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Oral hygiene in long-term care: Before, during, and after the pandemic

Dr. Brooke Fukuoka talks about a few systems that make providing oral health-care needs for the dependent population much more effective.

Oral health in long-term care has been a long-standing challenge for dental professionals. As I explore this space, I have found that caregivers are sometimes unfairly blamed for the poor oral conditions that are seen in dependent populations. There have been multiple great caregiver training and collaborative programs that have ultimately failed due to lack of funding and/or caregiver turnover. In light of these programs falling short of solving the problem, what if we shift our thinking? What if we stop relying on caregivers and take it upon ourselves to ensure that oral hygiene services are being provided? As leaders in oral health, we need to drive these programs down a more sustainable path that will lead to better oral health for dependent populations. Instead of reinventing the wheel, perhaps we need a new driver.

It is this type of thinking that led us to develop various methods that place the dental professional in the driver’s seat. In this article we will discuss: our assisted and guided oral hygiene programs, what we use for these programs, and a documentation system designed specifically to provide oral hygiene assistance for dependent and semidependent populations.

Assisted oral hygiene
In collaboration with a work group consisting of members from Your Special Smiles PLLC (Jingjing Qian, RDH-EA, and myself), a consultant (Paul Glassman, DDS, MA, MBA), faculty from Idaho State University Dental Hygiene Sciences (Rachelle Williams, MS, RDH-EA, and Ellen Rogo, PhD, RDH), and the leadership of the Idaho Oral Health Program (Kelli Broyles, RDH-EA, and Matt Zaborowski, MPH, CPH), we have defined assisted oral hygiene as:

Physical assistance with oral hygiene procedures for individuals who are unable to adequately perform their recommended self-care oral hygiene regimen. Assisted oral hygiene is a specific service and may be delivered separately or as part of a remote oral health support program.

It is important to note that these definitions are working definitions that we have developed to facilitate communication and disseminate information. They have not been made official by dental authorities outside our work group.

Proper oral hygiene is not always a simple task. Think about trying to get a large man who has violent outbursts to brush his teeth when he does not want to. What about a 97-year-old woman who has dementia, cannot drink thin liquids, and does not like people touching her face? The idea that oral hygiene is simple, and that it “only takes two minutes,” assumes complete cooperation, no conversation, and no infection control protocols. We have found a more realistic estimate of the time to provide adequate oral hygiene for a dependent or semidependent adult to be 15–20 minutes per individual.

If this responsibility is placed on a caregiver, that person would spend up to 10 hours per day providing oral hygiene for a 30-resident facility. See how this may be an unrealistic expectation based on time alone?

In our assisted oral hygiene program, we provide dental team members who can focus their time and energy exclusively on oral hygiene for participating residents. Various structures can be created to carry out such a program. The following describes how our program is structured and each team member’s responsibilities.

Dentist responsibilities: The dentist reviews the resident’s medical history and determines if any modifications are needed in the provision of oral hygiene. Medical or behavioral consultations may be necessary. Live interaction with residents may be needed. The dentist gives the hygienist this information in order to develop a safe and effective hygiene plan. The dentist periodically monitors the program using teledentistry or in-person interactions.

Hygienist responsibilities: The hygienist uses information from the dentist along with photos, videos, and live interactions to determine the products needed. A formal hygiene plan is then written for each resident. The hygienist trains the assistant to carry out the hygiene plan. The hygienist monitors the program using teledentistry or in-person interactions.

Oral hygiene assistant responsibilities: The oral hygiene assistant learns the specific hygiene plan for each resident from the hygienist and carries out that plan under the direct visual supervision of the dentist or hygienist. The dentist or hygienist determines when the assistant is capable of independently providing these services for each resident. It is important to note that some residents may present unique challenges that require a longer period of supervision. After the oral hygiene assistant is working more independently, the dentist or hygienist continues to check in periodically through in-person interaction or teledentistry.

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