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.

[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