Oral Healthcare for Elders: A Missing Link

Angie Stone, RDH, BS


Elderly residents in nursing homes are known to have poor oral hygiene and extensive oral disease, suffering from the poorest oral health of any population (Journal of the American Geriatrics Society, 2006). This information initially came from Oral Health in America: A Report from the Surgeon General, published in 2000 by the US Department of Health and Human Services. Poor oral health can lead to aspiration pneumonia, heart attack, stroke, and uncontrollable diabetes; and all these conditions can cause death. Therefore, the elderly run the risk of dying from dirty teeth.

Even though the surgeon general’s report is 15 years old now, this statistic appears to still hold true today. In my opinion, this is an atrocity and yet another way our government, as well as the medical and dental professions, are ignoring one of the most basic needs of this most vulnerable population. This problem is not going to go away; in fact, it is going to explode in the next 2 decades as baby boomers begin needing the services of skilled nursing facilities.

I have spent the better part of the last 13 years attempting to figure out why this statistic holds true and have learned that there are several realities that make it so. Most of us think that if and when we become dependent on others for our care, dental care is included in the overall package. It becomes very clear that, in most cases, if a dependent elder is in need of dental care, the services needed are almost nonexistent. People do not pay attention to the fact that our federally funded Medicare system pays nothing toward dental services. Nor does the public understand that state Medicaid funds pay very little, and that coverage varies by state. Furthermore, the lack of money is only the beginning of the challenges.

Dependent elders often find it difficult to impossible to physically get to a dental office. While most offices are wheelchair/disabled accessible at this time, simply finding transportation to an appointment can pose a big challenge. Family and friends rarely have the time to take a loved one out. If they do have the time, it is likely they may find it difficult, if not impossible, to get the elder into a car. While some care facilities provide transportation to a medical or dental appointment, there can be challenges with these options. If the ride costs the elder money, he or she may not be able to afford it. If the facility needs to send a team member with the resident, this can leave it short-handed and sometimes be a barrier to the resident going when needed.

Bringing Care to the Elderly
It would seem logical that dental services could be brought into the nursing homes. This type of service is becoming more and more popular, but the majority of the approximately 1.5 million elderly nursing home residents are not being served. These “home care” businesses are expensive to start up and very expensive to keep running. As a result, after residents have a dental exam, treatment plans often do not get completed unless the resident is complaining of pain. Before realizing what was going on, this kind of care resulted in my grandmother losing 60% of her teeth in just the 2 years that she spent in a “skilled” nursing facility. In my opinion, this is more than unacceptable.

Along my own journey, I have been fortunate enough to have cleaned elderly residents’ teeth in the nursing home environment. What a relief for my residents and me that there was a dentist affiliated with the nursing home who provided oral examinations, going room to room and using a flashlight. These “exams” were nothing more than going through the motions, so the facility was in compliance with the mandate that all residents have a dental exam annually. However, the good thing about this system was that, with the completion of an exam and the approval from the dentist, I was allowed to clean residents’ teeth. I was also able to bill Medicare for these cleanings. If someone is disabled, Medicare will pay for a prophylaxis once every 3 months in my state. Being able to provide this service was certainly a positive thing and should have certainly helped improve the statistic mentioned above. But what I discovered was, even though I was seeing many residents every 3 months, they still had dental conditions that were worsening. Why would this be happening, when I had been providing services? The answer is simple, and all dental professionals know the answer—simply cleaning teeth every 3 months, and/or having an annual dental exam, is not enough to ensure good oral health, especially in this often medically compromised population. In addition, what would make us think dependent elders would be able to perform the needed self-care in between professional visits, if they are lucky enough to have access to basic services in the first place?

The Reality for Elderly Residents
You may be thinking that the care team at the facility is “supposed to be” assisting residents with oral care. Well, one would be correct in thinking that; however, the reality is in most cases, they do not, and there are many reasons for this. Combative residents with psychological challenges, often on a variety of prescription drugs, make nursing assistants leery of providing oral care. Time constraints are the most frequently reported reason for not brushing and flossing the residents’ teeth. These issues can certainly be major challenges, and while these are some of the major issues discussed, there is another one: proper professional education!

There are 2 basic ways to become a nursing assistant. One is to go through a course at a community college. The other is to get on-the-job training in a nursing home. There can be arguments as to which avenue is the best, but it cannot be argued that one is better than another when it comes to oral care training. Formalized programs dedicate, at most, one hour to the topic of oral care. That is lecture and hands-on training. Some nursing assistants report even less time spent on the topic.

And yet, as dental professionals, we get upset when we see a resident whose oral care has not been performed adequately. In fact, it is not unusual for us to write notes back to the care team letting them know that they need to be doing a better job. This is somewhat unreasonable, as we have no idea what their job responsibilities and duties include on a daily basis. It is normal for one nursing assistant to have 12 to 15 residents to take care of per shift. He or she needs to assist a resident with, or accomplish without the help of the resident, all the activities of daily living (ADLs). These ADLs include but are not limited to: bathing, dressing, feeding, and administering medications (in some facilities). Nursing assistants provide emotional support, and it is not unusual for them to take on the role a family member would fill, as many residents may not have visitors coming to see them very often. It has been noted that a nursing assistant needs to spend 2 hours per shift with each resident. That is 24 to 30 hours of work per shift, for one person. Something has to give, and oral care is simply taken off the list. No one checks to see if oral care has been provided and done correctly and, furthermore, the majority of these care providers don’t like to do it. Interestingly, they would rather clean up residents after a bowel movement than perform adequate oral care.

Many people have picked up the idea of training nursing assistants to provide better oral care. There are a lot of programs doing that; however, there is no proof (documented follow-up) that these courses actually lead to improved oral health of the residents. Research has actually shown that training does not lead to an improvement. So, amidst all these challenges, it makes sense that elderly nursing home residents have extensive oral disease and poor oral hygiene and suffer the worst oral health of any population.

I truly believe that this unfortunate situation must and can be changed.

In my opinion, dental hygienists providing weekly oral care and encouraging the daily use of xylitol will greatly improve the oral health of this elderly population. These hygienists should be the professionals providing the oral care to this population, not nursing assistants. They are trained to be prevention experts. Research shows that when professional brushing is done weekly, the rates of aspiration pneumonia decrease. We also know improving oral health can help control diabetes, prevent periodontal disease, and even lessen the risk of heart attack and stroke.

The use of xylitol with this population has demonstrated a reduction in plaque levels. (This was seen in research done by Shirley Gutkowski, RDH, BSDH, and the author, which was published in the October issue of Integrative Medicine: Clinician’s Journal.) During a period of 12 weeks, residents were given 100% xylitol mints or gum, depending upon their abilities, twice daily. They also utilized a xylitol mouth spray twice daily. Examination of photos pre- and post-study of disclosed teeth revealed a dramatic reduction in plaque on the teeth.

Combining dental hygienists, weekly brushing, and xylitol use is a large piece of the puzzle when reducing the oral disease of this population. I know this, because I have implemented this protocol and have witnessed its success. In more than 2.5 years of managing this protocol with nursing home residents, I have seen residents under our care maintain good oral hygiene. It is possible, with the right approach and protocol to this health challenge, that a majority of elderly residents can, in most cases, keep the teeth they enter into the nursing care facilities with and certainly need not die with—or from—dirty teeth.

Ms. Stone has been adjunct faculty in both dental assisting and dental hygiene programs. She has also educated dental professionals about various dental hygiene topics internationally, having reached professionals on-site in 40 states and 5 countries and territories. In addition to numerous published articles, her original research regarding xylitol and elders was published in a peer reviewed medical journal in October of 2013. Ms. Stone’s book, Dying from Dirty Teeth, was introduced in March 2015. Her company, HyLife, LLC, brings oral care services to dependent elders because they shouldn’t “die from dirty teeth.” She is a 6-time attendee of CareerFusion and was awarded the Sunstar Award of Distinction in 2012 for her work with xylitol and the geriatric population. She can be reached by calling (608) 884-0038 or via the email address astone@hylifellc.com.

Disclosure: Ms. Stone is the owner and founder of HyLife, which brings oral care services to the elderly.