#12 – Goes to Nursing Home / Riverside School | Dental Practice Coaching

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#12 – Goes to Nursing Home / Riverside School

Introduction

As of January 2001, there were over 40 million Americans over the age of 65. Many of our older Americans, due to economics, lack of perceived need, or lack physical access will be forced to live in nursing homes. Today we see many of these seniors as physically limited, sickly, poor, and/or with reduced mental abilities. However, in their time, they were as responsible for the success of their families and communities as we are today in ours.

Part of our vision is to help the disadvantaged to make their lives easier. Where possible, we will offer a comprehensive program to assisted living and nursing homes in our area. This program will be provided with all of the love and respect we would give to our own parents if they were in this situation. Here are our goals.

A. Understanding the residents’ psychological and medical issues
B. Finding an effective plaque removal techniques for disabled residents
C. Using chemical agents (fluoride and artificial saliva)
D. Giving staff in-service presentations on resident oral healthcare
E. Working with residents to maintain good oral health
F. Communicate with other health professionals to improve the overall health of the residents

Providing our level quality in extended care facilities requires a huge effort in coordination/cooperation. Family members, home staff, and our staff, physicians, pharmacists, and social workers must all work together.

We will provide written records, treatment plans, communication with family members, great cleaning, and preventive care appointments, rational treatment recommendations, loving care, reduced fees, training for the facility’s staff, and much more.

Operating in a Nursing Home

A. Who works at a nursing home
1. Administrator
a. Runs the nursing home
b. Establishes policies and procedures
c. Responsible for maintenance of facility, grounds, equipment
d. Hires, fires, manages staff
e. Responsible for all finances
2. Medical Director
a. Required if facility receives Medicare/Medicaid
b. Responsible for all medical/dental policies/outcomes
c. Must be a licensed physician

3. Attending Physician
a. Usually a resident continues seeing the physician that cared for them before they entered the facility
b. Facility will have a physician available for residents who have no preference
c. All treatment is reviewed by director for appropriateness
d. Must review and agree with any medications prescribed by dentist
e. Must see patient every 3 months

4. Director of Nursing
a. Plans/supervises all nursing services
b. Responsible to Medical Director
c. Most have an RN available 8 hrs/day, 2 days/week
d. Responsible for written plan of care for each resident
e. Will assess residents for dental needs
f. Responsible that all residents oral home care is adequate
g. Orients new staff; responsible for in-service training

5. Nurses’ Aide
a. Not trained/certified nurses, must have high school degree
b. Low pay; much turnover
c. Responsible for most day to day care of residents

6. Social Worker
a. Helps find resources (including financial) for residents
b. Help family members with decisions
c. Help find funding for dental programs
d. Provides legal support (living wills, etc.)
e. Not available at all facilities
f. Help family members with decisions

7. Physical Therapist
a. Employed by home
b. Help residents with physical problems. Find ways to use muscles better. Rehabilitation.

8. Occupational Therapist
a. Find ways to help residents physically be able to do oral hygiene (design grips for brushes, handles for floss, etc.)
b. Improve functional skills of residents.

B. Diagnostic guidelines
1. Standards for our clients and extended care facility guidelines are very different.
2. Clinical implication of aging.
a. Loss of social roles (family, occupation)
b. Loss of income
c. Reduced physical abilities
1. impaired vision – harder to read, progressive blindness, more light sensitive
2. lack of taste – not age related, caused by xerostomia, medications, diabetis
3. heaving – loss progresses with age
3. Only 1 treatment plan will usually be given
4. Seldom use antibiotics
5. Amount of treatment is determined by lifestyle

C. Signs/symptoms – Tx
1. Xerostomia
a. Signs of Xerostomia
1. Smooth glossy tongue
2. White tissue around teeth
3. Caused by many diseases and medications
4. Rampant decay
5. Burning, sore tongue
b. Treatment
1. Biotene saliva substitute
2. Fluoride paste prescription
3. Chlorhexidrine rinse

2. Decay
a. Look around roots
b. Tx
1. Look for sugar consumption (dietary counseling)
2. Fluoride prescription

3. Mentally disabled – Chlorhexidrine spray (calibrate to 1.2 ml/spray) twice daily (early AM, at bedtime). One spray on front teeth.

a) Mouth rinse or paste would be swallowed or aspirated
b) May not cooperate for brushing
4. Control is directly related to facility staff.
5. Try to control small areas with fluoride.

3. Periodontal disease
a. Signs – gum inflammation, bone loss, loose teeth
b. Treatment
1. Improve brush/floss
2. Chlorhexidrine rinse twice daily
3. Don’t remove tooth unless painful

4. Loose dentures
a. Even 1 loose tooth helps neuromuscular control of dentures
b. Consider over denture
c. Avoid constructing any new appliance

D. Consideration for providing informed consent
1. Give resident/family time to get all questions answered
2. Discuss risks/benefits of various treatment alternatives and the lack of treatment
3. Write down what was discussed on the treatment sheet
4. No warranties
5. Get written or verbal consent for treatment

Document all treatments

The state of Ohio requires that nursing home facilities provide an annual “in service seminar” for their staff as well as provide care for their patients.

A. Why do we go to these facilities? These people, as a group, are low pay, unappreciative, high health risk, hard to manage, heavily medicated, inconvenient problems. Most are on Medicare. Those private pay complain about our fees. The treatment is primarily to avoid infections, pain, and helping them chew effectively. We work in poor conditions, bent over, with poor visibility. Why bother? Because everyone has the right to feel good and look good even if they are old, poor, or have reduced mental capacity. We have been blessed in many ways health, careers, friends. This is a chance to give back a little of what we have received.

B. We service _____________ now, however we hope to add others soon.

C. How will your “nursing home” day run?
1. Packing up to get ready the day before should include:
a. Supervise the chairside assistants. Have they packed everything you need?
1. Toothbrushes
2. Floss
3. Toothpaste
4. Treatment sheets
5. Client Files and several blanks
6. Hygiene Instruments (how many, what kind)
a) Hand scaler packets
b) Mirrors
c) Exploring points
d) Cotton pliers
7. Bibs
8. Bib clips
9. Cups for rinsing
10. Emisis pans
11. Reline and repair acrylic
12. Lab knives
13. Lab engine to adjust dentures
14. Denture sore spot marking sticks
15. Mouth props
16. Denture cleaners
17. Sterilizing solution and containers
18. Triumph
19. 2×2 gauze

2. Arrive at the office at the time Dr. tells you and load the car
3. Procedure at nursing home
a. Unload the car
b. Take supplies to the room designated for the hygienists. It will be clean and smell like a hospital
c. Set up all the supplies and equipment
d. Secretary will make sure all the charts are pulled on the clients that are to be seen that day. We try to see every patient twice each year.
e. Check the medical history for a client when you seat him/her. If the history indicates the client should be pre-medicated, have one of the nurses provide the medication(s)
f. See the article in the master manual that will show you how to adapt a headrest for the wheelchair-bound.
g. Your chairside will
1. Screen the health and dental history
2. Seat your client
3. Place bib and brush clients teeth
4. Remove and clean appliances
h. Use the cavitron whenever possible. This is kinder, faster, and easier on you.
i. Do a thorough oral exam

Nursing homes are always understaffed and overworked. Our job is to respect them and help those dedicated people do their jobs. Most won’t have any training in dental care. We will try to help them to see dentistry as a positive step in comfort to their patients rather than, just another time consuming task.

In-service for Staff

You and your dentist will be responsible for upgrading the dental IQ of the staff. This in-service training, to be successful, must be informal, fun, and very practical.

A. Arranging
1. Decide on the topic(s) with your dentist
2. Call the facility director to determine
a. Where the meeting will occur
b. Topics covered
c. How long it will last
d. Who should attend
e. How other staff who don’t attend will get the information
f. Any other topics that director wants covered
1. What is their existing preventive care program and who is responsible?
2. What problems are they having?
3. Bring master copies of handouts that the facility can duplicate as needed

B. Presentation
1. The dining room is usually the best place
2. topics
a. denture care
b. toothbrushing for clients, “head cradle” technique
c. oral health screening
d. differences: edentulous, natural teeth, partial dentures
e. dental medications
f. working with us
3. Don’t try to cover too much at one presentation
4. Presentations should last 15-20 minutes with 5-10minutes for questions and answers

5. Here are a few hints that may help motivate them:
a. Spend a few moments in your training session answering their personal questions about their own mouths and dental experiences. It shows you care about them.
b. Be sympathetic about their work-load and show that you’re there to lighten it, not add to it.
c. Increase the caretaker’s confidence by removing such barriers as fear of being bitten and fear of causing bleeding by brushing. You can motivate a person to work harder if you address these problems directly.
d. Check on the progress of several patients. As their gingivitis clears or their dentures become cleaner, reward the care provider by writing comments to charge nurses or notes of congratulations in the staff lounge.
e. Admit to having a case of tunnel vision because you are primarily concerned with the mouth, while they must care for the “whole body.” Explain the impact of a clean, healthy mouth on a person’s total well-being.
f. Be understanding and supportive of the caregiver’s efforts. Continue to encourage regular, thorough oral care but verbalize your knowledge of barriers, i.e. combative patients, lack of time.
g. Be daring. When teaching toothbrushing for a combative patient and the head cradling technique, have the care providers choose one of their “difficult” patients for demonstration. They will be motivated to try new techniques and will respect you for taking a risk.
h. Suggest the use of rubber gloves for oral care procedures.
i. Arrange a special treat such as a pizza party for the aides if you notice an improvement in oral care.

Residential Home Care Program

A. Adapting hygiene aids for ease of client control
1. Arthritic clients often need big handles. Stick the handle in a rubber ball or bicycle grip (slit the closed end). Even tongue blades can be taped around the handle.
2. Floss holders can use the same type of handle enlargers
B. Add quick cure acrylic handles to the cap of the toothpaste to make it easier to twist off. Make sure the cap is saved when the tube is used up.
C. For clients with memory loss or Alzheimers write out a detailed list, step-by-step, of what needs to be done:
1. pick up toothbrush
2. turn on cold water faucet
3. wet toothbrush bristles
4. turn off water
5. pick up toothpaste tube
6. etc.

The list only needs to be as long as your client’s memory is short. Some may need only a sign next to the bathroom mirror saying “brush and floss.”
D. Caring for comatose clients
1. Use a mouth prop
2. Brush without toothpaste
3. Remove saliva and debris with 2×2 gauze
4. These clients should have their teeth cleaned 4-5 times per day

E. Care of toothbrushes
1. Each should have the client’s name on it
2. They should be air dried after use
3. Replace them every 3-4 months

F. Prescription fluoride is excellent for all client’s with teeth
G. Saliva substitutes will keep the mouth cleaner and more comfortable for clients with dry mouth

In-Service

We can only do so much on a one day in-service every 6 months routine. If we are going to do our best for these clients, we must train the nursing home staff. They can provide the daily care necessary to maintain the health of the residents.

Your task will be to run some of these in-service training sessions. Educate and motivate through exciting, meaningful presentations. Spend a few minutes with the director or the head of nursing and discuss what you can do, the value to the staff and ultimately, how the residents will benefit. Here’s a checklist of topics to discuss.

1. Administrator’s objectives and yours
2. Content of presentation
3. Who will attend, when, where, etc.
4. How to evaluate effectiveness

The following paper outlines many ideas for your in-service training sessions for the nursing home staff.

Prevention in Nursing Homes

A. Ask residents when they want to clean their mouth. Staff may be more flexible in the evening.
B. Edentulous clients need mouth (gums, roof of mouth, inside of cheeks, and tongue) cleaned daily with a toothbrush or gauze.
C. Use a very small amount of toothpaste for taste only. Too much will foam and force spitting. Mouthwash is a good alternative.
D. Residents on tube feedings need regular mouth cleaning at least twice a day. They tend to be mouth breathers, which thickens mucous around tongue, cheeks, and teeth.
E. Pay attention to bad breath as it may indicate:
1. Decay, gum disease
2. Bowel obstruction, throat infection
3. Fruity smell may mean diabetes
F. While a build-up of a white cottony substance on the tongue and in the mouth could be thrush, especially if the resident is on antibiotics.
G. Upper dentures are held in by suction – to remove them, place fingers at the back teeth on each side and gently rock the denture side to side to release the suction.
H. Partials need to be removed evenly, never pull up on only one side or end as this can bend them.
I. Dentures should be removed after meals, rinsed, the mouth rinsed, and the denture cleaned to remove food particles that get under the denture and may cause irritation.
J. Weight gain and weight loss many cause dentures to fit poorly.
K. Always store dentures in clean water when they are out of the mouth – never store them in a dry container. If the resident will not be wearing the dentures for a day or more, be sure to rinse and put clean water in the container every shift.
L. When cleaning dentures, partially fill the sink with water. Holding the denture over the water while cleaning will prevent breakage if you should accidentally drop it.
M. Adaptive devices are available to help residents do oral hygiene for themselves – weighted handles, built-up handles, universal cuff, etc.
N. You cannot FORCE any patient to have mouth care done.
O. Toothpaste, liquids, etc. should never be put in the mouth of a resident who is comatose, combative, or has swallowing difficulties.
P. The steps the caregiver should do before giving mouth care to a resident (after determining how much assistance is needed) is:
1. Greet the resident and explain the procedure (even if the resident is comatose)
2. Ask the resident if there are any sore areas
3. Put on protective gloves
4. Apply lip lubricant
Q. In caring for residents’ dentures:
1. Dentures should be scrubbed with a denture brush and denture cleanser toothpaste
2. Dentures should never be placed directly in the sink while being cleaned
3. Dentures which are very dirty should be soaked overnight to loosen the debris
4. Dentures should be examined regularly for fractures, sharp edges, and missing or loose teeth

THE IMPORTANCE OF REGULAR ORAL HYGIENE CARE

Overall health depends on many things, one of which is maintaining good oral health. As a nursing assistant, your job in maintaining the oral health of your residents is very important. Not only are you contributing to the residents’ improved oral health, you are helping maintain a positive self-image. Good oral hygiene minimizes tooth loss and oral pain, improves the ability to chew and enjoy food, and helps prevent disease and infection.

A healthy mouth is a clean mouth. The daily elimination of plaque, the sticky colorless film that forms in the mouth, can help prevent disease and infection. Plaque contains bacteria that produce acids and toxins which cause cavities, gum disease, and other oral infections.

This section will show you how to perform daily oral hygiene care on residents with teeth, dentures, not teeth, or others with partial dentures.

Self Care

It is important to avoid making assumptions about the ability of an individual to care for his or her own mouth properly. Toothbrushing and denture care are complex tasks which require concentration, memory, and dexterity. Ask the individual to demonstrate how (s)he takes care of his or her mouth. Determine the level of intervention required with each patient on a one-to-one basis. Review the level of care periodically to evaluate whether “self-care” is still applicable. Some “self-care” individuals need supervision while others such as a geriatric patient or a group home resident need a reminder note on the mirror. Instruct the care provider accordingly. In an institution, the ultimate responsibility for maintaining a healthy oral cavity on a daily basis lies with the care provider. Emphasize that point in your in-service training.

TYPE OF BRUSH
Soft, rounded bristles in a small, flat head removes plaque the best.

TOOTHPASTE
Toothpaste should contain fluoride. For unconscious residents, use a wet brush with no paste.

SUPPLIES: Gloves, glass of water, toothbrush, toothpaste, rinse or other product prescribed by the dentist.

TECHNIQUE FOR BRUSHING
Wear gloves. Raise the bed to a comfortable height or have resident sit in a chair. Place a towel on resident’s chest. Remove all complete or partial dentures. Place a pea-sized amount of recommended toothpaste on the brush.

Upper jaw: Front surfaces
A. Begin by brushing the last tooth of the left or right side of the upper jaw.
B. Hold the brush against the tooth at a 45-degree angle toward the gum-line. This angle is best for removing plaque away from the gumline where it tends to collect.
C. Gently move the brush back and forth. Clean the front surfaces of all the teeth in the upper jaw in this manner, one or two teeth at a time. Continue until the front surface of every tooth in the upper jaw is clean.

Upper jaw: Inside surfaces
A. Brush the inside surfaces of the upper teeth using the same technique as above.
B. To brush the back surfaces of the upper front teeth, hold the brush vertically and brush up and down.
C. Clean the inside surfaces of each tooth in the upper jaw.

Upper jaw: Chewing surfaces
A. Brush all the chewing surfaces of the upper teeth with a back and forth scrubbing motion.

Lower jaw: All surfaces
A. Repeat all of the above steps for the lower teeth.

Tongue
1. Brush the top of the tongue with the toothbrush. Go as far back as you can without causing the resident to gag.

Mouth
B. Have the resident rinse with lukewarm water.
C. Have resident use any rinses prescribed by the dentist after flossing and cleaning the tissues (see below for directions).
D. If resident can’t rinse, use gauze to wipe away paste if used.

SPECIAL TIPS FOR SPECIAL NEEDS RESIDENTS
Residents who have limited hand or arm movement but who want to participate as much as possible in their own oral hygiene can use an adapted toothbrush. Below are listed other options for helping residents who have special needs.

E. In some cases an electric toothbrush can compensate for arthritis or loss of muscle control. It also massages the gums (gingivae) and is a very effective cleaning device.
F. Adapt a regular toothbrush for the resident with arthritis or poor muscle control with either a ball made of aluminum foil, a rubber band, gauze and masking tape, a Styrofoam ball or any other device which will help the special-needs resident better able to hold a toothbrush. If the resident cannot lift his/her hand all the way up to the mouth, you can make the brush longer by attaching a smooth piece of wood or another toothbrush handle to the existing handle.

FLOSSING: A GUIDE FOR THE NURSING ASSISTANT

Although brushing the teeth cleans the top and sides of teeth, only dental floss can get between the teeth and under the gumline. It is important to floss the teeth of those residents who have some or all of their teeth once a day.

FLOSS – GETTING STARTED
Remove about 18 inches of floss from the holder. Wrap around the middle finger of each hand. Using forefingers and thumbs, hold about 1 to 2 inches of floss tightly between the forefingers and thumbs. Tip: use a floss holder instead of trying to fit your fingers in someone’s mouth. (See tips below.)

TECHNIQUES FOR FLOSSING
Wear gloves.
1. Use the same routine you used when you were brushing the resident’s teeth, beginning with the last tooth of one side of the upper jaw and continuing tooth-by-tooth around the jaw.
2. Slide the floss gently back and forth between the teeth until you reach the gumline. When the floss reaches the gumline, curve it into a C-shape against one tooth; gently slide it into the space between the gum and tooth.
3. Scrape the side of the tooth by moving the floss up and down against the tooth. Before removing the floss, ease it over the gum and curve it around the adjacent tooth and scrape it.
4. Repeat this method on the rest of the teeth in a systematic order.

SPECIAL FLOSSING TIPS FOR NON-REMOVABLE BRIDGES
A. Using a floss threader
A floss threader looks something like a needle threader. It is used to insert the floss under the non-removable bridge. The floss is threaded through the loop and the needle-shaped end is placed under the bridge.
B. Using specially textured dental floss
Specially textured dental floss has stiff needle-like ends that can be placed between the teeth or beneath a non-removable dental appliance. It has thick and spongy sections which make it easier to clean hard-to-reach areas.
SPECIAL TIPS FOR RESIDENTS WITH LIMITED HAND OR ARM MOVEMENT
A floss holder will keep dental floss tight, which is important for effective cleaning. Gently squeezing the prongs while threading the holder pulls the floss tight for proper cleaning. Proxybrush can be used in between teeth with space.

CLEANING THE MOUTH: A GUIDE FOR THE NURSING ASSISTANT

In addition to brushing and flossing, which are important parts of an oral hygiene plan, cleaning the mouth, including the palate (roof of the mouth), the soft tissue, the inside of the cheek, and the tongue, helps to remove food particles and other debris. It also increases circulation and promotes healthier tissue tone.

CLEANING DENTURES: A GUIDE FOR THE NURSING ASSISTANT

SUPPLIES: gloves, flashlight, towel, denture brush (or toothbrush), denture cleaner (or mild soap), denture cup.

TECHNIQUES FOR CLEANING COMPLETE OR PARTIAL DENTURES
All dental appliances should ideally be cleaned after each meal. Due to the heavy responsibilities of the staff, this is usually impossible. Usually the best time is after the resident goes to bed at night. The appliances should be out overnight. Left in the mouth they prevent the tongue from cleaning the mouth.

Wear gloves.

1. Always line the sink with a towel or fill the sink ½ full of water before cleaning the dentures to cushion the denture in case it is dropped.
2. Rinse the dentures under a stream of water and put some denture cleaner or soap on a denture brush.
3. Carefully brush all parts of the denture.
4. Scrub the outside of the denture with the flat side of the denture brush.
5. Scrub the harder-to-reach inner areas of the denture with the smaller, pointed side of the brush.
6. Do not bend the metal clasps of removable partial dentures when you clean them but do clean the clasps.
7. Rinse dentures carefully under a light stream of warm running water.
8. Partial dentures can be difficult to remove. Carefully lift them by pulling up or on a clasp on each side. Lift both sides back and forth a little at a time. Have one of HealthPark’s staff help you if necessary.

STORING DENTURES
If the resident is not going to wear the denture(s) after cleaning, place the denture(s) in a denture cup and fill with clean, cool water. Encourage the resident to leave the appliances out at night.

REINSERTION
Always make sure the mouth is clean, including the tongue, gums, roof of the mouth (palate), and insides of the cheeks before putting the denture(s) back in the mouth.

TIPS FOR STAIN REMOVAL
An effective homemade solution for cleaning stains on plastic dentures can be made by mixing 2 teaspoons (1/2 oz.) of bleach and 1 teaspoon (1/4 oz.) Calgon cleaner in 1 cup (8 oz.) of warm water. Do not use this solution on dentures containing metal parts. Do not soak dentures in this solution for more than 15 minutes.

Tip for hard deposit removal – White/clear vinegar soak for 30 minutes. Stubborn deposits can be soaked in ½ cup LimeAway and ½ cup water for 15 minutes.

CARE FOR EDENTULOUS RESIDENTS
Clean appliances prevent bad breath and mouth sores.

SUPPLIES: gloves, towel, flashlight, washcloth, soft toothbrush and gauze, paper cups, water, mouthwash or swabs (optional), emesis basin.

SEQUENCE: (twice daily)
A. Identify resident; introduce self, explain procedure; assemble materials.
B. Raise bed to comfortable semi-sitting position or place resident in a sitting position.
C. Place towel under resident’s chin.
D. Wear gloves
E. Remove any dentures; have resident rinse out his/her mouth vigorously with mouthwash or water to remove any loose food debris (and expectorate into the emesis basin).
F. Gently clean the gums, cheeks, tongue, and palate with a wet washcloth, soft, wet toothbrush, or moist gauze. Be sure to clean all areas that are covered by dentures.
G. Have resident rinse out mouth with water (and expectorate into emesis basin). If resident cannot rinse, gently remove debris with moist gauze.
H. Dry mouth and chin with towel; wipe excess liquid from mouth with gauze or use suction to prevent choking or aspiration.
I. Overdentures fit over teeth stumps. When the mouth and dentures are clean, place a fluoride gel into the denture depression that fits over the tooth stumps and reseat the dentures.
J. Encourage the resident to leave the appliances out over night (ideal) or at least 2 hours during the day. Store in water in an enclosed denture cup.

CARE FOR RESIDENTS WITH DRY MOUTH

Some residents will need special care to prevent the mouth tissues from drying. Xerostomia (or dry mouth) occurs when the saliva supply is greatly reduced, sometimes as a result of certain kinds of medications, salivary gland disease, mouth breathing, or radiation therapy to the head or neck. Saliva is needed to lubricate the mouth, clear food from around the teeth, and neutralize the acids produced by the bacteria in plaque. As a result of diminished salivary flow, severe dental decay can ravage the teeth. The ability to swallow, move the tongue, or wear removable dentures can become difficult. Also, if dried mucous is allowed to remain in a resident’s mouth, there is the danger of aspiration.

For these residents, and particularly the intubated resident, it is essential that the teeth and mouth be kept clean and moist. The teeth, tongue, and gums should be wiped several times each day with a piece of gauze moistened with water, or glycerin and water, to prevent sores, and to prevent the accumulation of crusts on the lips, gums, and teeth. The resident’s lips should be lightly lubricated to prevent drying and cracking.

Our dentist will request that the physician review the chart to determine if changes in medications would be possible. The forms of fluoride to be used (dentifrices, mouth rinses, pastes, or gels) are determined by sensitivity and decay potential. Also, since the practice of sucking candies is a common self-treatment for dry mouth, the substitution of sugar-free candies or sugarless chewing gum is necessary.

Dietary changes may be indicated to ease or alleviate the discomfort associated with dry mouth. Patients should be advised to avoid spicy, acidic, or dry and bulky foods, alcoholic and carbonated beverages, caffeine and tobacco. A high fluid intake should be encouraged unless it is medically contraindicated.

A saliva substitute can be applied by spraying, squirting, or wiping along the mucosal surfaces as often as needed to keep the mouth moist.

SCREENING THE MOUTH: A GUIDE FOR NURSING ASSISTANTS

Screening of the mouth for early signs of disease is important. Many oral health problems are much easier to treat if they are found early. Swallowing problems, chewing problems, and mouth pain are three warning signs
of oral health problems.

SCREENING ORAL TISSUES

It is important for you to pay attention to the color, moisture level, and intactness of the gums and tissues inside the mouth. People with light colored skin usually have glistening pink gums and oral tissues. People with darker skin have a purplish red color to their oral tissues.

Lumps, swelling, white or red patches, ulcers, bleeding or the presence of pus indicate infections. Swollen, inflamed tissues, or pus around the teeth indicate gum disease.

SCREENING THE TEETH

Look at the teeth for changes in coloration and intactness. Chalky white areas are beginning decay. Brown or black areas are often fully developed cavities. Tell the nursing supervisor if you see chipped or loose teeth or any signs of decay. Any time there is pain, tell the nurses so they may call HealthPark immediately. Otherwise, a dentist will evaluate at the next regular visit.

Techniques for Screening
A. Take out all removable dental appliances

B. Examine the mouth
1. Lips and corners of the mouth
2. Inside surfaces of the upper and lower lips
3. Inside surfaces of the cheeks
4. Gums (gingival) next to the teeth or ridges where the teeth used to be
5. Teeth
6. Roof of the mouth

A. Face
1. Moles – size, color, evenness of borders
2. Facial symmetry

B. Tongue
Grasp the tip with a piece of wet gauze; pullout and examine the tongue margins.

C. Salivation
The amount and consistency should be observed. Thin, serous fluid is normal. Thick, ropy saliva is suggestive of abnormalities, such as xerstomia from Sjogren’s syndrome or other cause, diabetes, or sinusitis.

D. Other Considerations
The overall clinical impression based on the soft tissue examination should also consider other factors, for instance, halitosis and its possible causes (allergies, periodontal disease, or tooth conditions, such as caries or abscesses).

E. Evaluation of Appliances
Cleanliness, integrity, fit, stability, and retention.
1. First, remove the appliance and inspect it for cracks, holes or other defects of the base material, and missing or chipped prosthetic teeth. Also check removable partial dentures for broken clasps or other portions of the framework.
2. Examine the device for excessive wear by looking at the posterior teeth of the prosthesis. Excessive wear of occlusal surfaces indicates a reduced vertical dimension of occlusion (reduced facial height from nose to chin), and places the patient at risk for angular cheilitis and TMJ (temporomandibular joint) disfunction.
3. Examine the inside surface of the prosthesis for denture adhesion or temporary reline material. These are placed to improve an ill-fitting denture.
4. Next, reseat the prosthesis and check the fit. Stability of a complete denture is assessed by using the index fingers to apply unilateral alternating forces to the first molar occlusal surface areas (just posterior) to the bicuspids/premolars); then move the denture laterally without rotating or torquing it. If the prosthesis moves 2mm or more, the denture lacks stability and is thought to relate poorly to the underlying bone.
5. Last, the denture is evaluated for its ability to withstand vertical dislodging forces by asking the patient to open as wide as is comfortable. If the denture dislodges, it lacks retention and relates poorly to the underlying soft tissue.

In-Service

A GUIDE FOR THE NURSING ASSISTANT

As the person who provides the most “hands-on” oral care in the nursing facility, it will be your job to brush the teeth of residents who can’t brush for themselves.

If a patient needs your help, the following supplies should be at the bedside:

A. Toothbrush
B. Toothpaste and dental floss or 4-ply yarn
C. Glass of water or mouthwash
D. Emesis basis
E. Towel
F. Denture cup (if needed)

Note: the word “patient” as used in this document includes both patients in nursing homes or infirmaries, and residents or quests in boarding homes.

Selection of resident and staff positions during oral hygiene care will vary with the resident’s functional status, teeth status, and patient cooperation. In caring for the bedridden resident move the resident to your side of the bed. Turn the resident’s head toward you. Place an emesis basin under the chin. A variation is to position yourself near the top of the resident’s head or lean across his/her body to limit possible arm movements. For the wheelchair resident, move to the sink, stand behind, and use your left (if right handed) arm to circle the resident’s head, retract the lip and keep the head still. In some situations, two staff members may be needed to provide sufficient control. One person may use either of the previously mentioned positions while the second holds the upper or lower extremities or both. In all cases, the nurse(s) and resident should be comfortable with an adequate source of light for maximum visibility.

As soon as you have found an effective position, open the resident’s mouth. If the resident cannot open his/her mouth at will, a tongue blade wrapped in gauze may be used. Don’t use your fingers. Work the prop back carefully and don’t catch the lip. A rolled up washcloth also works. If the residents cannot open his mouth wider, spray the teeth with chlorhexidrine.

CARE OF RESIDENTS WITH NATURAL TEETH

SUPPLIES: gloves, towel, washcloth, gauze, lip lubricant (make sure it is not petroleum-based for patients on oxygen), soft toothbrush, dentifrice (containing fluoride), dental floss, floss holder, paper cups, water, mouth rinse (as prescribed by dentist), emesis basin

Note: It is advisable for the registered nurse to screen for oral disorders and diseases before beginning the oral hygiene care sequence on each resident.

SEQUENCE:
A. Identify resident; introduce yourself; explain procedure; assemble materials.
B. Raise bed to comfortable semi-sitting position or place resident in a sitting position if ambulatory.
C. Place towel under resident’s chin; gently turn resident’s face to one side if necessary.
D. Wear gloves; lubricate resident’s lips, if dry, with a non-petroleum-based lubricant such as K-Y Jelly. Petroleum-based lubricants (such as Vaseline) should be avoided if the resident has oxygen tubing or if the integrity of the nurse’s gloves are compromised by petroleum-based products, (i.e., if the gloves are latex).
E. Remove any partial dentures gently.
F. Insert mouth prop on one side of the mouth if needed. (Prop will need to be repositioned to the other side of the mouth to complete oral hygiene care on non-propped side.)
G. Remove any dried mucous or food which has accumulated on the tongue, cheeks, gum tissue, or palate with moist gauze or a tongue-blade wrapped with moist gauze.
H. Moisten dry gingival tissues to prevent discomfort when brushing the teeth.
I. Wet toothbrush; apply a pea-sized amount of dentifrice to toothbrush bristles.
J. Retract the cheek; gently position the toothbrush on the outside of the teeth with the bristles angled (45) toward the gum line.
K. Brush two to three teeth at a time in a circular motion.
L. Advance the toothbrush around the mouth brushing two to three teeth at a time while keeping the bristles along the gum line. Continue brushing even if the gums bleed.
M. After completing the brushing of the outside surfaces of the teeth, place the toothbrush on the inside surfaces of the back teeth with the bristles angled toward the gum line. Use the toothbrush to move the tongue aside while brushing the lower teeth.
N. For the inside surfaces of both upper and lower front teeth, hold the toothbrush vertically; move it in an up-and-down motion.
O. To brush the chewing surfaces of the back teeth, use a back-and-forth scrubbing motion.
P. If the resident is capable of rinsing our his/her mouth with water or mouthwash, have the resident do so (and expectorate into the emesis basin).
Q. Otherwise, wipe the resident’s tongue, cheeks, gum tissue, and palate with moist gauze or a tongue blade wrapped with moist gauze to remove toothpaste.
R. Use dental floss to clean between all teeth and underneath the gumline. Holding the floss tightly, use a gentle sawing motion to insert the floss between the teeth. Never “snap” the floss into the gums.
S. Scrape the side of the tooth by moving the floss against the tooth away from the gum.
T. Before removing the floss, ease it over the gum, curve the floss around the adjacent tooth and scrape it; remove floss and repeat this method on the rest of the teeth in a systematic order.
U. Brush the tongue to remove food and bacteria by placing the toothbrush bristles as far back in the mouth as possible without causing gagging; slide the brush forward to the tip of the tongue several times.
V. Dry mouth and chin with towel; wipe excess liquid from the mouth with gauze or use suction to prevent choking or aspiration.
W. Apply lubricant to the lips.
X. Apply fluoride rinse or gel or other therapeutic rinse prescribed by the dentist to resident’s teeth.
Y. Clean and replace equipment after providing oral hygiene care.
Z. A Sonicare can be excellent aid.

Diagnosis of Diseases

Most dentists have almost no exposure to treating institutionalized clients. It is so much easier to bring these clients to our office. However, even though we won’t provide care as well or as easily at an institution, part of who we are is to impact the dental health of our entire community and that means institutions are part of our outreach program.

Nursing home/extended care clients require a different mindset from the clients we see at our office. Follow these guidelines:
A. Clients often don’t care about appearance. Only improve a client’s appearance if:
1. The client requests it and the caregiver agrees.
2. The caregiver requests. Occasionally the caregiver will not be comfortable with the client’s appearance.
B. The other medical, functional, and behavioral problems make even simple treatment more difficult.
C. Teeth will show significant wear and anterior teeth can become thin.
D. Due to increased density, acid etch is easier (quicker) in enamel and slower in dentin.
E. Greatly reduced pulpal sensitivity – often won’t need anesthetic.
F. Some residents without teeth don’t need them. (It is estimated that an 85-year-old loses 90% of motor control.)
1. Resident states doesn’t want them
2. Resident has old, poorly fitting dentures and likes them
a. Hyperplasia, epali, and other irritations rarely lead to a malignancy
3. An old, comfortable set of dentures is always better than new dentures
4. Resident is too ill to learn to use new dentures.
a. Terminally ill
b. Poor salivary flow
c. Poor muscle control (stroke, Parkinson’s, etc.)
G. Construct new appliances when:
1. Old ones can’t be repaired
2. Old ones are lost/destroyed
3. Remaining teeth are extracted and resident can’t chew
4. Resident isn’t eating well
5. Never extract teeth due to loss of periodontal support. One pair of teeth opposing each other that are loose are better than ideal dentures

Incremental Treatment Approach

This treatment sequence can be interrupted at any step (caregiver’s or resident’s choice, illness, etc.) Teeth are not needed to maintain adequate nutrition.
A. Exam, treatment of pain (extractions), prophy, PC, x-rays, if available, regular recalls, repair existing appliances
B. Fillings, endo, deep scale, perio
C. Fixed or new removable appliances

Factors determining level of care

A. Limited cooperation, physical/medical/psychiatric problems, resident’s attitude, can’t be transported to our office or are terminally ill.
B. Cooperates/communicates and wants treatment
C. Resident would function well in the “outside” world

COMMON MEDICAL CONDITIONS
Many of the more common medical conditions of the geriatric patient are listed below:

A. ANGULAR CHEILOSIS
1. Appears at corners of mouth as extremely sore crevices.
2. Can be Candida Albicans fungus infection
3. Associated with loss of vertica dimension sometimes
4. Associated with Vitamin B-complex deficiency
5. Treatment – Nystatin ointment three times daily

B. APHTHOUS ULCERS
1. Extremely tender single multiple ulcers with yellow brown depressed centers surrounded by red halo lesion on tongue, inner surface of lips, or gingival or buccal mucosa.
2. Not caused by virus
3. Thought to come from emotional stress. Look for allergies, diabetes, bowel disease and endocrine disorders.

C. ARTHRITIS
1. Most specifically, rheumatoid arthritis
2. Present in about one percent of the population
3. Affects females 2-3 times as much as males
4. Can be in T-M joint and affect jaw movements
5. Frequently associated with physical or emotional stress

D. ARTERIOSCLEROSIS
1. Most common of coronary artery diseases
2. Associated with hypertension, diabetes, obesity and old age
3. Predilection for males and occurs most often in 50-59 age group
4. Basically, two types
a. Angina pectoris – mild, transient ischemia
b. Myocardial infarction – damage to heart muscle due to coronary artery occlusion
5. Careful with dental treatment with these patients

E. BURNING MOUTH
1. Many causes – psychological, nutritional, neuritis

F. BELL’S PALSY
1. Abrupt facial paralysis. Drooping of corner of mouth and therefore drooling. Speech and eating difficulty.
2. Self-cleansing is difficult to impossible. Automatic toothbrush.

G. CANDIDIASES (Thrush)
1. Caused by fungus Candida Albicans
2. Creamy, white patches which, when removed, reveals an inflamed, painful mucosa.
3. Results from poor fitting appliances, poor oral hygiene, immune suppression, radiation therapy, long term antibiotics/steroids
4. Treatment – Mystatin mouth rinses and oral hygiene instruction

H. CEREBRAL PALSY
1. Severe attrition, malocclusion, mouth breathing, drooling, tissue biting. Lack of normal chewing and swallowing process. No natural cleansing mechanism. Usually on soft diet.
2. Use mouth prop. Allow individual to do brushing using an adaptation. Follow up with automatic toothbrush.

I. CEREBROVASCULAR ACCIDENT (STROKE)
1. Third major cause of death in the elderly
2. Patient may exhibit speech problems and hemiplagia
3. Partial paralysis could affect oral care
4. Patient’s head may be tilted to one side with “drooling” saliva
5. Special and understanding care given to these patients

J. CHRONIC BRONCHITIS
1. Usually persons who have lived in heavily polluted areas or are heavy smokers
2. Recurrent coughing spells, with or without sputum
3. Chronic inflammation can eventually cause lack of lung function

K. COMOTOSE
1. Consult with attending physician
2. May need mouth prop
3. Brush with prescription fluoride, chlorhexidrine spray twice daily

L. DIABETES
1. Approximately 2% of population is diabetic
2. Is a disturbance of carbohydrate metabolism due to an inadequate secretion of insulin from pancreas
3. Two main types of diabetics
a. Juvenile (“brittle” diabetic)
1. harder to control – must be careful in dentistry to prevent hyperglycemia and post-operative infections
b. Adult-onset – no real problem if patient is taking insulin and observing diet
4. Overgrowth of tissue, bleeds easily, bone loss
5. May require antibiotic prophylaxis

M. DOWN’S SYNDROME
1. Missing and abnormally shaped teeth
2. Individual may fail to profit from educational experience and instruction. Follow up with toothbrush.

N. DILANTIN HYPERPLASIA
1. Overgrowth of gingival tissues
2. Tx – excellent oral hygiene
3. Try to avoid surgery

O. DYPSNEA
1. Shortness of breath
2. May be due to any number of chronic pulmonary diseases
3. Patient may exhibit chronic coughing

P. GASTROINTESTINAL
1. Gastritis, ulcers, diarrhea, constipation, and intestinal obstruction are common disorders
2. Patient may compromise diet, thereby adversely affecting such body functions as healing and response to stress

Q. GLOSSODYNIA (“BURNING TONGUE”)
1. May be noted especially in females aged 50 – 60
2. May be local or systemic factors
3. Sometimes associated with Vitamin “B” complex deficiency

R. HERPES SIMPLEX
1. The virus manifests clinically as multiple shallow ulcers on the oral mucosa and/or the vermillion border of the lip
2. Client may eat less due to pain
3. Treatment is symptomatic with the disease being self-limiting and usually subsiding in seven to ten days
4. Application of Abreva (5 times per day until symptoms disappear) as treatment

S. HYPERKERATOSIS
1. Presents clinically as a white patch on the oral mucous membrane which cannot be wiped off with a cotton roll or finger pressure.
2. Most frequent sites are the cheeks, angles of the lips, the alveolar mucosa, tongue, lip and floor of the mouth
3. Differential Diagnosis by simple observation it is not possible to distinguish pre-malignant Leukoplana from benign hyperkeratosis. The presence around the lesion border of thin atrophic mucosa must be considered highly suspicious and a biopsy is advisable.

T. LICHEN PLANUS
1. An inflammatory disease of the skin and mucous membrane.
2. Characterized by kerototic lesions of various patterns, lace-like – white patches on tongue and buccal mucosa.
3. Tx – topical steroids or anti-fungals
4. Seems to happen to nervous persons who “keep it inside.”

U. MUSCULAR DYSTROPHY
1. Shifting, spreading, or protrusion of teeth. Loss of cheek and lip control. Open-bite.
2. Automatic toothbrush. Sufficient time allotted for individual to complete brushing.

V. NUTRITIONAL DEFICIENCIES AND RESULTANT DISORDERS
1. A major concern in geriatric patients is the presence of subclinical or marginal malnutrition.
2. Symptoms may be absent or difficult to interpret.
3. The deficiencies may occur as a result of:
a. Primary deficiency, where there is a lack of nutrients in the diet
b. Secondary (conditioned) deficiency which results from failure to absorb or to properly utilize nutrients, increased nutrient requirements, i.e.: illness, etc., or excessive exertion.
4. In the geriatric patient, the process between marginal and frank nutrition is more easily precipitated.
5. Nutritional deficiencies can affect the oral structures.
a. Vitamin B2 (Riboflavin) deficiency can result in angular chelosis
b. Chronic Niacin deficiency results in pellagra, characterized by neurologic, mucous membrane and gastrointestinal symptoms.
c. Vitamin C deficiency results in general weakness, retarded wound healing, petechial patches due to fragility of capillary walls. Gingival bleeding and marked bone resorption.
d. Vitamin A deficiency affects epithelial structures and, if severe, interferes with amelogenesis.
e. Vitamin D influences tooth formation indirectly by regulating calcium-phosphorus metabolism.

W. PARKINSONISM
1. Tremors in muscles of chewing, tongue, bruxing, tongue thrust, trouble swallowing.
2. Instruction in toothbrushing. Will usually need assistance in brushing. Watch for aspiration.

X. PETECHIA
1. A minute rounded spot of hemorrage – on the surface, such as skin, mucous membrane or serous membrane.

Y. RHEUMATIC FEVER
1. A patient with a history of rheumatic fever is a candidate for rheumatic heart disease.
2. Vegetations develop on the heart endocardium and, if severe enough, will prevent proper functioning of the heart valves.
3. Primary medical concern is to prevent bacterial endocarditis. This is best done by prophylactic treatment with penicillin.

Z. VENEREAL DISEASE
1. GONORREHEA – An infectious disease involving chiefly the mucous membranes of the genitourinary tract, occasionally the eye, with possible hematogerious spread to serious and synovial membranes in other parts of the body.
2. SYPHILIS – A chronic contagious venereal disease capable of involving any organ or tissue and characterized by florid (bright red) manifestations, frequent relapses, and years of asymptomatic latency.
3. Examining gloves are indicated when suspected.

AA. XEROSTOMIA
1. Dry mouth – as a result of :
a. Failure of saliva glands to develop
b. Disturbance of innervation of salivary glands
c. Systemic disease – diabetes, Vit. B Complex deficiency, post-menopause syndrome, psychic influences, aging, or irradiation
2. Treatment – Symptomatic, frequent intake of fruit juices may moisten the mouth and produce some salivary stimulation.

Riverside School
Directions:
Go to main Entrance, Ask for Lana.

Contact: Lana Blosser

General Info:
We will be working with small groups of 15-20 adults, all with some mental or physical handicaps.
Approximate mentality level is third grade (about 8 years old).
Keep things simple.
Respect them as adults but communicate with them in simple straight-forward terms.
Have fun, you’re working with a very special group of people who are really enjoying your visit (They love to have us come and visit them!)

Things you will need:
1. Dudley the Dinosaur or Incredible Ride (Colgate video) (7-8 mins long)
2. Daisy the Dinosaur model and chompers model with large toothbrushes for demonstration
3. Take along an electric TB encourage one for those that are having trouble (give out Triumph handouts
and business cards)
4. Take a few perio aids for patients with partials and missing teeth and gum problems.
5. Goodie bags – put new toothbrush, floss, flossman, business cards in a bag to be given out to each
participant
6. Take along the cavity model, perio disease model and perio charts
7. Can take along a few spare x-rays like Panorex’s to show them tooth pictures
8. Rewards: sugarless bubblegum and stickers

Read through the info from the manual and look through the games. Decide what is right for you – the visit is up to you.

Here is an example of a typical visit:
1. Start by introducing yourselves and tell a little bit about yourselves
2. Run the Dudley the Dinosaur video to attract their attention and start by having fun
3. Then go into some question and answer with them, see info on questions with 2nd and 3rd graders
4. Demonstrate good brushing and flossing and let them participate and help (hands on)
5. Review nutrition and fluoride
6. If sink available, work with them one on one brushing
7. Give rewards for good participation and good answers to questions, give out stickers and sugarless gum (see to it they all get rewards for something)
8. Give out handout games that they can do at home

This is just an example of how a visit could go – do what feels comfortable for each of you.
Good luck – have fun!
Note – each team is responsible for doing their goodie bags with their own business cards – anyone willing to help with handicapped toothbrushes see the RDH team leader.