Growth and Ageing Assignment

You have been put in charge of a dental team providing dental care to a large
(100 bed) nursing home facility. Discuss the likely dental health needs of the
residents of this facility and describe how you would plan and deliver appropriate
care to them?
The strategy used to identify the literarure listed involved a thorugh search of
the QMUL Artcile Search Database using key search terms and limiting this to the
UK. Further searches included Cochrane Review, Pub Med, British Dental Journal,
International Association for Dental Research and individual journal websites, eg
Gerodontology.
Dental Health in Instituionalised Older People
As one ages, ones teeth transform considerably. The adult dentition is expected
to last a lifetime and oral health should be a lifetime concept. High quality oral
healthcare should be available to all people regardless of their age or
circumstances. However the reality is rather different. The Adult Dental Health
Survey UK 1998 found that age is the single biggest reason for the decrease in
sound and untreated teeth. Nevertheless, this pattern of elderly people
expecting to lose their teeth is changing because of the baby boomer
generation who are expected to maintain and enhance the demand for dental
care amongst the new cohort of elderly1.
This recent trend amongst the elderly is not indicative of dental care in nursing
home facilities. A study looking at residents of nursing homes across Bristol 2
found considerable neglect with regards to oral health. Over 70% of the residents
had not seen a dentist for over five years. Amongst the denture wearers 82%
were unable to clean their dentures and needed assistance from the staff and
denture-related stomatitis affected 33%. Quite shockingly, unhygienic dentures
were worn by almost all of the subjects. Those fortunate enough to be in the
dentate population suffered a similar plight. On average, two-thirds of each tooth
surface were covered in plaque. Gingivitis was moderately severe with dental
calculus present in 82% of subjects and root caries in 63% of subjects. The
overriding message from this study was that residents of care homes required
assistance with cleaning their dentures and teeth yet the appropriate level of
care was not provided for by the staff.

1 CHESTER W. DOUGLASS, D.M.D., PH.D. and CHERILYN G. SHEETS, D.D.S. PATIENTS

EXPECTATIONS FOR ORAL HEALTH CARE IN THE 21ST CENTURY The Journal of
the American Dental Association June 2000 vol. 131 no. suppl 1 3S-7S

Frenkel H, Harvey I, Newcombe RG. Oral health care among nursing home residents in Avon. Gerodontology
2000;17(1):33-8.

A further study3 found consistent results with the above research. The findings
showed high levels of both coronal and root caries. Plaque retention is a problem
in elderly people who have difficulty in mechanically removing plaque owing to
diminished manual dexterity, impaired vision, or illness. Poor denture hygiene
has been found. Although residents preferred assistance in cleaning their teeth
and dentures, only 94 reported that the staff had helped them. The compelling
part of this research was that even in cases where staff helped the residents
clean their dentures and teeth, they wer no cleaner than those cleaned by
residenets. This suggest a possible training issue.
The study also found that many residents received medications known to
produce xerostomia, 396 were given syrups containing sugar and 385 residents
reported suffering with dry mouth. In this case this lead to denture stomatis
(particulary with residents who wear dentures at night), angular chelitis, oral
ulcerations, sore and fissured tongues. The role of medication and poly pharmacy
plays a part in oral health for the elderly.
The research found that the managers indicated that there was no systematic
approach to arranging dental care. Dental care was sought only when residents
or their relatives complained of acute dental problems such as pain or a broken
denture. Dental assessments were not carried out when residents were admitted,
neither was a care plan developed that included intraoral care. No emphasis is
given to prevention in a care home environment.

Dental factors that contribute to quality of life

There are many disabling effects of dental and oral disorders that are frequent
amongst elderly and that have a profound impact on health. A study deploying a
questionnaire4 in a nursing home found that the majority of the residents had
difficulty eating, communicating and had problems with taste. Research has
found that elderly edentulous patients could not eat food which was necessary
for a stable diet for example raw carrots, apples, steaks or nuts. 5 Further research
3 D Simons a, EAM Kidd b, D Beighton b; Oral health of elderly occupants in
residential homes The Lancet, Volume 353, Issue 9166, Page 1761, 22 May 1999

4 D Simons a, EAM Kidd b, D Beighton b; Oral health of elderly occupants in

residential homes The Lancet, Volume 353, Issue 9166, Page 1761, 22 May
1999
5 Sheiham J.G. Steele W. Marcenes S. Finch, A.W.G. Walls. The impact of oral
health on stated ability to eat certain foods; Findings from the National Diet and
Nutrition Survey of Older People in Great Britain. Gerontology Volume 16 Issue 1
pages 11 -20 July 1999.

as shown poor oral health may be an important contributing factor to the

development of significant involuntary weight loss among the frail elderly6.The
poor oral status of the institutionalised elderly, found in this and previous
studies, may contribute to the eating problems and low nutrient and vitamin C
levels found in this group. These results, combined with the reduced ability of
elderly people to communicate, may cause weight loss, dehydration, and debility.
Oral diseases are usually not fatal to older people, but as the research
demonstrated can affect their ability to eat, speak and socialise and contribute to
ones general well being. An interesting study 7 challenges the perception that old
people are not concenrned about their oral health particlurly when they are in a
nursing home. A study conducted face to face interviews with over 450 adults
over 65 across the UK. The studys conclusions were that the majority of older
people see good oral health as important to quality of life. It also found that
there were gender variations. Men were more concerned about physical
dimensions such as eating whereas women were more concerned with
psychosocial domain such as self confidence. This is a good insight to developing
a treatment plan and helps a dentist appreacite specifi need a of this group. Old
people are not homogenous but variable.
Further research carried out in Israel8 found difference between Homebound
elderly people reported greater difficulties than nonhomebound people in
communication, eating, relaxation, and life satisfaction as related to oral health.
Married and divorced persons expressed less effect on their quality of life than
single and widowed people. Subjects with nonfamily caregivers reported greater
effect of oral health on quality of life (18.37) than subjects with family caregivers
(8.38) The negative effect of a professional nonfamily caregiver also emphasizes
the positive influence of the family network support system. Elderly people who
were cared for by their spouses or children expressed less negative effect on
their quality of life. Higher education had a positive effect on quality of life. Thif
further affirms the importance of oral health to the elderly.
Dental health is linked to health, happiness and good general health. Locker^
indicates that people often avoid having food in eompany because of problems
6 Sullivan D.H, Martin W, Flaxman H and Hagen J.E Oral health problems and
involuntary weight loss in a population of frail elderly Journal of American
Geriatric Society 1993 July 41 (7) 725-731.
7

McGrath, C., Bedi, R. (1999): The Importance Of Oral Health To Older Peoples Quality Of Life. Gerodontology;
16(1):59-63.

8 Avraham Zini DMD, MPH, Harold D. Sgan-Cohen DMD, MPH - The Effect of Oral
Health on Quality of Life in an Underprivileged Homebound and NonHomebound Elderly Population in Jerusalem Journal of the American Geriatrics
Society Volume 56, Issue 1, pages 99104, January 2008

eating and associated embarrassment. He emphasised the importance of

aesthetically acceptable and functionally adequate dentitions so people can feel
confident about eating at home or in company. Fiske et aP^ explored the
emotional reactions to tooth loss and found that tooth loss affected self-esteem,
confidence, enjoyment of food, selection of food, socialisation and forming close
relationships even when teeth were replacedby dentures

Treatment planning Issues

As people age their health deteriorates and when treatment planning for this
population this needs to be considered. It is believed that there are currently
700,000 people with dementia in the UK, of whom 15,000 have early onset
dementia, ie onset before the age of 65. This is considered a major
underestimate by up to three times because of the way the data relies on
referrals to services. A further compelling statistic is that of of all the people
living in care homes, 64% have some form of dementia 9
It is well recognised that oral health declines as dementia progresses. The impact
of the disorder, especially in the latter stages, leads to poor oral hygiene with an
increase in periodontal disease,6higher levels of coronal and cervical decay and a
greater incidence of other dental problems such as denture wearing or the ability
to comply with oral care procedures. 10 The commonest medications used in
dementia also have the potential to cause xerostomia and, if medications are
syrup-based, the potential for the development of caries is increased. be awre
of the oral manifestations of systemic diseases and the impact they may have on
the treatment plan. Avoid interaction with and look for oral side effects of drugs
taken
The decision making process in planning oral healthcare for people with
dementia or with other forms of cognitive impairments should incorporate a
multidisciplinary care team approach involving the medical practioner,
psyhicatric team, relatives and carers. Treatment should begin from diagnosis so
that oral care can be planned throughout the disease process and does not
become crisis management in the final phase of the condition. Treatment
planning must take account of the stage of the illness and the level of cognitive
impairment. Take a multidicpilinary approach and liase with other individuals
responsible for each patient care e.g general medical practioner, carer
physiotherapist, family.
Another study found that access to dental care for the frail and elderelyw as
worse than other groups. 11 One of the reasons for this is accessibility issues
including transport difficulties, access to surgery, communication problems.
9 Alzheimer's Society. Dementia UK. The full report. London: Alzheimer's Society,
2007.
10

Dougall A, Fiske J. Access to special care dentistry, part 9. Special care dentistry services for older people.

When considering treatment planning the number of visits etc should account for
this. The study also found that Patients are retaining some or all of thgeir teeth
into old age and therefore require more complex treatment. Teeth that require
extraction are likely to be heavily restored and more likely to require a surgical
approach.

Fiske J, Griffiths J, Jamieson R, Manger D. Guidelines for oral health care for long-stay patients and residents.
Gerodontology 2000;17(1):55-64

Requirments for providing appropriate care

Planning and delivering appropriate level of care to the residents of my hospital
will require a muiltidiciplinary approach and liase with other individuals
responsible for each patient care e.g general medical practioner, carers
physiotherapist, family. However, bearing in mind that we are living in the age of
austerity. Too much resource cannot be used up. However, in the curerent
climate and austerity resources are limited.
The first thing I would implement is an initial assessment 12 of oral health on
arrival to the nursing home. This initial assessment would involve a simple
questionnaire which would alert staff to any problems with regards to oral health.
This questionnaire would then be reviewed by staff who would pick up on
anything of concern and provide the residenmt with the appropatie level of care
by getting a dentist tp do a more complex examination involving and oral
examination. These questionnaire would be submitted every 6 months. If
possible this questionnaire should be carried out with family rather than staff to
eliminate bias.
The influence of diet and nutrition on oral and general health is fundamentally
important.. Davies'" suggested that good nutrition can have a marked effect on
the health, happiness and independence of older people whereas the poor oral
status of institutionalised older people maycontribute to eating problems, weight
loss, dehydration and debility". Sugars are not only detrimental to dental health,
they can also have a negative impact on general health'\ Thus the reduction of
sugar intake for dental health can also benefit general health e.g. reduced
incidence of obesity, diabetes, coronary artery disease. The food served to the
residents should be healthy and majority of them should have healthy chjoices.
Also dietary advice should be givn and sugar should be limited. Healthy eating
choices in line with health promotion.
11 Chris Fox Evidence summary: why is access to dental care for frail elderly
people worse than for other groups? British Dental Journal 208, 119 - 122 (2010)

12

Fiske J, Griffiths J, Jamieson R, Manger D. Guidelines for oral health care for long-stay patients and residents.
Gerodontology 2000;17(1):55-64.

A further thing i would implement is changing the facilities available to the

residents. I believe that facilities should provide or privacy and dignity in
personal oral care. Every resident if budget allows will hav ensuite room tailored
with fixtures and adaptions that meet their needs. Good lighting and reminders
would also be on their room. This strategy will help promote independence and
self care in a dignified manner.
There is little data on the availability of oral hygiene equipment however there is
a wealth of professional anecdotal evidence about the difficulty in obtaining
toothbrushes in hospitals. Despite the fact that a toothbrush is the cheapest and
most effective tool for oral hygiene.

and is more effective than a foam stick. mouth care packs and foam sticks are
still in general use. . It is reeommended that managers of long stay and
residential accommodation take on theresponsibility of ensuring that appropriate
oral hygiene equiptnent is readily available and thatstaff are made aware of
procedures for obtaining. A;; residents will be provided wityh a tootbrush, regular
tooth paste, floss, mouthwash and denture cleaning equipment.

The role of the staff is fundamentally important. The majority of residenets are
partially or totally dependent on nursing staff and caregivers to maintain oral
hygiene. Reasearch as shown A study13 showed that a one hour practical
demonstration to nondental health care staff in a nursing home improves oral
health considerably. The study indicates that training of care-givers can improve
oral hygiene and health in nursing homes and other long-term care facilities by
enhancing the knowledge of the nursing staff through a short one-time lecture
and educational demonstration.Furthermore, the outcome of this study was
assessed 6 months after the intervention, and apparently the nursing staff was
fully aware of their participation in a health promotional study. All tyhe staff in
my care home would receive this training and to support the concerpt of oral
health care. Oral health education and promotion training should be provided.
A further concept related to staff and carers is that Many residents rely upon
carers' perception of need for access to dental services-'' and treatment is
generally only provided when there is a perceived oral problem. This culture will
be changed and any resident wanting to go dentist can ask for it. They can go to
their previous dentist. ". In accordance with the prineiples of good quality
residential care, people should be encouraged to retain continuity of dental care
where appropriate and be supported in their choice. Emergency dental care
should be available within twenty-four hours with clear referral mechanisms for
routine advice and treatment. Continuing dental care should be available for
13 Frenkel H, Harvey I, Newcombe RG. Improving oral health in institution-alised
elderly people by educating caregivers: a randomised controlled trial.
Community Dent Oral Epidemiol 2001;29:289-97

anyone in long-stay and residential accommodation, and this includes people in

seeure units. Access and referral to dental services should be included in
admission, transfer and discharge procedures.

Communication between the dental team and other disciplines is most effective
when the dental team provides an input to multi-disciplinary care and
assessment. Collaborative eare planning which provides an opportunity to
demonstrate the contribution of oral health care to general health and well-being
should be endorsed.
Finally, amongst for the care home there will be a code of conduct serving as a
constitioun. Negotiated and agreed standards and procedures for oral care
promote a structure and process for putting theory into practice and supporting
staff in what may be viewed as an unrewarding task. Locally negotiated
standards should include: Oral health assessment on admission Training
programmes for care staffAccess to emergency dental services Facilitation of
contact with appropriate dental services.Basic principles of good infection control
should be practised by all health care workers involved in oral care It is important
that managers are made aware of the health risks to residents and staff from
poor standards of infeetion control in mouth care. This will go some way towards
justifying the cost implications. The development of standards which can be
audited promote improved quality of care and facilitate the identification of
problem areas.
Communication between the dental team and other disciplines is most effective
when the dental team provides an input to multi-disciplinary care and
assessment. Collaborative eare planning which provides an opportunity to
demonstrate the contribution of oral health care to general health and well-being
should be endorsed.