Monday, 4 November 2019

Controlling Oral Diseases for Residents in Long Term Care Homes  
L Lynda McKeown RDH, HBA, MA 

“Simple and cheap public health methods are available to prevent and control oral/dental disease because the causes are known: they are diet and dirt”[1].

My experiences as a dental hygienist in various roles over many years  confirms Sheiham’s comments “diet and dirt”  cause oral diseases. This paper  addresses the issues of ‘diet and dirt’  for residents in Long Term Care Homes.  Individuals  move to  Long Term Care homes, because they can no longer live on their own. The reasons are usually due to physical and or cognitive  deterioration.  Thus they need nursing care and personal. At this point in time mouth care is included as part of personal care, as such is provided usually by nursing staff assigning to personal support workers / health care aids.
   The issues surrounding the provision of adequate  mouth care are complex.  I don't admit to having all the answers. Perhaps others with similar experiences will share their successes.  The challenges can be overcome.  
Diets which contain refined carbohydrates  and sugars combined  with ‘dirt’  harmful bacteria  in the mouth cause oral disease.  Restoring diseased teeth is  expensive. When  these treatments are done  in a mouth that is not kept clean the restorations  fail. Often destruction to the teeth  has advanced so far  that oral surgery is  required.  Surgical solutions for residents usually  requires hospitalization. General anesthetic can be  expensive and put frail residents with complex medical histories at risk.
 I see residents on the call of the family, and/or by request of nursing staff. I started in1997. Tom had been a client of mine  in private practice. He developed Alzheimer’s disease and could no longer be cared for at home. His wife  and his family dentist requested  I see him at his long term care residence. Much to their credit they recognized that routine oral care was not a priority for staff. Tom’s cognitive and physical abilities were insufficient for oral self care. And his mouth left to its own defenses would not remain in a healthy state. Much time and money had been invested in a functional dentition and healthy tissue. This was my first  experience in a LTC facility as a ‘worker’.
 My mother lived in Long Term Care for 4 years  but that was more than two decades ago. She  had Alzheimer’s and remained at home with help, until she fell and broke her hip.  After the surgical repair of her hip . she required ‘nursing’ care and was moved as a resident  to the long term care section of the local hospital.  I took her for dental and dental hygiene visits, while she could still walk up stairs to the offices. When that was no longer possible and her mobility was by way of wheelchair I took her  to a dentist we could access via elevator and wheelchair. I admit I did no personal onsite mouth care for her, the reason  was fear, fear of losing my license.  At the time-The Royal College Dental Surgeons of Ontario licensed dental hygienists and did not permit dental hygienists to work in the mouth unless supervised and or directed by a dentist  physically on site. Fear of being called before RCDSO was a major deterrent It seems so silly now as I reflect. 
Once I became a ‘worker’ I discovered that residents were not getting proper mouth care. Abundant debris and disease causing plaque adhered to teeth and tissue. In addition evening snacks often consisted of peanut butter sandwiches. Other sticky high carbohydrate, or highly refined sugars were consumed during the day. These are ‘tasty morsels’ for acid forming, decay causing bacteria. 
People  assume that mouth care involves tooth brushing and anybody  is capable of the task.. And why wouldn’t they? Most toothbrush and tooth paste commercials show the brush whizzing across the tooth nowhere near where the bacteria are located. But the bacteria  don’t adhere to the smooth flat surface of teeth due to the action of the teeth, tongue and saliva.  The bacteria hide in fissures and around the gingival margin.. To  clean the mouth effectively a person needs to have  cognitive and technical abilities. The oral physiotherapy tools, the various sizes of brushes and floss must be properly adapted   into fissures and gingival margins harbouring disease causing  bacteria. Sheiham states  “it is no surprise that the bacteria is waving  at the brush as it goes past.”[2]
My goal to put it in ‘nursing jargon’ of ‘wounds’ was to heal the gingival wounds(bleeding gums) and avoid the reoccurrence by removing the irritating ‘debris’. This I achieved by  ‘non invasive’ debridement—no sharp ‘picky’ instruments. 
Harmful plaque/biofilm needs to be removed on a daily basis to disrupt the disease cycle. Scaling/ debridement  every 3 months is not the answer to maintain health, from my observation. The disease causing bacteria must be reduced on a regular basis to prevent ‘wounds’ of the gingival tissue and decay of the teeth.
Soft foods can be nutritious, although they might not be very enjoyable, but most of the soft highly processed foods are often sticky, high in refined sugar. Supplements such as Ensure are high in sugar content. Highly processed sticky foods can contribute to dental caries and gingival inflammation. Highly processed foods do not  require much chewing.[3] So the nerve and blood vessels in the teeth get less ‘exercise’. Parkinson’s disease patients are given oral exercises to do dailyIndividual health in organs in the organism is dependent on biological mechanisms in a dynamic balance. 
In the oral cavity, interventions between saliva, diet, oral microflora, tooth  surfaces and the oral mucosa support a healthy condition Therefore proper interventions related to oral diseases must include activities at several levels in order to reestablish ecological balance and therefore health.[4] The human body is remarkably resilient. Our organic systems  have an amazing ability to  reestablish ecological balance. But the resilience is dependent on the quality of the internal defense mechanisms such as the oral immune system or the ability of odontoblasts to form reparative dentine.  The body’s resilience can be stressed by  external factors such as foods with refined sugars and carbohydrates.[5]
In LTC residents are given something to eat and drink throughout the day. The pH of the saliva does not get a chance to rebalance,  reduce bacteria that cause tooth decay.
Of course it is a fact of life that the human organism is not intended to live forever. When a person arrives in a long term care facility they and /or their family is no longer able to look after them at home. As a society I think we are morally responsible to maintain the residents’ health and quality of life, as long as possible. This includes oral health- palliative dental  hygiene –clean comfortable. 
 Factors such as overload of  bacteria  on teeth and oral tissues may cause stress to a person’s system, resulting in imbalance  and the emergence of disease. In some individuals the reaction to bacteria may lead to an excessive host response resulting in a general inflammation response. Plaque/ biofilm -Debris-removal  with oral physiotherapy tools continues to be the most effective and reliable way to avoid ‘gingival wounds’ and  severe inflammation. Of course the mouth cleaning, to be effective, has to be sufficiently thorough and performed at appropriate intervals.[6]

Mouths health can  be maintained. Diets can be controlled and the ‘dirt’ harmful bacteria  removed. I have learned quite a bit from the residents in the last decade. For instance teeth may fracture at the gingival margin  Frequently endodontically treated teeth, non vital  teeth with crowns fracture.  Bridges may break off but abutment teeth remain functional and  pain free with palliative dental hygiene care. 

Following are some observations from looking in mouths on a weekly basis for more than two decades. From my experience if a mouth is properly cleaned, sanitized   and cleaned thoroughly at least once  week using  antimicrobials  and proper oral physiotherapy tools the tissue will be healthy and the dentition functional enough.  Not necessarily  what we would accept in a private practice clinical setting. 

Helen’s  daughter hired me to do mouth care It was evident the staff was not cleaning the mouth routinely. Although the same amount  of plaque /biofilm had accumulated each week the  tissue did not bleed, it was not ‘wounded’. I did ‘non invasive ‘treatment each week. This included oral physiotherapy tools; stimulator, Soft small head brush, proxa brushes, and unwaxed floss. Each tool used with  an antimicrobial  rinse and ‘dip and brush’ method. Periodically every couple of weeks or at least once a month Fluoride  was applied on teeth.
 Helen’s bridge broke off but she had no pain. Her dentition remained functional until her death.

Bill’s brother John took Bill to the dentist’s office for monthly dental hygiene treatment. It became evident  that this was insufficient. I was called in to see Bill once a week. John is  adamantly opposed to fluoride. I used .2% CHX rinse Perio Plus ‘dip and brush’  with a variety of oral physiotherapy aids for non invasive plaque removal. Bill was  ambulatory and able to go with his brother to dentist. Bill had extensive/expensive dental treatment. Almost every tooth was crowned. Bill developed a pocket  on buccal 4.6? 5-6 mm kept clean with Curaprox  embrasure system used  vertically into pocket with .2% CHX rinse to sanitize pocket. John took his brother for  consults with dental specialists. Bill had pain with tooth and  we thought might have to be extracted. But another example of the body’s resilience and  dental hygienist sanitizing mouth. The problem resolved.  

                                                                      IMPORTANCE OF GOOD ORAL CARE:
Digestion starts in the mouth. Research indicates that a clean mouth prevents aspiration pneumonia, gum disease, and helps prevent heart disease and Diabetes.
 Salivary flow is reduced by some medications and medical treatments. Reduced saliva flow results in less natural washing away of oral bacteria. Thus it is important that oral bacterial plaque and biofilm be removed daily with various oral physiotherapy aids. Oral health maintenance requires both physical  and cognitive ability. Many people who develop physical and or mental disabilities  need help with this ‘cleaning’ activity.


References
[1]   Sheiham A. Assessment of Role of Western Dentistry  in the Oral Health Alliance Promoting Oral Health in Deprived Communities International Seminars 1991 and 1992 Mautsch W and Sheiham A., editors Berlin, German foundation for international development, 1995; pp120, 132

[2] Ibid  p129
3 Lingstrom P, van Houte J,Kashket S. Food starches and dental caries. Crit Rev Oral Biol Med.2000;11(3):366-80  
4 Ericksen, H. M., Dimitro V., Rohlin et al The oral ecosystem: implications for education  European Journal of dental education 200;10:.192-196
5 Ibid.
6 B.Soder IJDH 4 (suppl.1), 2006;22-25

  




Thursday, 18 August 2016

PHILOSOPHIC PONDERING
We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time[i]
Philosophy and a curious mind was a legacy from my grandfather. Recently I read a book by Rebecca Goldstein “36 Arguments for the Existence of God, a work of fiction” In her appendix  Argument 36 The argument from the Intelligibility of the Universe ( Spinoza’s God)
My grandfather was old, in his late 80s when I was a teen. He spewed out words of Spinoza, and Greek philosophers. In Grade XIII I wrote an essay for Peggy Fulton’s English class on Spinoza “ A Great Philosopher”. I still have the hand written paper. I see it is pretty much plagiarized. At any rate the essence of Spinoza’s thought is that the universe is perfectly lawful and necessary, worthy of our awe,  provides all the answers about itself- is God, neither transcendent nor transcendental. Seeds  were planted in my mind, and later germinated as I studied philosophy with Frank Doan at Lakehead University. It seems  odd that 50 years after my  grandpa’s death  I should come upon a novel with Spinoza’s philosophy, as its theme.
Goldstein’s novel led me to another of her books Betraying Spinoza. She tells the reader that Spinoza  received  a vehemence letter from a student, who turned aside from his teacher’s thought, and told him why, in  terms.  Spinoza was  dying of tuberculosis but he gathered enough strength to respond (December 1675):
”the first and foremost rule to remember is that we have no control over anything other than the progress of our own understanding. And the second rule is to care only about that which we have control. We don’t have control over others’ understanding no matter how hard we try to help them advance.”[ii]
Spinoza was unable to keep the student ‘Albert Burgh from descending into narrow minded confusion.
As teachers we have to keep  in mind that the power to pursue knowledge, understanding. and truth remains with the student. We can do what we can. We can encourage and set examples. But we cannot learn for the student. This desire to make the effort to seek knowledge, and understanding  lies with the students themselves. Students  must learn to set aside  superstitions and false beliefs. According to Spinoza[iii] “Superstitions as opposed  to religion offer us false cures for our finitude. They make us believe that we are more cosmically important than we are…,”
To become fully functioning autonomous human beings learn to make judgments based on reason,  be objective, balance the facts. 



[i] [i]  T.S. Eliot Four Quartets Little Gidding  ( p222 Collected Poems 1907-1962  Faber and Faber 1963)

[ii] Rebecca  Goldstein Betraying Spinoza Random House (2006) Page169
[iii] ibid p122

Sunday, 10 July 2011

Bad breath in the workplace

Fresh Breath for the Workplace

Being physically near to someone in the workplace can have certain consequences.
For instance, offensive mouth odour (halitosis) cannot be contained and may be extremely offensive to spouses, friends, acquaintances and, or co-workers.
Society uses odours as a means to define and interact with the world. The intimate emotionally charged nature of the olfactory/smelling experience ensures that value coded odours such as bad breath are interiorized by people in a deeply personal way. Thus bad breath odour becomes a very public issue in the workplace. Like it or not smells and odours affect us physically, psychologically and socially.
Unfortunately, individuals are unaware of their own odour as it cannot  be smelled by oneself. The  sinister thing about bad breath is that  the odour can be most repulsive and
cause distress to people nearby.
Since smells and odours have such a high ability to produce emotional responses, defense tactics such as negative body language may be used  around people with bad breath. These  defensive behaviours can erode an individual’s self image. Thus breath odour can have devastating social and employment consequences.  It is a difficult but important issue to approach with co-workers. Sometimes breath odour indicates an untreated systemic medical condition.


Sociology Oral health behaviors & dental hygienists

Gallagher and Moody wrote an article in 1981 Dentists and the Oral Health Behavior of Patients: A Sociological Perspective. They state:
Dentistry has long had an interest in the prevention of oral pathology, but without remarkable effect and without widespread professional consensus as to how this interest is to be implemented. [i]
Dentistry  developed in the mid to late 1800s. Dentistry arose out of the public health movement. Adams (2000)[ii] tells us that in Canada the public health movement centered around the belief that there was direct connection between physical health, cleanliness and morality. Dentists were very active in these movements and they worked to improve the health, cleanliness and morality. Nettleton’s (1992) genealogical study looks at the relations between dental power and the establishment of dental knowledge.[iii]  In her text Nettleton examines the circumstances, techniques, and events such as regular 2x daily tooth brushing, professional cleaning, that led to the mouth and the teeth becoming the focus of a distinct discipline called dentistry. She demonstrates how in Britain, the dental profession established its object,- teeth subject to decay, by allying itself with public health. Public health helped dentistry justify the need for monitoring children’s mouths to ensure the prevention of infectious disease.
Dental hygiene was created in the early 1900s as ‘dentistry’s agent’ to provide education and ‘mouth keeping’ to ensure the prevention of decaying teeth and infectious disease. “ Dental hygienists it was suggested, could work either in schools or dental offices, performing the unremunerative  but important public health and preventive dental work, for a fraction of the cost and with little training” (Adams 2000)[iv] Dentistry was more interested in extracting and  filling teeth than teaching children or treating gums. So dentistry assigned the ‘mouthkeeping’ tasks to the female dental hygienists.

In a 1981 article Gallagher and Moody state that: “Many dentists delegate most of their prophylactic and preventive work to dental hygienists and assistants” They pose several questions for researchers. ‘Does the dentist’s role become diluted if he delegates to paradental personnel those preventive functions where his own influence and prestige might be most effective?’ And 'Who can best influence the patient’s oral behavior in the long run?'[v]

Dentistry became an official profession in Canada in 1867. Society gave to dentistry the authority and professional autonomy to be the dominant profession in oral health care delivery. Dentistry views itself, as does much of society, as the profession that has control over professional oral care, the restoration and   maintenance of the teeth and tissues in the mouth.  Dentistry possesses power as expressed in the social organization of oral health care delivery, power they worked hard to establish.
 The mouth, and the practices that surround the mouth, are   ordinarily mundane and academically unexplored areas. However, the oral cavity provides an opportunity for sociologists to examine multiple processes.  These various processes create the conditions for the possibility of reorganization of oral health care delivery.  As networks of professions, consumers, bureaucrats, and politicians oscillate between the curative, medical treatment model and the preventive wellness model of health, new knowledge of oral health should emerge.  
Dental hygienists have been part of oral care delivery for more than 50 years in Canada. Primary prevention seeks to maintain a healthy mouth and functional dentition, a healthy mouth for healthy living.  Dental hygiene was created to meet these needs, to encourage primarily young children to adopt and maintain healthy behaviors.
Dental hygiene appears to be occupationally stabilized in 2011.  Dental hygiene is self regulating in most of Canada, and self initiating in many provinces. Dental hygienists are recognized by many as the professional who provides consistent preventive care and education in healthy behaviors.
Now that the profession is ‘stabilized’ do dental hygienists improve the oral health behaviors of patients/clients? 
Examine the social landscape of oral health care, beyond the confines of the dental hygiene cubicle in the dental office to take a different perspective of the world of dentistry, oral care, and evolution of dental hygiene. The mouth, and its multiple processes often taken for granted, considered  mundane topics provide opportunities for sociology researchers.
L McKeown July 2011                    www.oralcare.ca


[i] Gallagher, E. B.  Moody, P.M. (1981) Dentists and the Oral Health Behavior of Patients: A Sociological Perspective
Journal of Behavioral Medicine  4(3) 283-295.
[ii] Adams, T. L (2000) A Dentist and a Gentleman Toronto University Toronto Press p90
[iii] Nettleton, Sarah (1992) Power, Pain and Dentistry.  Great Britain: St. Edmunsbury Press.  p123-4  
[iv] Adams, T. L (2000) A Dentist and a Gentleman Toronto: University Toronto Press p.122
[v] Gallagher & Moody (1981)p295

Friday, 1 July 2011

Dental Hygiene education


Following are some thoughts about dental hygiene gaining degree education. It is important that dental hygienists are able to obtain a degree, not as a matter of  a ‘credential’ to carry out the role of dental hygiene. A degree will not improve opportunities for employment or financial gain for dental hygienists in dental private practice. Additional knowledge  gained from a degree program will benefit dental hygienists.
The problem as I see it now is, if  dental hygiene college graduates   become dissatisfied in private dental practices (dentists the primary employer) dental hygienists do not have the credentials to easily change jobs.
I believe it is important to have the ability to complete a degree though/after the present dental hygiene diploma programs.
Recently, I have seen and heard the term, ‘creeping credentialism’. ( Physiotherapy  and respiratory  therapy now require an MA for entrance to practice.) DH has been caught in this entry to practice issue as several Universities were about  to implement  degree programs.
I  wondered what ‘creeping credentialism’ meant although I did not give it much thought  until I began to read  Jane Jacobs  book  In Dark Age Ahead   chapter 3, titled ‘credentialing versus educating’  Jacobs speaks to  credentialing and education.
“Credentialing, not educating , has become the primary business of education of North American universities.” .. “the credential is … a passport to a consideration for a job.”
Today, young people recognize that post secondary education is a key to a good job.
Her words provoked my thought.
From her comments I don’t think DH fits in the category of ’credential’ rather we are presently in the ‘training’ category. Credential as I understand it now, refers to a degree. It seems to me that we are encouraging DHs to obtain a degree so dental hygienists have a greater understanding of social issues, a broader general knowledge than they can gain in the present diploma structure. With increased knowledge dental hygienists can provide oral health care in areas of society beyond the private dental practice. If  dental hygienists are dissatisfied with private practice they have a means to move to another career without having to start all over again.
The degree is not going to increase DHs ability to obtain jobs in private practice. Most dental practices won’t pay for the university ‘credential’. However without a degree in CA society today the majority of DHs are ‘dead ended’
On the dismal side of things perhaps the students won’t get an ‘education’ in a degree program. Another note of Jacobs:
Expansion of first rate faculty … has not kept pace with expansion of enrollments and courses offered; professors lack the time and energy they could once devote to personal contact with students. … so many papers to mark, relative to numbers and qualities of mentors to mark them, changed the nature of the test papers. Some came to  consist of True or False? and  which of the following is correct?” types of questions, fit for robots to answer and to rate rather than stimulants and assessments of critical thinking and depth of understanding…
Ever the idealist, I still believe that a student does gain a broader range of knowledge in a general degree program, despite Jacob’s comments.
Perhaps DHEC and CDHA can be influential at the Federal level to release the ‘hold’ on dental hygiene degree programs, and to encourage more degree completion linkages.  Dental hygienists with  a degree, the ‘credential’ will have more ‘knowledge’ about various social issues, and  hopefully more respect as oral health care providers. In my opinion oral health providers need greater visibility throughout society if the health of the mouth is to be taken seriously.

Monday, 27 June 2011

Power Foucault Dental Hygiene

Power  All work,including dental hygiene, like social life itself, is a collective. Power as analyzed by Foucault(1980)[i] is something that circulates. Power relations are rooted in the system of social networks, rather like the capillaries forming a total network in the body or the fine meshes of a living spider web states philosopher Foucault.  It never resides in any one person or group’s hands.  His approach  to power opens up the possibility for applying the sociological imagination and studying the micro-practices surrounding the oral cavity, and dental hygiene a provider of care. 

Power is only power when addressing individuals who are free (autonomous) to choose to act in one way or another.  Power is exercised with intention.  Power is actions upon others' actions in order to interfere with them.  Power presupposes freedom in the sense that power is not enforcement, but ways of making people by themselves behave in other ways than would have done. One way of doing this is by threatening with violence. However, suggesting how happy people will become if they buy an off-roader is an exercise of power as well. Marketing provides  a large body of knowledge of techniques for how to (try to) produce such behavior.

The ordinarily mundane and academically unexplored area of the oral cavity provides an opportunity to examine multiple processes.  These various processes create the conditions for the possibility of reorganization of oral health care delivery. 

Dental hygiene students must meet criteria  to enter  dental hygiene programs. She/he must  pass exams successfully to exit dental hygiene programs. Then, write more exams to qualify for registration/licensure  to legally practice as a dental hygienist. In Canada the National Dental Hygiene Examing Board examinations and a Jurisprudence exam in Ontario must be completed successfully to be able to gain admittance to a dental hygiene operatory. After payment of fees the  dental hygienist gains authorization to practice.

Specified objectives are expected to be  accomplished in effective and efficient ways. Dental hygienists are trained/educated to: gather information about a client’s health and medical history, to examine the mouth and teeth to identify, itemize and quantify plaque/biofilm deposits,  note areas of bleeding and calculus  and periodontal pocket depths. Much of this is done with sharp instruments

Through technology of the chair (Nettleton, 1992) the DH controls the client’s posture, back and forth  and up and down. The strong sometimes blinding light shines in the client’s mouth. The client provides intimate exposure of her/his mouth. The client must be taught lessons, trained  in proper mouthkeeping. This lesson is not learned at the 1st teaching so must be repeated at regular three, four six month intervals. Although the DH has control of the client in the chair, the dentist controls the practice and the employment situation.

References
Foucault  M. (1980) Power/Knowledge: Selected Interviews and Other Writings.  Ed.  C. Cordon.  New York: Pantheon
Nettleton  S. (1992)  Power Pain and Dentistry Great Britain: St Edmunsbury Press.



Friday, 24 June 2011

What‘s the Mouth got to do with other diseases?

The reporter from the local newspaper was interviewing me. He wanted to know more about the  Breath Odour Clinic. The conversation somehow moved from the topic of treating clients with oral malodor at the  clinic to bacterial plaque removal for residents in long term care facilities. As I rambled on about lowering the bacterial 'loads' in the mouth to prevent other illnesses Jim, the reporter, interrupted. "What's the mouth got to do with other diseases?" "Various bacteria in the mouth have been found to contribute to other disease in the body," I replied.
During our conversation, I had 'introduced' Jim to Prophyromonas Gingivalis, Treponema Denticola and Bacteriodes Forsythus in relation to periodontal disease and chronic bad breath. He was 'mildly' interested. After all, he had a job to do. He had to prepare an article for the health section of the paper. He was being appropriately attentive as I supplied information about testing for breath odor.
Then I remembered something on my desk. My sister had e-mailed an article prepared by Christian Millman,  for a Men's Health section for ABC News. I was able to quote: "Farmers, cowboys and other sensible men always examine a horse's mouth before buying the animal. One good look can sum up the horse's health history and predict how long the old boy will live. A human mouth isn't much different. Keep your pie hole clean so disease causing bacteria don't gain entry to your blood stream."
I could tell that I 'caught' his attention. It was my good fortune that another part of the article referred to bacteria we had previously mentioned when we talked about breath odor problems.
Dr. Robert J. Genco of the University of Buffalo studies 1372 people at the Gila River Indian community in Arizona. He found that those with gum disease had triple the risk of heart attacks in a 10-year period. He believes that oral bacteria enter the blood stream through small tears in the gums. The bacteria Genco suggests, may infect the liver and cause it to produce artery clogging proteins, or the bacteria may directly infect the heart arteries and somehow cause blockages. The exact mode of attack is still a mystery, but porphyromonas gingivalis bacteria have been found in fatty arterial blockages that cause heart failure.
A further portion of the article related to our discussion about residents in long term care: "With every breath, your lungs suck down a stew of bacteria including chlamydia, pneumonia and pseudommas aeruginosa, two bugs that cause respiratory disease. Our immune systems usually destroy these invaders, but when a person's resistance is low, such as during an illness or after surgery, these bugs can infect our lungs and cause bacterial pneumonia."
I explained to Jim that if a person in a long term care facility has a great deal of bacterial accumulation in their mouth, the 'barrier systems' of the mouth may 'break down' resulting in respiratory pneumonia. If a resident has to be moved to an acute care facility for treatment, this is costly to the publicly funded health care system. Therefore, it is cost effective to keep the mouth clean.