The Dreaded Dependent Adult

It took some digging, but we found the origin of the quote “insanity is doing the same thing over and over again and expecting different results.” BrainyQuote.
com attributes it to Albert Einstein. No one wants to admit to doing this constant tail chasing, but in dentistry we do it all the time, particularly with elderly adults and people dependent upon others, namely nursing home residents. This behavior is not in the best interest of these patients, and it is time to improve their oral health management.
When we see this population in private practice, depending on the cleanliness of the oral cavity, our eyes roll, and on some level we become irate. In the case of nursing home residents in the office, we make notations in the record that accompanies the resident telling nursing home staff that oral care needs to be achieved at a more acceptable level. Quite possibly the administrator of the facility is called, and we tell him or her about the horrors of plaque on the teeth. The administrator also rolls his or her eyes, but for quite a different reason than we did. The aforementioned clients many times have difficulty performing oral care for a variety of reasons. Here are a few reasons that come to mind quickly:

• not wanting to perform oral care routinely
• not being able to perform oral care
• they can’t remember it is time to do it
• brushing is painful
• they don’t have the correct products.

Illustration by Nathan Zak

Did we say anything about them not knowing how to do it? Consider how the dental team approaches lack of personal home care. Typically, patients have a finger waved at them, they are told they are not performing to the office’s standard, and one of the team members reiterates how the patient is supposed to brush and floss. This is the exact same advice the team provided at the last visit, but when the patient returns for the next professional cleaning session, we expect to see a difference in the oral care situation. Einstein’s utterance takes on another facet.
So, what might we suggest for the dependent adult population? Get ready, because what we are suggesting requires a huge paradigm shift. In the last 5 years, products to serve this population have come onto the horizon.

Xylitol

• decreased cariogenicity
• increased oral pH
• increased facial muscle tone
• increased salivary flow (xerostomia is a problem in dependent adults for a variety of reasons)
• increased enamel remineralization
• decreased sugar clearance times
• improved food taste.

When all of these hurdles are cleared, the list of incessant problems plaguing nursing home residents becomes smaller. Xylitol used as an additive to water will provide benefits such as decreased presence of Streptococcus mutans as well as hydration for the patient. How simple is this to incorporate compared to the Modified Bass Brushing Technique? Xylitol has also been linked to decreased candida infections and increased bone strength.^1,2 It’s an all around winner for this population.
Another great way to incorporate xylitol to this group is through mouth spray. Viewed as a treat by many, xylitol mouth spray will create palliative affects to the dry oral tissues and boost the xylitol effects.
The biggest drawback listed in the literature regarding xylitol is the GI upset that can be associated with it. As many dependent adults are on medications that cause constipation, this could be listed as an added benefit once the body becomes accustomed to the dosage.

Casein Phosphopeptide Amorphous Calcium Phosphate

Second on the list is the casein phosphopeptide amorphous calcium phosphate (CPP ACP) molecule developed in Australia. More commonly called Recaldent, this product is found in MI Paste (GC America), MI Paste Plus (GC America), and Trident White chewing gum (Cadbury Schweppes). For people with hypo-salivary function, it’s a must to replace the calcium and phosphate that the enamel needs to heal. Most salivary replacement products alleviate some of the oral discomfort for a short time; however, they replace none of the nutrients that saliva provides. In this time of advanced medical treatments that keep people healthy and alive, it’s a shame dentistry hasn’t kept pace with the need to replace saliva. This product can be offered to patients directly in the dental office. If the shift is made, it would make sense to expect a different outcome at the next professional cleaning appointment.

Glass Ionomers

On the restorative side of things, glass ionomers are not a good choice for longevity or aesthetics for a young, active, and healthy person. However, they should be considered on a routine basis for use in the population we have been discussing. The bond of a glass ionomer and its ability to arrest decay as well as fill the void bacteria creates make it a perfect choice. Dental hygienists can also place some of the newer glass ionomers as a temporary filling in the course of their day. Glass ion-omer sealants, developed for children, have the added benefit of bonding to all surfaces of the tooth. So a tooth that cannot be, or is not being, accessed by a toothbrush can be coated with glass ionomer to protect it from oral pathogens. Even when glass ionomers cannot be seen with the unaided dental eye, it is still there as evidenced by SEM photography. Therefore, the tooth is protected against biofilm growth and inevitable tooth decay.

NURSING HOME STAFF

Based upon the information presented thus far, it is obvious how nursing home residents can benefit from state-of-the-art dental products. Now, let’s take this information a step further and discuss how and why this type of information would be most beneficial for nursing home staff members. Historically, certified nursing assistants (CNA) are the people responsible for providing oral care. These people are not only in charge of the oral health for 8 or more residents, they are also entrusted with caring for residents’ physical and emotional needs (Table 1).
The education of a nursing assistant is short (72 hours), of which nearly 30 minutes pertains to oral care. This 30-minute lesson centers around brushing and flossing residents’ teeth and cleaning oral prosthetics. Typically, oral care information in CNA textbooks is in the same chapter as hair care and bathing. It is considered strictly daily hygiene. While textbooks mention “signs to report to a nurse,” including bad breath, bleeding gums, and broken fillings, to name a few, there is no mention of periodontal disease and the manifestations of the disease. The authors did, with much surprise, find one textbook published in 2005 that made reference to pyorrhea!
Nursing and nursing assistant students have no comprehension of the oral cavity as a wound that needs cleaning. They have no idea that the debris left on teeth harbors E coli, S pneumonia, or H influenza. That any of those organisms on their own can create havoc in the person they’re caring for is never on their thought horizon. The idea that they may be growing out a culture ready for aspiration is also nowhere in their minds. The practicum for oral care centers around CNA candidates brushing each other’s teeth while the brushee sits in a chair. Students, acting as residents, are co-operative with each other, and all have more than 80% of their natural teeth. The majority of the students are younger than 25 years of age, which brings up obvious oral condition differences between the two populations. Due to the design of the oral care practicum, most students have never seen a crowned tooth or a dental implant. They may have witnessed prosthetics, but certainly most don’t have them in their own mouths. This is not to mention the difference in muscle tone and the amount of food debris we in the dental field are used to seeing in elderly or dependent adults.
Studies done by dental hygienists and nurses regarding oral care in dependent care facilities tell us a lot about how oral care is managed… and its importance. For instance, time is often suggested as a hurdle to providing proper oral care to residents. They are running from crisis to crisis, with barely enough time to go to the bathroom themselves. Long gone are the days when CNAs had time to congregate at the back door to smoke half the day away, if those days ever really existed.
Another reported roadblock to oral care is the fear of being bitten. While the dental team gets upset by patients who cannot or will not turn their heads this way and that, nurses and CNAs worry about combative residents. They continually report residents who tighten their lips, flail their arms, and make their mouths   into moving targets while the nurses or CNAs attempt to provide oral care. Their education has not provided any information regarding these issues. How should the dental community recommend the CNA approach this type of resident? This paper has answers where one would not look at first glance. Xylitol and Recaldent use, along with expanded use of glass ionomers, decreases the need of dealing with these combative residents.
A CNA’s annual income is approximately $19,000, with the median income rate just more than $10 per hour. The turnover is an outstanding 43% in nursing homes compared to those working with home health agencies, where the pay is better and the turnover is only 25% (http://hhcsinc.com/News_2006_ND.pdf). With this pay, should oral care really be the CNA’s responsibility, or should it be on the shoulders of the dental community? Is it really practical to continually expect overworked, overly responsible, underpaid CNAs to provide oral care equivalent to that of a person who practices it every day? Can a CNA really learn to clean teeth with a toothbrush as well as a dental hygienist or dentist? Who is going to teach them how? They are not even educated to know the difference between a row of teeth completely covered in calculus and teeth that are simply yellow.
Some members of the dental profession have noticed a need for oral care education for nursing home staff members, but very few have really identified what the focus of the education should be. Inservice training sessions continue to be centered around the 45° Modified Bass Brushing Technique, flossing, and cleaning dentures and partials. This provides staff members with the same education they received in their formal training, and based upon the condition of residents’ mouths, it obviously is not effective. It appears to be a quagmire. We think we’re on sound ground when we take a step to educate those who care for the dependent population, but this is where Einstein’s quote comes into play. How can we expect a different outcome if we continually do the same thing? We need to step back and put together a different plan to get the results we want, ie, healthier and happier dependent adults. So, we need to ask, “What is the best way to get better oral care for the residents?” This is a different question than, “How do we get staff to take better care of residents’ mouths?”

As the first stipulation, let us concede that nursing staff members at all levels in dependent care facilities are working hard. With that in mind, we need to have solutions that do not further tax the already overworked CNA. We need solutions that will gain cooperation from residents, and we need solutions that will actually improve oral health. Rather than more manpower, science is the answer, the same science we discussed in the first portion of this article: xylitol, Recaldent, and glass ionomers as temporary fillings (Table 2).
With adaptation of the recommended protocol, the CNA can easily achieve oral care, and the oral health of residents will improve greatly. CNAs dress residents every morning and undress them every evening; this time can be double duty if the resident chews a piece of gum during that monitored time. Applying Recaldent paste with a gloved finger takes a few short seconds, and if the resident clinches shut it can be applied to buccal and facial surfaces and still reduce bacterial load in the mouth by 50%. Administering breath spray only requires that residents open their mouths; there is no need even to have contact with residents to provide this care. All of these applications take less time and effort by CNAs than attempting to perfect the Modified Bass Technique and flossing.
One of the best-selling toothpastes in nursing facilities doesn’t have a pleasant taste, resulting in poor compliance; Recaldent Paste has a pleasant flavor. In addition, xylitol is sweet, and residents view it as a treat. Pleasant-tasting products result in less resistance, and increased compliance can increase taste ability by decreasing bacterial numbers in the oral cavity and increasing salivary flow. When food tastes good and oral tissues are adequately hydrated, quality of life (QoL) increases, which is a triumph for any facility. Who would have thought it could be accomplished so easily?
While all of this is true, let’s take a break from the new and talk about toothbrushes. On the surface, power brushes seem to be the best option for this population. However, between expensive items “taking a walk” and vibrations of a power brush being difficult for this population to overcome, they are not a good option. Neither are the normal toothbrushes routinely distributed in facilities. While trying to keep costs down, administrators in-evitably purchase inexpensive and poorly manufactured toothbrushes. Giving a good manual toothbrush to a resident in a care facility will do much more than any lecture delivered to facility staff members.
These are the kinds of things the dental community as a whole, dentists as well as dental hygienists, must look to in an effort to help those who depend on us. Nagging and finger wagging about brushing and flossing for this group is not even supported by the science and should stop at once.

Ms. Stone holds an associate’s degree in dental hygiene and a bachelor’s degree in psychology. Her career in the dental profession began with 5 years active duty in the US Navy as a dental technician, after which she dental assisted for another 9 years. She has been providing clinical hygiene services for the last decade.  Ms. Stone has been an adjunct instructor of clinical and didactic dental hygiene and has taught dental assisting. She consults with dental business and hygiene operations through McKenzie Management, has spoken nationally on the topic of oral healthcare for dependent elderly, and provides inservice training sessions on this same topic at nursing homes and assisted living facilities. She can be reached at angie@mckenziemgmt.com.

Disclosure: Ms. Stone holds lecture sponsorships for GC America.

Ms. Gutkowski resides in Sun Prairie, Wisc, is active in the ADHA, and is an international speaker and award-winning writer. She is also a CareerFusion co-director, and can be reached at crosslinkpresent@aol.com.

Disclosure: Ms. Gutkowski holds lecture sponsorships for GC America and XLEAR.