Oral Care for Nursing Home Residents

Oral Health and the Elderly

The need for dental care actually increases with age, chronic illness and handicap. Good oral health is essential for chewing, nutrition, and speech. In addition, oral health plays an important role in self-image and social interaction. These important functions highlight the need for regular oral health services.

Poor oral health in nursing home residents can contribute to systemic diseases such as stroke, heart disease and increased rate of pneumonia, as well as malnutrition, impaired speech, and facial deformity. All these consequences detract from their quality of life.

Oral diseases are more common, more extensive, and more difficult to manage in nursing home residents than in younger population groups.

Teeth become more susceptible to decay because medications used by the elderly reduce the normal flow of saliva. Saliva helps neutralize decay and cleans and lubricates the gums and lining of the mouth. Saliva also contains enzymes and immunoglobulins, which kill the bacteria, which constantly attack the mouth. Without adequate saliva, and good oral hygiene, most oral diseases are accelerated. The problem of a dry mouth is called "xerostomia" and it is very common among nursing home residents.

As a group, elderly nursing home residents have far fewer natural teeth than younger groups. Remaining teeth become more brittle, and old fillings and other dental work begin to fail. Periodontal disease is at its end-stage among the elderly, making loose teeth, bleeding gums, and foul odors common. Oral cancer is most common among the elderly.

Brushing and Flossing

When a resident is able to provide their own oral care (which should be encouraged when appropriate) it is essential that they are observed on a regular basis to assess the need for assistance and/or adjuncts. Arthritis, stroke, as well as many other dexterity issues decrease ones ability to provide their own oral care. There are many adjuncts available to allow the elderly to continue to care for themselves with supervision and limited assistance. The key is to know when help is needed.

How to Assist with Brushing and Flossing

Plaque, that sticky material that forms on teeth each day, is responsible for causing both tooth decay and periodontal disease.

Removal of plaque by daily brushing and flossing has tremendous value in preventing oral diseases.

Plaque deposits can harden over time to form a cement-like coating called "calculus". Only a dentist or dental hygienist can safely remove calculus. Calculus should be removed every six months for most people. Some people accumulate calculus more rapidly and may require more frequent cleanings.

Brushing
Procedure

Brushing

All Residents should have their teeth brushed at least twice a day. Each resident must have his/her own-labeled toothbrush. A straight handled, soft, nylon bristled toothbrush will clean the teeth without damaging the gums. The toothbrush should be replaced every two to three months. Toothbrushes can be labeled by writing the resident's name on a piece of surgical tape affixed to the toothbrush handle.

Procedure

  1. Use a pea sized amount of fluoride toothpaste and place the head of the toothbrush alongside the teeth with the bristle tips angled at 45° toward the gum line as illustrated below. Clean the junction between the teeth and gums, as well as the teeth themselves.
  2. Move the brush gently back and forth in short strokes approximately the width of one tooth. Use a gentle circular motion.
  3. To insure that all surfaces of the teeth are brushed, use a set pattern. Brush the outer surfaces first, and then the inner surfaces of the upper and then the lower teeth, as illustrated in the diagram at left. Brush the biting surfaces of the teeth last.
  4. Gently brush the tongue, and also any areas where teeth are missing to remove plaque and freshen breath. If gagging is a problem, place the resident's head forward and down with instructions to breathe rapidly through the nose. This will help control the gag reflex.

The gums may bleed during the first few brushings until the deposits are removed and the inflammation is reduced.

Brushing With Electric Toothbrushes

You may find an electric toothbrush easier to use for some residents.

  • The bristles must be moistened and only a small amount of toothpaste is needed.
  • Brush a small area at a time. Turn the electric toothbrush on after it is in position in the mouth.
  • Position the electric toothbrush the same as for manual brushing, at a 45° angle toward the gum line.
  • Follow a pattern around the mouth to insure that all areas are cleaned.
  • Rinse the brush and mouth frequently.
  • The tongue and cheeks can also be cleaned.
  • Store the brush upright to ensure longevity.
  • The soft bristled portion of the brush must be replaced every two to three months.
Flossing
Flossing

Flossing

The use of dental floss is the only way to effectively clean between the teeth. For residents who have many remaining natural teeth and who can cooperate with you, it is a very important preventive service. The proper technique for using dental floss on another person should be demonstrated to you by a dental professional.

Procedure
  1. Break off about 18 inches of floss and wind most of it around one of your middle fingers. Wind the rest around the same finger on the other hand. This finger can "take up" the floss as it becomes soiled. A dental floss holder, a V-shaped plastic device that holds the floss securely, may be used instead of the fingers.
  2. Use thumbs and forefingers with an inch of floss between them to guide floss between the teeth.
  3. Holding the floss tightly use a gentle sawing motion to insert the floss between the teeth. Never snap the floss into the gums! When the floss reaches the gum line, curve it into a "C" shape against one tooth and gently slide it into the space between the tooth and gum until resistance is felt. While holding the floss tightly against the tooth, move the floss away from the gum by scraping the side of the tooth.
  4. Without removing the floss, curve it around the adjacent tooth and scrape it, too. Scrape floss down on the upper teeth and up on the bottom teeth. Repeat this method on all the teeth using a clean section of floss for each space.

The gums may initially bleed when flossing.

Care of Disabled or Unconscious Residents

Residents with mental or physical impairments that prevent them from being able to brush their teeth or clean their dentures really need help from the nursing staff.

Care of Disabled or Unconscious ResidentDaily oral hygiene should be part of every residents care. When possible, oral hygiene should be provided following meals. The mouth should be cleaned at least twice per day.

Some residents have difficulty grasping a toothbrush. With some modification, a toothbrush can be made which is easier to hold than a standard toothbrush. Illustrated at left is a toothbrush fitted with a Styrofoam ball to make it easier to grip. Other types of modifications are also possible.

Consult with your facility’s Occupational Therapist for toothbrush modification ideas.

 

 

Procedure

  1. Assist the resident into a comfortable position, elevating the head and back if possible. An upright position is ideal if the resident is able.
  2. Place a washcloth or towel across the resident's chest, and place an emesis basin under their chin.
  3. Gently turn the resident's head towards you, if possible. Remove any dentures or partial dentures. Refer to the section on dentures for how to remove and clean the dentures.
  4. Floss the resident’s teeth if possible.
  5. Use a soft-bristled toothbrush to brush all the resident's teeth. If the resident is unable to rinse and spit, use a low-foaming toothpaste, such as Biotene. Refer to the previous section for brushing tips. If the resident has no teeth, use a soft toothbrush, moistened gauze pads, or toothettes to clean the mouth and tongue.
  6. If the resident cannot open their mouth, lubricate their lips with Vaseline, and use one or more tongue blades inserted between the lips to gently pry open the mouth. Clean the side opposite the mouth prop, and then switch to clean the other side.
  7. In some cases, the use of an electric toothbrush may facilitate providing daily care.

If a person is is resistant or combative it is essential not to overlook oral care. Brushing the teeth is not a painful process but having cavities, abscess, or infection can be.  If someone is resistant, assess problems in the oral cavity that may be causing pain.  For someone who is uncooperative, try the following:

  1. Assess the time of day that you are caring for the resident. We all prefer to have our teeth brushed at different times. Some prefer before breakfast, some after, some right after dinner, some right before bed, etc. When someone is dealing with issues such as dementia, changes in routine can be very disruptive. Assessing when, where, along with if they have appointments, they need a nap, they are hungry, etc. can be beneficial.
  2. If you know that you have only 15-30 seconds to brush someone's teeth before they become combative, follow a routine in which you can stop and take up where you left off when you return for the next oral care session.
Example: Mrs. Jones is not wanting to have her teeth brushed. You've determined the best times of day to brush her teeth. Using a foam bite block, wash cloth, or tongue depressors taped together, gently insert into front portion of mouth. Beginning on the top center teeth use a circular motion to clean. Progress to top right, top left. Mrs Jones becomes combative and you cannot continue without undue stress to both of you. Stop. Relax. It is ok to not complete the procedure at each sitting. Make a note as to where you left off and when you return later in the day begin at the spot you stopped. It make take a couple of days to complete the whole mouth. This is ok. The key is to remove the bacteria on a regular basis throughout the whole mouth.

For a resident who is unconscious, tube fed, or on a pureed diet, it is essential they receive daily oral care. Plaque, bacteria, infection and calculus accumulate just as quickly and often faster than someone on a regular diet. When caring for the unconscious, the resident needs to be turned onto her side with a basin or towel placed to catch saliva. When a resident is in hospice it can be very comforting to moisten the mouth and clean the teeth and tongue. This can be done with an ultra soft toothbrush, a moistened washcloth or toothette if there are mouth sores.

Checking for Xerostomia and Oral Cancer

It is important to do a monthly check for xerostomia (dry mouth) and oral cancer. If you notice a person is having a hard time swallowing, changing their eating habits, the mouth is red, the lips stick together, or the lips are dry, have the person assessed for xerostomia. There are many products to alleviate this condition. Also, it is essential to offer water before, during and after meals as well as throughout the day.

A regular check for oral cancer is essential as well. Oral cancer is at the highest rate between the ages of 65 and 75 and can be painless and easy to miss if a person is unable to check their own mouth for changes. Look regularly for any red or white lesions, lumps or ulcerations that do not resolve within 7 to 10 days.  Also note any changes in moles or sores on the face and neck. The ABCD of skin cancer (moles) is:
A - asymetry - both sides should be the same shape
B - border - there should be a smooth border
C - color - the darker the mole the higher the risk
D - diameter - about the size of a pencil eraser or smaller

Denture Care and Cleaning

Daily care of the mouth should not stop with the loss of natural teeth. Cleanliness of dentures and the soft tissues of the mouth have an influence on the comfort and health of the resident. Food, plaque, stains, and calculus collect on dentures the same as on natural teeth. The tongue, gum ridges, inside of cheeks and roof of the mouth should be cleaned at least twice a day. Dentures should be removed at least once per day and thoroughly brushed and cleaned. A variety of denture cleaning brushes and "toothpaste's" for dentures are available. For most residents, it is most convenient to clean dentures or partial dentures at night, before bedtime. After dentures have been cleaned, they should be stored in water in a denture cup.

Dentures must always be stored in water. Dryness causes the dentures to shrink and warp!

The gum tissues under dentures need to be free of contact with the dentures at night. This allows the tissues to recover from the presence of bacteria and constant pressure during denture wear. When dentures are left in all the time, denture sores increase, and damage can be done to the underlying bone and tissue. Some residents will refuse to leave their dentures out at night. If this is the case, an alternative is to leave them out for a time during the day.

Oral Care for Nursing Home Residents Oral Health and the Elderly The need for dental care actually increases with age, chronic illness and handicap. Good oral health is essential for chewing, nutrition, and speech. In addition, oral health plays an important role in self-image and social interaction. These important functions highlight the need for regular oral health services.  Poor oral health in nursing home residents can contribute to systemic diseases such as stroke, heart disease and increased rate of pneumonia, as well as malnutrition, impaired speech, and facial deformity. All these consequences detract from their quality of life.  Oral diseases are more common, more extensive, and more difficult to manage in nursing home residents than in younger population groups.  Teeth become more susceptible to decay because medications used by the elderly reduce the normal flow of saliva. Saliva helps neutralize decay and cleans and lubricates the gums and lining of the mouth. Saliva also contains enzymes and immunoglobulins, which kill the bacteria, which constantly attack the mouth. Without adequate saliva, and good oral hygiene, most oral diseases are accelerated. The problem of a dry mouth is called "xerostomia" and it is very common among nursing home residents.  As a group, elderly nursing home residents have far fewer natural teeth than younger groups. Remaining teeth become more brittle, and old fillings and other dental work begin to fail. Periodontal disease is at its end-stage among the elderly, making loose teeth, bleeding gums, and foul odors common. Oral cancer is most common among the elderly.   Brushing and Flossing When a resident is able to provide their own oral care (which should be encouraged when appropriate) it is essential that they are observed on a regular basis to assess the need for assistance and/or adjuncts. Arthritis, stroke, as well as many other dexterity issues decrease ones ability to provide their own oral care. There are many adjuncts available to allow the elderly to continue to care for themselves with supervision and limited assistance.  The key is to know when help is needed.  How to Assist with Brushing and Flossing Plaque, that sticky material that forms on teeth each day, is responsible for causing both tooth decay and periodontal disease.  Removal of plaque by daily brushing and flossing has tremendous value in preventing oral diseases.  Plaque deposits can harden over time to form a cement-like coating called "calculus". Only a dentist or dental hygienist can safely remove calculus. Calculus should be removed every six months for most people. Some people accumulate calculus more rapidly and may require more frequent cleanings.      	 Brushing All Residents should have their teeth brushed at least twice a day. Each resident must have his/her own-labeled toothbrush. A straight handled, soft, nylon bristled toothbrush will clean the teeth without damaging the gums. The toothbrush should be replaced every two to three months. Toothbrushes can be labeled by writing the resident's name on a piece of surgical tape affixed to the toothbrush handle.  Procedure      Use a pea sized amount of fluoride toothpaste and place the head of the toothbrush alongside the teeth with the bristle tips angled at 45° toward the gum line as illustrated below. Clean the junction between the teeth and gums, as well as the teeth themselves.     Move the brush gently back and forth in short strokes approximately the width of one tooth. Use a gentle circular motion.     To insure that all surfaces of the teeth are brushed, use a set pattern. Brush the outer surfaces first, and then the inner surfaces of the upper and then the lower teeth, as illustrated in the diagram at left. Brush the biting surfaces of the teeth last.     Gently brush the tongue, and also any areas where teeth are missing to remove plaque and freshen breath. If gagging is a problem, place the resident's head forward and down with instructions to breathe rapidly through the nose. This will help control the gag reflex.  The gums may bleed during the first few brushings until the deposits are removed and the inflammation is reduced.  Brushing With Electric Toothbrushes You may find an electric toothbrush easier to use for some residents.      The bristles must be moistened and only a small amount of toothpaste is needed.     Brush a small area at a time. Turn the electric toothbrush on after it is in position in the mouth.     Position the electric toothbrush the same as for manual brushing, at a 45° angle toward the gum line.     Follow a pattern around the mouth to insure that all areas are cleaned.     Rinse the brush and mouth frequently.     The tongue and cheeks can also be cleaned.     Store the brush upright to ensure longevity.     The soft bristled portion of the brush must be replaced every two to three months.  Flossing The use of dental floss is the only way to effectively clean between the teeth. For residents who have many remaining natural teeth and who can cooperate with you, it is a very important preventive service. The proper technique for using dental floss on another person should be demonstrated to you by a dental professional.     	Procedure      Break off about 18 inches of floss and wind most of it around one of your middle fingers. Wind the rest around the same finger on the other hand. This finger can "take up" the floss as it becomes soiled. A dental floss holder, a V-shaped plastic device that holds the floss securely, may be used instead of the fingers.     Use thumbs and forefingers with an inch of floss between them to guide floss between the teeth.     Holding the floss tightly use a gentle sawing motion to insert the floss between the teeth. Never snap the floss into the gums! When the floss reaches the gum line, curve it into a "C" shape against one tooth and gently slide it into the space between the tooth and gum until resistance is felt. While holding the floss tightly against the tooth, move the floss away from the gum by scraping the side of the tooth.     Without removing the floss, curve it around the adjacent tooth and scrape it, too. Scrape floss down on the upper teeth and up on the bottom teeth. Repeat this method on all the teeth using a clean section of floss for each space.  The gums may initially bleed when flossing.   Care of Disabled or Unconscious Residents Residents with mental or physical impairments that prevent them from being able to brush their teeth or clean their dentures really need help from the nursing staff.   	Daily oral hygiene should be part of every residents care. When possible, oral hygiene should be provided following meals. The mouth should be cleaned at least twice per day.  Some residents have difficulty grasping a toothbrush. With some modification, a toothbrush can be made which is easier to hold than a standard toothbrush. Illustrated at left is a toothbrush fitted with a Styrofoam ball to make it easier to grip. Other types of modifications are also possible.  Consult with your facility’s Occupational Therapist for toothbrush modification ideas.   Procedure      Assist the resident into a comfortable position, elevating the head and back if possible. An upright position is ideal if the resident is able.     Place a washcloth or towel across the resident's chest, and place an emesis basin under their chin.     Gently turn the resident's head towards you, if possible. Remove any dentures or partial dentures. Refer to the section on dentures for how to remove and clean the dentures.     Floss the resident’s teeth if possible.     Use a soft-bristled toothbrush to brush all the resident's teeth. If the resident is unable to rinse and spit, use a low-foaming toothpaste, such as Biotene. Refer to the previous section for brushing tips. If the resident has no teeth, use a soft toothbrush, moistened gauze pads, or toothettes to clean the mouth and tongue.     If the resident cannot open their mouth, lubricate their lips with Vaseline, and use one or more tongue blades inserted between the lips to gently pry open the mouth. Clean the side opposite the mouth prop, and then switch to clean the other side.     In some cases, the use of an electric toothbrush may facilitate providing daily care.  If a person is is resistant or combative it is essential not to overlook oral care. Brushing the teeth is not a painful process but having cavities, abscess, or infection can be.  If someone is resistant, assess problems in the oral cavity that may be causing pain.  For someone who is uncooperative, try the following:      Assess the time of day that you are caring for the resident. We all prefer to have our teeth brushed at different times. Some prefer before breakfast, some after, some right after dinner, some right before bed, etc. When someone is dealing with issues such as dementia, changes in routine can be very disruptive. Assessing when, where, along with if they have appointments, they need a nap, they are hungry, etc. can be beneficial.     If you know that you have only 15-30 seconds to brush someone's teeth before they become combative, follow a routine in which you can stop and take up where you left off when you return for the next oral care session.  Example: Mrs. Jones is not wanting to have her teeth brushed. You've determined the best times of day to brush her teeth. Using a foam bite block, wash cloth, or tongue depressors taped together, gently insert into front portion of mouth. Beginning on the top center teeth use a circular motion to clean. Progress to top right, top left. Mrs Jones becomes combative and you cannot continue without undue stress to both of you. Stop. Relax. It is ok to not complete the procedure at each sitting. Make a note as to where you left off and when you return later in the day begin at the spot you stopped. It make take a couple of days to complete the whole mouth. This is ok. The key is to remove the bacteria on a regular basis throughout the whole mouth.  For a resident who is unconscious, tube fed, or on a pureed diet, it is essential they receive daily oral care. Plaque, bacteria, infection and calculus accumulate just as quickly and often faster than someone on a regular diet. When caring for the unconscious, the resident needs to be turned onto her side with a basin or towel placed to catch saliva. When a resident is in hospice it can be very comforting to moisten the mouth and clean the teeth and tongue. This can be done with an ultra soft toothbrush, a moistened washcloth or toothette if there are mouth sores.   Checking for Xerostomia and Oral Cancer It is important to do a monthly check for xerostomia (dry mouth) and oral cancer. If you notice a person is having a hard time swallowing, changing their eating habits, the mouth is red, the lips stick together, or the lips are dry, have the person assessed for xerostomia. There are many products to alleviate this condition. Also, it is essential to offer water before, during and after meals as well as throughout the day.  A regular check for oral cancer is essential as well. Oral cancer is at the highest rate between the ages of 65 and 75 and can be painless and easy to miss if a person is unable to check their own mouth for changes. Look regularly for any red or white lesions, lumps or ulcerations that do not resolve within 7 to 10 days.  Also note any changes in moles or sores on the face and neck. The ABCD of skin cancer (moles) is: A - asymetry - both sides should be the same shape B - border - there should be a smooth border C - color - the darker the mole the higher the risk D - diameter - about the size of a pencil eraser or smaller   Denture Care and CleaningProcedures

  1. Remove dentures before bedtime. See the next section for more information about removing dentures.
  2. Place a clean towel in sink and fill partially with water. This will prevent a denture break if you drop the slippery dentures while cleaning them.
  3. Brush dentures inside and outside using a denture brush and denture cleaner. Carefully clean any denture clasps. See the illustration of a lower partial denture on the right. Rinse thoroughly.
  4. Place dentures in a denture cup and cover with lukewarm water.
  5. Have resident brush remaining teeth (if any), toothless ridges and tongue with a normal toothbrush and toothpaste.



Soaking Dentures and Stain Removal

Commercial soaking cleansers (e.g. tablets) are effective for loosening some deposits. The dentures should not stay in the solution for longer than the cleaning action time or it will harm the dentures.

To remove hard deposits soak the denture overnight in a solution of 1/4 cup of white vinegar and 3/4 cup of lukewarm water. Brush and rinse the denture before replacing it in the resident’s mouth.

A dentist or dental hygienist should remove persistent stain and deposits. Do not use bleach or abrasive cleaning products.

Ultrasonic cleaners are available to assist in cleaning of dentures. Follow the instructions included with the ultrasonic cleaner. Brush and rinse the dentures before replacing them in the resident's mouth.

Points to Remember

  • Food, plaque, stains and calculus (tartar) collects on dentures as well as natural teeth.
  • Sores and infections in the mouth can be caused by unclean dentures.
  • Dentures should be removed and cleaned daily.
  • The gums, ridges, and tongue should be cleaned daily.
  • Sores and infections persisting more than seven to ten days should be brought to the attention of a dentist.
  • Dentures should be removed every night to allow the lining of the mouth to rest.
  • Dentures should always be stored in water to prevent drying and warping when not in the mouth.
  • Dentures should be labeled to prevent loss.
  • Cleanliness of dentures and of the gums, ridges, and tongue has an influence on the comfort and health of the resident.

Removing and Replacing Dentures

Please handle with great care during removal and cleaning.
Dentures are often very important to residents

  1. If possible, have the resident remove their own denture.
  2. To remove dentures, gently apply downward pressure on one side of the upper denture. This will release the suction of the upper denture.
  3. Rotate the denture to one side and then to the other side while removing them from the mouth. To remove the lower denture use the same technique as for the upper denture but use an upward pressure.
  4. Replace the lower denture in the mouth before the upper denture.
  5. Make sure the resident doesn’t open too wide when inserting the denture. This actually tightens the mouth opening. Place one side of the denture into the mouth, then rotate it into position.

Denture Adhesives

Sometimes residents need to use a denture adhesive to give their dentures added stability. Lower dentures may require some adhesive because of bone loss in the gums. We generally recommend cream denture adhesives. Follow package directions for best results.

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