Lessons learned from a “boots on the ground” experience

providing oral hygiene in nursing homes

Pam Stein, D.M.D., M.P.H.
University of Kentucky College of Dentistry
pam.stein@uky.edu

Special Care Dentistry Association

Annual Meeting
April 29, 2012

This project was funded by the Dental Trade Alliance Foundation

The Why and How of our Project
Issue: Very few nursing home residents
receive adequate daily oral hygiene care.

Aim: To improve daily oral hygiene care by

training a nursing assistant to become one
nursing home’s “oral health specialist”.
 There is good evidence to support this
model of oral care.

A 2008 study in a Florida nursing home found:

Nursing home residents who had daily mouth care

provided by nursing assistants whose only job was
to provide oral care had much less risk (3 times less
risk) of dying from pneumonia than those
residents who did not receive the daily care from
the nursing assistant designated to do oral care.
Bassim CW, Gibson G, Ward T, Paphides BM, DeNucci DJ. Modification of Risk of Mortality from Pneumonia with
Oral Hygiene Care, J Am Ger Soc, 2008, 56 (9): 1601-1607.
The first step was to develop a partnership
with local long-term care facility.

Administrator

Director of Nursing

Social Worker
We developed a written plan and shared
with the leadership of the facility.

Ask for advice as to how the plan might

realistically work for their residents and staff.
We then identified nursing assistant to be
trained and developed the curriculum.

We researched literature
for elements of
past successful
training programs
Training began with 4 Self-Instructional
PowerPoints

• Importance of Daily Oral Care

• Guidelines for Daily Oral Care
• Checking for Problems
• Residents Requiring Special Care
 A video helped overcome barrier
of care-resistance.

Video Created by Dr. Rita Jablonski

- Strategies for Care Resistance

during oral care

- Available for viewing on POGO

Jablonski RA, Munro CL, Grap MJ, et al. Mouth care in nursing homes: knowledge, beliefs, and practices of nursing
assistants. Geriatr Nurs 2009;30:99-107.

Chalmers JM. Behavior management and communication strategies for dental professionals when caring for patients
with dementia. Spec Care Dentist 2000;20(4):147-54.
Hands-on training with oral hygiene
tools helped build confidence.
Ongoing bedside coaching included weekly
visits to the facility.

-traveling room to room

to deliver oral hygiene
care with the nursing
assistant
-talking with the nursing
assistant about her
struggles
-providing positive
feedback for successes
We had a presence at the nursing
home for months.

This allowed us to get

to know residents and
their families and learn
about their concerns
and suggestions.
We spent time in conversations with
nursing staff (esp charge nurses) because
we wanted to know:
What are the real - “Outbreaks” of flu or
challenges they face other contagious illness
every day with other - Trying to prevent
care (besides oral)
pneumonia and hospital
admits
How our oral health - Lots of talk about
training might help them
“wound care”
address their other more
general concerns
 AHA! Now maybe we can get buy
in for sustainability!

-Wound animation
-Incorporate infection control into our training
-Provide stats (research) about decreased
pneumonia due to oral hygiene to
administration

Azarpazhooh A, Leake JL. Systematic review of the association between

respiratory diseases and oral health. J Periodontol 2006;77(9):1465-82.
Wound Care Animation

Bacteria_Rev2.exe
We scheduled follow-up meetings
with the leadership.
• This included the DON,
administrator and the
CEO of the parent
company
• Short OH basic training
for everyone with
infection control review
• Respiratory connection
We were both teacher and student

THIS WAS A VERY VALUABLE LEARNING

EXPERIENCE FOR US!!!!

That’s why we are here…. to share lessons learned.

 Lesson Learned
It is essential to identify a point person in
leadership at the nursing home to
communicate issues and concerns.

For us this was the Social Worker, but it could

be the Director of Nursing, Assistant Director
of Nursing or Administrator.
 Lessons Learned

Must have a dentist

available to treat
residents because with
increase in oral health
awareness and daily
oral care there was an
increased need to refer.
 Lessons Learned
Some residents were on a diet prohibiting thin
liquids. A regimen which included mouthwash,
water and toothpaste could have been a choking
hazard.

Further, resident’s dietary restrictions often

changed making it difficult to know on a daily
basis who was at risk of choking.
Addressed the dietary restrictions by:

YouTube video

Red “Safety Precautions” Flash card

Added to PowerPoint Presentations

Before providing oral care to anyone
check with the charge nurse or care
plan each day.

• Do you need to change

the oral hygiene routine
to eliminate liquids and
toothpaste for any
residents?
 Do NOT use toothpaste, mouthwash
or water for the following residents
• Comatose residents
• Residents on a restricted diet of thickened
liquids that can’t have thin liquids
• Care resistant residents
• Residents who hold liquids in mouth/ can’t or
won’t spit but instead swallow liquids placed
in mouth

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 How to provide oral care without
toothpaste, mouthwash or water?
• Simply moisten a toothbrush with a very small
amount of water or mouthwash and brush teeth as
you normally would.
• If possible, floss teeth
• After brushing and flossing wipe the mouth out with
a toothette or gauze moistened with mouthwash.
 Lessons Learned
The nursing assistant we trained as the oral
health specialist worked 6am-2pm

Residents enjoyed having their teeth brushed

and asked for the care at other times.

We developed a 25 minute presentation

for all nursing assistants at the facility.
We created a free website that provides
resources for dental professionals, nursing
homes and families:
Powerpoints (30 min, 1 hr, 2 hr)
Powerpoints with voice over
YouTube Video (11 minutes)
Written Materials
Task and Supply Lists, Safety precautions
Competencies
Pre-test and Post-test
Forms (referral, documentation)
Links to other on-line resources
References for related research
Kentucky House Bill 510 signed
into law 4/12/12.

Appropriates $150,000 from penalty fund to train

nursing assistants to become “oral health
specialists” in several long term care facilities in
Kentucky to study the health and financial
outcomes. DOES THIS SAVE MEDICAID MONEY???

Will use our training materials and model for this

pilot project.
Web Address of resources created.

http://www.uky.edu/NursingHomeOralHealth/
 Acknowledgements
For their assistance with this project, the authors of this program would
like to thank:

Joanna Aalboe, MPH, Registered Dental Hygienist, Assistant Professor, University of

Kentucky College of Dentistry
Ada Carlile, Registered Dental Hygienist
Sandy Challman, Master of Instructional Technology, University of Kentucky College of
Dentistry
Kathryn Cunningham, MS Ed, Center for the Enhancement of Learning and Teaching,
University of Kentucky
Tom Dolan, Senior Medical Illustrator and Multimedia Developer, University of
Kentucky
Stephanie Harper, Social Services/Butterfly Program Coordinator
Dr. Robert Henry, Chief of Dental Services, Veteran's Administration Hospital,
Lexington Kentucky
Esther Nealy, Certified Nursing Assistant
Dr. Judith Skelton, PhD, Director of Outreach and Engagement, University of Kentucky
College of Dentistry