"One of the more dramatic discoveries in biomedical science in the 20th century has been the realization that tooth loss is not an inevitable consequence of aging, but the result of disease or injury," reported David Satcher, MD, PhD, U.S. Surgeon General, in "Oral Health in America: A Report of the Surgeon General."1
"The elderly carry a heavy burden of oral disease," Satcher alerted the public and healthcare professionals.
A few key statistics cited in the report were:
- 30 percent of older Americans lose their teeth, compared to 46 percent 20 years ago.
- 23 percent of older Americans have severe periodontal disease, which can lead to systemic diseases, such as diabetes mellitus, cardiac disease, stroke and respiratory diseases, specifically pneumonia.
- One-third of older Americans have untreated dental caries; while 50 percent over 75 years old have root caries.
- 30,000 oral and pharyngeal cancers are diagnosed in the U.S. annually, mostly in the elderly, and 8,000 individuals die.
- Oral diseases are most prevalent with a decline in general health, cognitive function and physical function.
- Being disabled, homebound or institutionalized increases the risk of poor oral health.
In 2008, the Alliance for Aging Research, Washington, DC, a national nonprofit citizen advocacy group, published another report, "Senior's Oral Health Care: Nothing to Smile About."2
The main thrust of the report was that charges for preventive and restorative dental care for those over age 65 are not covered by Medicare. For many seniors these costs are out-of-pocket expenses, making oral care an unaffordable luxury, according to the report.
Lack of preventive dental care increases the risk for severe, systemic diseases.
For example, 50 percent over age 75 have untreated caries that cause pain, dental abscesses and infection that can lead to bacteremia and septicemia, potentially a life-threatening event.
"Poor oral health puts seniors at a significant risk of experiencing severe health events," said Barbara J. Smith, MPH, PhD, manager, Geriatric & Special Needs Populations, at the American Dental Association.3
Smith points to the case of a nursing home resident who needed a tooth extraction but could not afford the $100 fee. When the tooth was not removed, he became septic from a dental infection and went into cardiac arrest. Following surgery, he was treated in the ICU for 3 days and had 15 days total in hospital, for an estimated $45,000.
"Clearly the lack of dental care for the vulnerable elderly can have catastrophic health and financial consequences," Smith noted.
In 2005, Patricia Coleman, PhD, APRN, BC, writing in Nursing Outlook, emphasized the need for nurses to gain more education and practice in oral care in the elderly.3
"While the nursing profession generally recognizes the importance of oral health in older populations, it has not played a prominent role in oral health promotion and disease prevention for this vulnerable segment of the population, nor has there been a tradition of collaboration with oral health professionals (e.g. dentists, dental hygienists)," wrote Coleman, at the time the John Hartford Foundation Building Academic Geriatric Nursing Capacity Scholar.
Coleman cited evidence that nursing school curricula included less than 1 credit hour on geriatric oral health. She added geriatric nurses express negative perceptions of oral health, such as disgust, fear, harm, unpleasant, burdensome and trivial.
Further, the researcher charged, it is hardly surprising that with gaps in oral health education that geriatric practice does not meet federal standards for oral healthcare. American Society for Geriatric Dentistry guidelines for long-term care facilities include oral hygiene and assessment.
In 2005, when Coleman completed her research, she concluded the standards were not completely met. Also, she noted recent studies documented RNs practicing in Medicare and Medicaid-funded LTC facilities failed to complete the required Minimum Data Set subsets related to assessment of oral care and planning interventions for identified problems.
Practices in ICUs
A 2004 study, "Survey of Oral Care Practices in U.S. Intensive Care Units," published in the American Journal of Infection Control, supported Coleman's claim that oral healthcare provided to medically compensated patients is not current nor evidence-based.4
In this randomly-selected survey of 506 respondents (97 percent of the nurses were RNs) in 102 ICUs in the U.S., 92 percent reported oral care was a high priority.
The primary methods of oral care delivered by nurses in the study were foam swabs, moisturizers and mouthwash. Eighty percent of the respondents rarely used toothbrushes and toothpaste for their patients.
Evidence-based practice (EBP) shows when toothbrushes are used there is better removal of dental plaque, which decreases nosocomial respiratory infections in ICU patients, specifically pneumonia.
The majority of the nurses reported they were interested in learning more about oral health EBP.
Interdisciplinary & Evidence-Based
In 2005, when Coleman discussed the lack of oral health best practices in nursing, the first strategy she recommended was for schools of nursing to seek funding from identified government and private donors to develop interdisciplinary training and/or research projects between nursing, dental professionals and primary care providers.
Coleman hypothesized these partnerships would spawn innovative strategies, and best practices in oral health practices would become more comprehensive. She envisioned more models of care for underserved elderly in the community and nursing homes, which would become reality. Today, an increasing number of these partnerships have increased the capacity for better oral healthcare in this population.
In 2005, Coleman suggested the lack of evidence-based nursing practice in oral healthcare for geriatric patients could be overcome through collaboration with dental health professionals and research by nurses and a body of best practices has emerged.
Probably the most comprehensive of these is the Hartford Center of Geriatric Nursing Excellence Nursing Standard of Practice Protocol: Providing Oral Health Care to Older Adults. Updated in 2012, the best practices presented range from patient assessment, to nursing care strategies and evaluation of expected outcomes for care delivered by nurses and the LTC facilities.
LIFE at Penn
Since 1998, the University of Pennsylvania School of Nursing has managed an all-inclusive, multidisciplinary care program to help eligible, frail elderly residents of West Philadelphia remain in their community. Living Independently For Elders (LIFE) is part of the 30-year-old national Program of All-Inclusive Care for the Elderly (PACE).
However, the Penn LIFE program is the first and only one to be owned by a school of nursing. LIFE members receive care at no cost if they have Medicare/Medicaid. Pennsylvania's Department of Public Welfare also contributes to the funding. While some members pay on a sliding scale.
Prior to 2007, LIFE used a mobile dental company to provide dental services for its members. When the program moved to a much larger office, the School of Nursing and Penn Dental Medicine started a collaborative clinical program, according to Joan Gluch, PhD, director, community health, and adjunct associate professor, Penn School of Dental Medicine.
"I was introduced to the LIFE program and the nursing faculty many years ago through mutual involvement in an outreach program in which medical, nursing, dental and social work students worked in teams to provide health promotion activities at community sites," said Gluch.
Today, the LIFE dental program serves 450 patients. Usually two or three, third- or fourth-year dental students practice hands-on dentistry with patients, while both undergraduate and graduate nursing students rotate through the service.
"Nursing students are learning increased skills in oral assessment and dental students are learning about geriatric dental care - and both are learning to work across disciplines," noted Eileen Sullivan Marx, PhD, CRNP, FAAN, RN, former associate professor, health community practices, and associate dean, practice and community affairs, at the Penn School of Nursing.
"The collaboration at LIFE between Penn Dental Medicine and the School of Nursing benefits all of the parties involved," Gluch summarized. "Along with elderly patients who receive care in a convenient location, there is a great educational benefit for both dental and nursing students."
References for this article can be accessed here.
Kay Bensing is a frequent contributor to ADVANCE.