Federal and state guidelines require that caregivers provide the best possible care and quality of life for all elderly clients. Many different elements combine together to enhance the well-being and health of those who are dependent on others for care.
 

IMPORTANT FOR HEALTH
Good oral care is one of those elements because it can have an effect on nutrition, hydration, skin, breath, infection, sanitation and
individual dignity, as well as social interaction. Oral care is not always easy. Illness and behavior may interfere with attempts to brush teeth or provide mouthwash. And these factors often cause caregivers to seriously ignore oral care in their clients, according
to reports.
 

BRUSH EVERY DAY
If the client you care for is unable to brush or needs assistance, here are some helpful suggestions:

• Wash your hands and put on disposable gloves. Sit or stand where you can see all the surfaces of the teeth.

• Use a regular or power toothbrush with soft bristles and a small head.

• Angle the brush at the gumline and brush gently.

• Use a pea-sized amount of toothpaste with fluoride, or none at all. Toothpaste can bother people who have swallowing problems. If this is the case for the person you care for, brush with water instead.

• Brush back and forth and side to side for 2 minutes.

• Brush the front, back and top of each tooth. Gently brush back and forth in short strokes.

• Gently brush the tongue after you brush the teeth.

• Help the person rinse with plain water.

• Use mouthwash in the same manner as mouthwash helps remove plaque and freshen breath.

• Give clients who can’t rinse a drink of water or consider sweeping the mouth with a finger wrapped in gauze.

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Note: Get a new toothbrush with soft bristles every three months, after a contagious illness or when the bristles are worn.
 

FLOSS EVERY DAY
Flossing cleans between the teeth where a toothbrush can’t reach, and is an important step in disease prevention in the mouth.
Some researchers believe there’s a link between regular flossing and a reduction in heart disease. Your client may need a caregiver to help them floss and that takes practice. Remember, waxed, unwaxed, flavored or plain floss all do the same thing. The client might like one more than another, or a certain type might be easier to use. Here are some flossing tips:

• Use a string of floss 18 inches long. Wrap around the middle finger of each hand.

• Grip the floss between the thumb and index finger of each hand.

• Start with the lower front teeth, then floss the upper front teeth. Next, work your way around to all the other teeth.

• Work the floss gently between the teeth until it reaches the gumline.

• Curve floss around each tooth and slip it under the gum. Slide the floss up and down. Do this for both sides of every tooth, one side at a time.

• Adjust the floss a little as you move from tooth to tooth so the floss is clean for each one.

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Note: If you have trouble flossing, try using a floss holder instead of holding the floss with your fingers. The dentist may prescribe a special rinse for the client. Fluoride rinses can help prevent cavities.

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AIDES DID POOR JOB

In a study done of five nursing homes in New York, aides were missing nearly everything involved in acceptable oral care for their residents. Some of the specific findings in this study included standards that ranged from a high of only 16 percent, to a low of 0 percent. In fact, “standards never met were brushing teeth at least two minutes, flossing, oral assessment, rinsing with mouthwash, and wearing clean gloves during oral care,” said researchers. Results of this study included:

• Length of toothbrushing averaged 5-16 seconds (two minutes is recommended).

• Mouthwash was never provided.

• In several instances, researchers noted that toothbrushing was done immediately after the aide had handled soiled incontinence products or washed the perineal area and they did not change gloves before beginning toothbrushing.

• In one instance, in fact, there was visible fecal material on an aide's gloves while cleaning the teeth of a resident.

• In no instance did the aide ask the resident if they had any mouth problems or concerns.

• Residents were often inappropriately positioned.

• No aide used praise/encouragement; complementary, supportive conversation; physical prompts or gestures to facilitate care.

• No aide ever smiled at their residents.

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The fact is, this type of caregiving situation is simply not acceptable by any standard of thoughtful, compassionate care. And – what’s it’s even more bizarre – the aides were being observed while they gave this care so they evidently thought that it was normal and okay.

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Not only is this type of care in direct violation of CMS guidelines for providing dignity and a good quality-of-life to the elderly, but it also can be dangerous. The reason: Uncorrected dental problems can cause serious health conditions, including heart problems. This is because researchers believe that, when oral problems exist, the bacteria in the mouth can enter the bloodstream and cause very serious, health problems. This is in addition to the oral problems themselves that can worsen with poor care and include serious mouth infections and tooth loss.

SURGEON GENERAL REPORT

The U.S. Surgeon General strongly recommends regular dental care in order to maintain good overall health. In a recent report, the Surgeon General’s office said that almost half of U.S. adults ages 35 to 44 have gingivitis, a reversible mouth inflammation disease, and about one-fourth have the more severe condition of periodontitis.

According to the report, severe periodontal disease affects 14 percent of adults ages 45 to 54, and 23 percent of those who are

65 to 74 year old. The fact is, many people have oral problems that, if left untreated, can eventually develop into serious health problems.

BE OBSERVANT

While providing oral care and using compassionate communication with your clients, all caregivers should be on the lookout for diseases and conditions that need treatment. You can find some of these things out by initiating friendly conversation with your clients and by using your own observations as you conduct their regular oral hygiene. The National Institutes of Health (NIH) recommends watching for the following:

• red, sore, swollen gums

• bleeding gums

• gums pulling away from teeth

• loose or sensitive teeth

• bad breath

• a bite that feels different

• dentures that do not fit well, or cause soreness or pain

DRY MOUTH

Caregivers should also be aware that certain medications including antidepressants, antihistamines and diuretics may cause a

condition known as “dry mouth,” which can lead to a significant increase in tooth decay and gum problems such as bleeding and inflammation due to a reduced production of saliva. Since the elderly are often taking many medications, this is a common problem.

 

The client's pharmacist or physician can give you information on which medications might be causing problems in the client’s mouth. Any indications of dry mouth should be reported to proper medical personnel because it is potentially a serious condition.

DIABETES

Note that special attentiveness to oral care should be given to your clients with diabetes. People with diabetes have an increased risk of getting oral diseases, so you need to be especially watchful to avoid serious complications of their disease.

 

SPECIAL CONSIDERATIONS FOR THOSE WITH DEMENTIA

Coping with routine dental tasks can be a real challenge for those with dementia, so you’ll need plenty of understanding and patience! Familiar daily activities such as tooth brushing and mouth rinsing become increasingly difficult, either because the client has lost the capacity for performing such activities or because they have forgotten how to do them.
 

Those with dementia may no longer understand what the toothbrush and toothpaste are for, or may be confused because they cannot remember the particular sequence of actions that are needed to clean their own teeth. The following are some quick tips for successful oral care for those who have dementia:

• Slow down. Be patient. Don’t rush.

• Explain what you’re going to do, and show them ahead of time.

• Don’t force them to do things that they may be afraid of, such as flossing or using an electric toothbrush.

• Let them help as much as possible.

• Give additional help with things like large-handled toothbrushes, if necessary.

• Above all, be friendly, understanding and compassionate at all times.

WATCH FOR CHANGES

Spotting dental problems in your clients before they become serious can sometimes be a challenge especially in those with advanced stages of dementia. Often, clients can be reluctant to report problems of pain or discomfort, either because they are afraid of the consequences, or they do not want to be a bother. So, you need to be vigilant when looking for potential oral problems. Things to watch for include:

• Difficulties with eating

• Increased agitation

• Sleep problems

• Refusal to wear dentures

• Signs of pain, such as groaning or grimacing, when chewing