including the dentist who provides resident care (four facilities), a local dental hygienist (seven), the public health unit's dental director (six) and a lecturer from a faculty of dentistry (one). The "train-the-trainer" approach was a popular choice, with 10 facilities selecting this option. Interestingly, 13 of the facilities indicated that they would like a local dentist with training in geriatric dentistry to provide their inservice training. What is not commonly known is that no formal graduate training programs in geriatric dentistry are provided by Canadian dental faculties. Continuing dental education in geriatric dentistry is also limited, Most geriatric training is therefore derived from journals, peer discussion, clinical experience and short courses.

Finally, facilities were asked, "How important do you feel dental inservice education is to your staff's ability to maintain the health of the residents' mouth and teeth?" Ten facilities responded "extremely important," 10 "very important" and one "moderately important." Apparently, the maintenance of dental health is a serious issue for the long-term care facilities in the Hamilton Wentworth and Brant County regions.

Discussion
Overall, a stronger alliance between the dental community and long-term care facilities is indicated by the results of the survey.

Despite the stated importance of dental health to the surveyed facilities and the recommendations of the Ontario Ministry of Health, only one-third of the facilities offered treatment by a dental team and few residents received an initial dental assessment. The dental community could provide practical support to facilities in these areas.

From a prevention perspective, it is disappointing that only 11 (52%) of the responding facilities would like to provide twice daily oral hygiene for their residents. While it is commendable that over half the facilities would like to provide periodic inspection of the residents' mouths, more emphasis on primary prevention practices could lead to better oral health for residents and, thus, less detection of oral conditions at periodic inspections. One of the most striking findings in this survey was that 18 of the respondent facilities would like to provide treatment by a dental team. Both the financing of such a service and how this service would be provided within the facility were beyond the scope of this survey.

While some facilities have already addressed the issue of providing staff with a sound knowledge of dental health and the practical skills to conduct routine preventive dental services for residents, there is still a long way to go in this area. Again, the dental community needs to work collaboratively with facilities to address their needs for relevant inservice education. Staff who have a sound knowledge of how and why oral health affects an elderly person's general health, nutrition and ability to socialize are more likely to accept their role in dental service delivery.

Nurses, nursing assistants and health care aides are the staff members most commonly responsible for the dental health care of longterm residents as well as the staff most frequently selected as those for whom continuing dental education would be of most benefit. Given the different training and responsibilities of these health care workers, thought should be given to providing different inservice programs to meet the needs of each. For example, nurses might find education on medications and dental health useful, while nursing assistants and health care aides might benefit most from training in specific oral hygiene care, how to modify toothbrushes for physically challenged residents and so forth. Because of the many demands placed on nurses in a long-term care facility, it would be of great benefit if nursing assistants and health care aides had sufficient knowledge and skill to conduct most oral hygiene care under nursing supervisions.6

Two concerns should be kept in mind when planning inservice education. First, a combination of training methods is most valuable. The lecture format allows a comprehensive overview of dental services, while videos and demonstration sessions offer a practical environment in which staff can practice their skills and obtain immediate feedback. Second, a train-the-trainer approach, in which at least one staff member in each facility is capable of training new staff members, would ensure that new staff have ready access to a resource person and to basic knowledge of dental health and care techniques.

To ensure that the continuing dental education needs of long-term care facility staff are met requires the collaborative effort of the dental community and the long-term care facilities themselves. Clear lines of communication between these two groups are key to staff understanding of the benefits of continuing dental education. When staff have a sound knowledge of the role of dental health in general health, nutrition and socialization of the elderly, there is more likely to be acceptance of staff roles in preventive dental service delivery. Only then will elderly residents of long-term care facilities be assured of the best dental care possible.

References

Statistics Canada. Population ageing and the elderly: Current demographic analysis (cat. no. 91-533E), Ottawa, Statistics Canada, 1993.

MacEntee, M.I., Weiss, R.T., Waxler-Morrison, N:E. and Morrison, B.J. Opinions of denists on the treatment of elderly patients in long-term care facilities, Journal of Public Health, 52(4), 1992, 239-44.

Palmer, C.A. Nutrition and oral health of the elderly, in A.Papas, L.C. Niessen and H.H Chauncey, eds., Geriatric dentistry: Aging and oral health, Toronto, Mosby Yearbook Inc., 265.

Dillman, D.A. Mail and telephone surveys: The total design method, New York, Wiley-Interscience, 1978.

Ontario Ministry of Health. Long-term care facility program manual Toronto, Ministry of Health, 1994.

Saunders, M.J. and Martin, W.E., eds, Dental regulations compliance manual for the nursing facility, San Antonio, Texas, American Society for Geriatric Dentistry and University of Texas Health Science Center at San Antonio, 1993.