Dentistry and Dementia

Dentistry and Dementia

Dental Work in Skilled NursingAm I a bad daughter? Yesterday, I learned the shocking truth that my mom has five missing teeth. My mom has lived in a higher level of care for over eight years. Seven years in assisted living in Seattle and the last 17 months in skilled nursing care in California.

My mother has had vascular dementia for over 10 years and I have been attending doctor appointments with her for years. Why did I never consider oral health and attending a dentist appointment?

It was pure luck that I visited my mom this week when the mobile dentist was there. Dr. Mark Mroch was awesome. He had a funny and engaging personality. My mom was completely enamored with him. They were joking back and I forth and I was cracking up.

According to dental records the five teeth were missing when my mom arrived in California. Now that I have processed this situation, I have some unanswered dental questions:

  • Why did no one tell the POA (Power of Attorney) of a dementia patient that her mom had five teeth missing when it was first discovered?
  • Has my mom with her dementia been responsible for her own dental hygiene for all these years?
  • Do assisted living and skilled nursing communities brush and floss teeth?
  • How often?
  • If the senior tells the caregiver that flossing hurts, do they just discontinue flossing and not tell the family?
  • Is a dentist required to request flossing in order for it to happen?

Can you please share what the oral hygiene policy is at your assisted living, skilled nursing or memory care community? I know the goal is to have the residents be as independent as possible and brush his or her own teeth. What if they are not doing a good job? When does staff step in to help? Do staff actually watch them brush their teeth or is this one of those back burner items that can get overlooked?

My mom lived in a social model of assisted living. She was borderline skilled nursing for a year or so before we moved her. Is the dental program for dementia different in a social vs. medical model of assisted living?

Please help me figure this out and maybe we can help some POA’s out there who never thought about oral hygiene before. It’s vital that we advocate for our loved one.

Thanks, Diane

Diane Twohy Masson writes this weekly blog to support and engage with other senior housing professionals.  Her first book is Senior Housing Marketing – How To Increase Your Occupancy and Stay Full.  Many sales teams and organizations have used the 12 keys contained in this book for their weekly book review.

Diane Masson has recently created a New Guide for the Silver Tsunami. Her second book offers a pro-active approach for a senior to navigate his or her way through the senior housing market. Selecting Senior Housing Options for Seniors IN the Silver Tsunami is coming soon to Amazon.com. www.tips2seniors.com

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12 Comments

  1. In our assisted living community, oral hygiene is an area that we discuss in our Individual Care Plan of each resident–during the first seven days and at least every six months. As part of the care plan, we assist with getting toothpaste, toothbrush, brushing, and cue for other, but we do not reach into a resident’s mouth. We suggest to families that they also do the above during their visits (especially in our dementia unit). We also suggest keeping regular dental cleaning appointments which may need to be more often-every three months. If a resident has advanced dementia, we don’t advocate dental work–implants, crowns, root canals– but rather pulling the tooth. Our residents go to outside dentists, but we always know if they are having a tooth pulled because it usually requires medication prior to and after the extraction. Family is normally involved with transporting the resident to these appointments and/or involved in the treatment decisions.

  2. Liz Kapitulik, LICSW, C-ASWCM, CPGCM
    Clinical Case Management

    I believe oral hygiene is not overlooked due to respect for independence but more an issue of direct care ratios in skilled facilities.

    Facilities subcontract for dental care but you probably won’t get a call for missing teeth – mostly when mom falls.

    UTI’s aren’t the only cause for delirium – periodontal disease can have the same effect so we need to be rigorous with all aspects of hygiene.

    Since familia cannot be there every day to provide dental care – talk with the CNAs who provide your loved ones direct care. They are the ones who see and hear everything and often are overlooked by nursing managers as a credible source of information. Usually they are delighted to be included and once empowered can make a huge difference in care and communication.

    Irene Campbell-Taylor
    Medical Consultant See publications

    Oral care for dependent persons is a nursing responsibility, almost universally detested by nurses and not performed even on a direct doctor’s order. Poor oral hygiene is the leading cause of bacterial pneumonia in nursing homes and long term care in particular – proven many times. The excuses given for not cleaning mouths can be remarkably creative. Apart from the suffering that develops the cost of antibiotics and extra nursing care are absurd especially when compared to a toothbrush and an appropriate medium for ridding the mouth of bacteria (not always toothpaste.)

    Jean Lawrence
    Many years ago when I was working as a HCA in Nursing homes, many of the residents had false teeth which I had to clean but of all the personal care that I used to give this was one that I found difficult. Any clients who still had their teeth, I would ensure that I encouraged them to brush their teeth every day.

    Many years on when I was working daily for the same client she complained of toothache and luckily I had a brilliant dentist myself, who agreed to do a home visit to her.

    I am sure that things have moved on since then, well hopefully they have.?

    Alan Toporovsky, DDS
    Owner, The Homeward Bound Dentist

    Diane, the answer to all your questions is basically NO. Pretty much all facilities have no clue about what goes on in the mouth. A big part of that is that neither nurses nor physicians receive any training about the oral cavity. The only way they might suspect something is wrong is if they see massive swelling outside the mouth. The staff of the facility have even less training. Yes, they should be assisting with home care, if the resident has in their record that they need assistance with other hygiene A’sDL. However, my experience, with is vast on this subject, is that most of the aides assigned to assist with A’sDL don’t know how to brush their own teeth! I have given classes in facilities about home care to the staff, and they have demonstrated their total lack in knowledge of home care. If they can’t take care of their own teeth, how can they take care of someone else’s? It is a very unfortunate situation. For those of you who don’t know me, I run a dental practice in New York called The Homeward Bound Dentist. I see dementia patients in assisted living facilities. If you have any questions for me, feel free to reach out to me anytime at 917.664.9193 or http://www.thehomewardbounddentist.com

    Diane Masson
    Regional Marketing Director at Freedom Management Co.

    Excellent discussion. I appreciate everyone’s input!

  3. All excellent points.
    Thanks!

  4. As a general dentist who has been going to see house-bound patients in their homes/nursing homes consistently for the past 3 years, I can honestly say there is very little attention placed on dental care inside of any nursing home, unless they complain of pain. Unless the POA is there daily to make sure a toothbrush is getting inside the resident’s mouth, as described above, a toothbrush with paste will, hopefully, most days (usually at night) is placed ready for the resident to use, but most CNA’s don’t stick around to make sure their residents actually do it before they go to bed.

    I have been laughed at in wanting to put in “Physician’s Orders”: “Make sure to have resident brush teeth twice daily” by the nurses at the nurses station. The nurses/CNAs have repeated told me they will not do it/they are not required to do it AND for those with dementia, are afraid to do so. It is maddening. I then let the POA know that this will not be performed for their loved ones.

    Joy V. Poskozim DDS, PC
    Chicago, IL

  5. From Linked In Home Care and Healthcare Advocacy

    Bobbie Greenhut
    CONSUMER & PATIENT ADVOCATE at Self

    IT’S SO UNFORTUNATE, BUT WHEN RELINQUISHING THE CARE OF A LOVED ONE TO A NURSING CARE FACILITY, OUR JOB BY FAR IS NOT DONE.. THERE IS STILL A GREAT RESPONSIBILITY UPON US TO ENSURE THAT THE PATIENT IS NOT BEING IGNORED, ABUSED, NEGLECTED OR OTHERWISE TREATED WITHOUT THE NECESSARY AND PROPER MEDICAL ATTENTION… THAT’S WHY BEFORE ANY DECISION MADE FOR PLACEMENT, COVERING ALL QUESTIONS ABOUT STAFF, CARE, AND FACILITY SHOULD BE ADDRESSED… THAT’S WHERE OUR RESPONSIBILITY BEGINS,… HOWEVER, THAT’S NOT WHERE IT ENDS…

    Bobbie Greenhut
    CONSUMER & PATIENT ADVOCATE at Self

    YOU ARE DEFINITELY NOT A BAD DAUGHTER.. THIS IS ALL A LEARNING EXPERIENCE…

    Dr. J. Vigeant
    Founder/Executive Director of Non-Profit at Ron Sills Memorial Ministries Hospice

    No, you are not a bad daughter and you have much company with Mom’s teeth issues. You can’t be everywhere doing/checking everything. That “higher level of care” isn’t necessarily so as my dearest late husband would have said. Dentistry is often relegated to the back burner in geriatrics care where I have seen, where it has no business being. Maybe get a family member or close friend to ask to follow up.

    Sean Jackson
    Dental Healthcare Provider

    This is a very large problem across America. My mission is to help solve this problem with my Non Profit Organization, Elderly Oral Health Care Consulting, Inc. We provide on site dental services to our underserved elderly population in Nursing Homes, Churches, Adult Foster Care Centers, Homeless Shelters, and even a person’s private home. We also provide educational hands on dental seminar to the health care providers in Nursing Homes and long term care facilities. For more info please visit our website. http://www.elderlyoralhealthcare.com

    Carol Roszel, RDH, BSDH, HIT
    Independent Oral Care Specialist with Hylife,LLC and CEO of NuDent Concepts, LLC

    According to the CDC the Elder population in this country has the worst oral health of any population. Having a mother in a SNF, and being a clinical hygienists for over 30 years, I’m very aware of this problem. Besides being a hygienist, I am also an Oral Care Specialist with HyLife, LLC where we provide brushing and interproximal cleaning along with supplementing the Elders with Xylitol products. We have had excellent luck with not only improving their oral health but also reducing the aspiration pneumonia, UTI’s and the effects of heart, diabetic and systemic infection complications. The problem is that the CNA’s are not trained to do the oral hygiene and the RN’s and CNA’s are so over worked that its and easy thing to overlook and got forgotten to do. Check out our website. hylifellc.com

  6. From Linked In – Senior Care Services

    MaryRose Regan
    Senior Care Services

    Great reminder to expect the unexpected…

  7. From Linked In – Alzheimer’s and Dementia Professionals

    Liz Kapitulik, LICSW, C-ASWCM, CPGCM
    Clinical Case Management

    Alan – let’s say personal dental hygiene isn’t an issue for staff – any tips for working with dementia patients’ oral care? As Jean courageously answered, it’s probably the most challenging part of direct care.

    Alan Toporovsky, DDS
    Owner, The Homeward Bound Dentist

    Absolutely. Staff, however, is an issue. Most dementia patients need help with oral hygiene, just like like they do the rest of their bodies. A properly educated staff will make a difference. I recommend an electric toothbrush called the SPIN BRUSH. I believe it is made now by arm and hammer. A simple, battery operated, inexpensive brush. You push the button, put it up against the teeth, and it does all the work. But you have to know where to put it. Not just the front teeth that you can clearly see, but the back teeth you can’t see. Not just the front of the teeth, but the backs of the teeth that you feel with your tongue. The person will possibly be resistant. The staff need to understand that they need persistence, just as with anything else they do. If the person gives them a hard time putting clothing on, are they not going to do it? same with oral hygiene.

    Jean Lawrence
    Top Contributor

    Having worked in the field of health and social care for numerous years and actually as a Dental Nurse as well initially, I can honestly say that I can deal with all personal care even with the odours that come with it, I always tried to think of how I would want to be treated myself or that of my parents or later on my children, however, I found dealing with patients teeth was the most difficult for me – strange as I could assist the dentist with all procedures without any concern at all. But when it came to having to finish off cleaning false teeth I found that really difficult – not sure why as I could everything else, even cleaning natural teeth in an elderly client but false teeth really affected me.

    Alan Toporovsky, DDS
    Owner, The Homeward Bound Dentist

    We all have our issues. There is a nurse in one of the facilities I go to who admitted to be she would rather deal with decubitii than teeth. Has to do with personal experiences as a child. But that is no excuse. Care givers in these facilities are not dealing with the residents’ teeth. Period. Not good.

    Jean Lawrence
    Top Contributor

    Alan, carer’s of people with dementia and actually any patients who need all care, need dental care daily and therefore a care assistant needs to be able to give this care, which back in the day when I was a care assistant I did find this more difficult than other personal care needs but I still carried it out.

    I was lucky to have worked as a dental nurse to a brilliant dentist and then was lucky enough to have 2 great dentists who not only looked after me – the really nervous patients but also vested my patients when they had problems with there teeth in their own homes.

    One point that I’d like to make is that some of us are terrified of dentists.

    Alan Toporovsky, DDS
    Owner, The Homeward Bound Dentist

    I understand that there are many people out there who are afraid of the dentist. does that mean that residents’ home care should be neglected because of a fear a caretaker has?

    Jean Lawrence
    Top Contributor

    Of course not Alan, I was just making the point that a lot of people are terrified of the dentist – not carer takers or care givers but actually the patient themselves.

    A dentist as well as a doctor can have all the qualifications possible but that doesn’t make them a good practitioner when it comes to putting the patient at ease.

    Alan Toporovsky, DDS
    Owner, The Homeward Bound Dentist

    Very true. Point well taken.

    Irene Campbell-Taylor
    Medical Consultant See publications
    Top Contributor

    Dr Toporovsky
    I appreciate your comments. I would like to add a few observations that, as a dnetist, you will probably shudder at but my position is that, since an unclean mouth is a leading source of nosocomial bacterial pneumonia, I will take any route possible to reduce the risk. As has been pointed out, many elders are highly resistive to tooth brushing – one of the reasons nurses dislike doing it so much, and, of course, the friction of brushing is required to remove plaque and its inherent bacteria. Rather than have constant, unpleasant fights, I developed a method of bacterial attack using Peridex in a spray bottle. Many are unaware that it is not only the teeth that need to be cleaned (edentulous patients require oral care as well) because plaque forms on all oral surfaces. the chlorhexidine in the Peridex cuts through the plaque to attack the bacteria. Granted, not the recommended approach but one that I have found improves the state of the mouth – although the teeth may still have furry coats. If the bacterial count is reduced to any significant degree the risk of pneumonia is also reduced. Having said all that, my opinion is that LTC requires the regular input of dentists and dental hygeinists as much as nurses and doctors and nurses must learn that a lack of oral care causes infections and even death from pneumonia in frail elders.

    Anita Westera
    research fellow at University of Wollongong

    Oral health and hygiene are so critical to general health and well being; A great project was funded by the Australian Government several years ago, which focussed on improving oral health in residential aged care – the resources are freely available at www[dot]health.gov.au/betteroralhealthtraining. The same group that initiated and developed this are now working on a similar initiative for community care services www[dot]health.gov.au/internet/main/publishing.nsf/Content/2E625F7A23ED6F71CA257BF0001B5D73/$File/ProfessionalPortfolio.pdf

    Alan Toporovsky, DDS
    Owner, The Homeward Bound Dentist

    Irene-
    Very interestig approach. The use of peridex will remove some bacteria. If you do not remove the plaque, you will not get ALL the bacteria, as there is a biofilm produced which the spray will not penetrate. Yes, brushing is difficult. As my previous comment said, I recommend the spin brush, as it does the work and is quite gentle. I use it myself and it works nicely. The combination of the brushing with the spray could be very interesting. Be careful-peridex tends to stain teeth.

    Irene Campbell-Taylor
    Medical Consultant See publications
    Top Contributor

    Yes, of course Peridex stains teeth but I’ve found that in the elderly, the duration of use isn’t enough to create stains and, of course, in the edentulous I find it works better than brushing because, when used properly, it can coat all surfaces, palate, cheeks, tongue, and under the tongue. It certainly won’t remove all bacteria but often just enough to make a difference. It seems preferable to no oral hygiene at all – the common case.

    Alan Toporovsky, DDS
    Owner, The Homeward Bound Dentist

    If it works for you, go for it. Why you are worried in edentulous cases, I don’t know. You don’t get the bacteria buildup on gingiva as you do teeth and gingiva. Big difference. Maybe if I find a case, I will try it.
    d
    Diane Masson
    Regional Marketing Director at Freedom Management Co.
    Top Contributor

    Awesome discussion. When my mom was with with dentist last week, he gave her some water to rinse out her mouth. Then he said spit it out in the bowl. The first time was successful. The 2nd time, she swallowed it. She has dementia and no short term memory. The dentist went with the flow. My mom swallowed gritty water…

  8. From Linked In – Senior Housing Forum

    Dr. Ethelle Lord President at R4Y and ICA
    Pioneer in dementia care training/Changing the course of dementia care by boosting dementia knowledge

    Oral hygiene is the number one problem in long-term care (this includes assisted living, hospitals, boarding homes, etc.). At http://www.icareassoc.com the very first video demonstrates well how to brush the teeth of someone living with dementia (special toothbrush, toothpaste, and method).

    We do indeed have to address this problem from day one and insist on the proper method of brushing their teeth. Even with false teeth, the video will demonstrate what to do and what problems you can develop.

    In 2015 the International Caregivers Association (ICA) will have a special webinar/presentation on detecting elder abuse by looking at the oral hygiene. I think it is absolutely inexcusable for management of these facilities not to take care of oral hygiene – the main reason is shortness of staffing and the time it takes to provide this service.

    Another suggestion the ICA has is to request dental hygienists to be present in all those facilities. After all, they do offer hair cuts – why not dental cleaning every 6 months?

    ~ Ethelle

    Dr. Ethelle Lord
    Pioneer in Alzheimer’s/Dementia coaching

    Diane Masson
    Regional Marketing Director at Freedom Management Co.
    Top Contributor

    Thanks Ethelle! Great info!

    Dr. Ethelle Lord President at R4Y and ICA
    Pioneer in dementia care training/Changing the course of dementia care by boosting dementia knowledge

    As a society and as a large group of baby boomers, I do believe we have the power to change the course of dementia care. Oral hygiene is a wonderful place to start, don’t you think?

    ~ Ethelle

    Dr. Ethelle Lord
    Pioneer in Alzheimer’s/Dementia coaching

    Nicole Fink
    RDH BS/President The Mobile Tooth Fairy

    I am a Dental Hygienist in WA and I own The Mobile Tooth Fairy P.S., I travel to these facilities to provide preventative oral health. There is a huge need and I would be happy to help anyone who may need my help.

  9. From Linked In – Marketing to Seniors

    Dan Bartlett
    Owner, Lifetime Solutions

    Great article Diane.It’s very important to maintain good dental care at all ages,but especially for our Seniors.Many times they have swallowing issues like my father had,and once he received regular care,the swallowing got better.It’s also beneficial for those with memory impairment,that are unable to express the discomfort they may be having.

  10. From Linked In – Licensed Nursing Home Administrators of America

    Michael Tartaglia
    Administrator at Greenwich Woods HCC

    you are not a bad daughter. Losing teeth happens with age. As long as she is not in pain or unable to eat, I would not stress on it. You can get an evaluation at this point but the consensus will probably be to allow the status quo to continue.

  11. Linked In – Boomers: Aging Beats the Alternatives

    Lorie Eber
    Personal Wellness Coach at Lorie Eber Wellness Coaching
    Top Contributor

    The facility is responsible for this care. I’ve had a mobile dentist come and make a partial for my Dad (the facility lost it once and it broke another time). They should definitely be brushing your Mom’s teeth and monitoring her oral hygiene.

    F. Todd Winninger
    “Funeral Shows”(c) Creator and Producer | 2nd Opinion and $avings on Funeral Expenses | Licensed Funeral Director (LFD)
    Top Contributor

    i think dentistry is considered complex and unimportant by many seniors — my mom quit going for years.

    Andrea L. Russo
    I am your ambassador of first impressions actively seeking a career position working with Seniors in my local area
    Top Contributor

    Dentistry is a very complex and for those without health care coverage of any kind is also a very highly $$ costly issue for all not just seniors. However, as one who recently had major ( oral surgery) done I would caution to say, that dental issues are very important and monitoring them for the elderly even more important. Poor dental hygiene in some cases can eventually lead to an overall health decline, especially in the elderly. Mobile dentistry, or free dental clinics are great. Maybe more marketing needs to be done or test marketed towards the overall importance of dental hygiene care for seniors.

    John Hartnett
    Meticulous and Highly Skilled Accounting Manager | Fortune 100 experience | Diverse industries

    This is a sore subject for me these days. I just got the semi-annual premium notice for my son (who is disabled) and the unnamed national company increased the premium by 22%, and this is for twice a year cleanings only. Anything else is extremely costly. the company blames Obamacare for the high increases.

    There is no Medicare coverage for me except if it happens to be a secondary cause. I have looked into dental coverage but most want at least 18 months of premiums before there is any coverage and require large copayments and deductibles

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