Long-Term Care Survey Alert

Published on Sun Aug 24, 2008 PDF

Find out why and how to target this important area of care and growing survey focus.

Taking simple steps to promote optimal oral and dental health can do more than you might think to improve resident outcomes, not to mention your facility's opportunity to achieve an F-tag free survey check-up.

Revised survey guidance for nutrition (F325) that goes into effect Sept. 1 specifically includes assessment of problems that affect chewing and oral intake, such as gingivitis, oral pain, dry mouth and loose or missing teeth (see "Survey & Clinical News" on p. 72).

Also, the new Quality Indicator Survey or QIS, which is operational in a number of states, includes oral health as an area of focus. The "QIS has structured preliminary investigative questions" and observations of residents' oral and dental health, says Cindy Mason, LCSW, NHA, LHRM, vice president of education for Nursing Home Quality in Centennial, CO, which provides QIS training. And nursing facilities participating in the QIS demonstration racked up significantly more F tags for dental services compared to facilities receiving traditional surveys, according to Andrew Kramer, president of Nursing Home Quality, in a presentation at the 2008 American Health Lawyers' Long-Term Care and the Law conference.

In the quality-of-life realm, simply having a clean mouth can help someone feel a lot better, says Steven Littlehale, MS, APRN, BC, chief clinical officer, PointRight Inc. in Lexington (formerly LTCQ Inc.). And preventing or alleviating common oral-health problems can help head off everything from systemic infection to advanced oral cancer. Dental problems have also been associated with cardiac disease, stroke and diabetes, according to the Ohio Dental Association.

Experts suggest how you can put together an effective oral health care program for residents that includes frontline caregivers and residents themselves.

• Provide residents with soft toothbrushes replaced at designated intervals. How often should the toothbrush be replaced? Every two weeks, says R. Thomas Glass, DDS, PhD, who has done research on this topic. His study showed that a toothbrush becomes heavily contaminated with microorganisms over that period of time. And the bristles also become sharp and jagged and can cause small breaks in the mouth that allow the bugs to enter the bloodstream, says Glass, professor of forensic sciences, pathology, and dental medicine and adjunct professor of microbiology at Oklahoma State University Center for Health Sciences in Tulsa.

Prevent relapses: Also replace the resident's toothbrush when he becomes ill, when he first feels better -- and when he is well, Glass adds. Otherwise the person could reinfect himself, he cautions.

If providing all of those toothbrushes sounds expensive, consider this, he urges: "You can buy toothbrushes in bulk," so we're "talking about pennies on the dollar," a real bargain compared to the cost of antibiotics.

What about motorized toothbrushes? Forget it, he says. "We have a study showing those heads become absolutely contaminated with very little use." And the motorized action traumatizes the oral cavity.

Don't overlook denture cleaning: Several large studies show that dentures become contaminated with microorganisms quickly, Glass notes. Glass thus advises soaking residents' dentures overnight in an anti-bacterial denture cleanser, such as Polident.

• Assess for and address dry mouth. The signs of dry mouth include cracked lips and/or sores, mouth infection, difficulty chewing, swallowing and talking, and a burning mouth, according to the Ohio Dental Association's Smiles for Seniors program. When the mouth is dry, which is usually caused by polypharmacy, it is more likely to develop abrasions that allow organisms "easy entry," Glass says.

"Not only does saliva lubricate [the mouth]," he adds, but it also contains immunoglobulin that inhibits microorganism growth.

Check the meds: "Over 400 meds cause dry mouth," cautioned dentist Ronald Reber in a presentation on oral health at the 2008 American Medical Directors Association annual meeting (for a comprehensive list of common meds to watch out for, go to http://www.oda.org/upload/Laclede-Biotene%20Drug-Chart.pdf). Some of the culprits include antihistamines and antipsychotics among others.

Proactive strategies: Consult with the physician to see if drying medications are necessary. Or check with the clinician to see if the dosing can be changed to ease when the resident experiences the drying effect, advised Reber. Also suggest the person drink plenty of fluids and avoid using alcohol-based mouthwash, which dries the mouth.

• Regularly check the resident's mouth for problems. The nurse should use a strong flashlight to visualize the inside of the resident's mouth. Carefully look at the most common sites for cancer: the sides of the tongue and the floor of the mouth, Glass advises. Wearing gloves, the nurse should use a four-by-four gauze to grasp the tongue, pull it out and turn it to the left and right to inspect. Such assessments are especially important for tobacco users.

Also check for salivary gland cancers, which are more common in the elderly patient with a dry mouth, he advises. To do a thorough assessment, put your gloved finger in the floor of the mouth to check for any bumps and lumps.

Eye-opening example: To see what can happen when healthcare providers don't inspect a person's mouth, see the picture of an elderly patient with an oral advanced squamous cell carcinoma posted at www.doctorspiller.com/squamouscell.htm. The 86-year-old woman had received cataract surgery two months previously, according to the website.

• Provide simple adaptive devices to help residents hold onto a toothbrush and do their own oral care as much as possible. You can educate residents/families to use these if the resident has trouble holding onto the toothbrush due to weakness from a stroke or arthritis, as examples, suggests Kathy L. Woodard, director of public service for the Ohio Dental Association.

Examples: You can make an assistive device by cutting a slit in a regular tennis ball and sliding the toothbrush handle in it or carefully wrapping aluminum foil around the toothbrush handle to make it bulkier, according to the Ohio Dental Association's Smiles for Seniors.

More ideas: Gum flossers are available that allow the patient to hold a plastic handle with a small piece of floss suspended in between. "It's easier to grip and the handles are angled for ergonomic advantage," says Elisa Bovee, an occupational therapist and consultant with Harmony Healthcare International in Topsfield, MA.

"Oftentimes the resident's use of these simple devices becomes a supervised task but maintains the resident's independence."

Also, OT or restorative nursing can work with residents to improve their oral health, which is extremely important for optimal nutrition and to avoid gum disease and related pain, says Bovee.