Optimal Health for Frail Older Adults: Best Practices Along the

Optimal Health for Frail Older Adults:

Best Practices Along the Continuum of Care

A resource produced by the

Committee on Clinical and Scientific Affairs

Ottawa, ON

July 2009

Table of Contents

Acknowledgements Page 4

Introduction Page 5

Best Practices for Aging Adults in Private Dental Practice Page 6

The Aging Population Page 6

The Importance of Prevention Page 6

Rational Dental Care for the Elderly Page 7

Medical Issues Page 8

Palliative Dental Care Page 10

Educational Resources Page 11

References Page 11

Best Practices for Dental Care for the Homebound Page 13

Best Practices for Oral Care in Long-Term Care (LTC) Facilities Page 13

Organizational Support Page 13

Multidisciplinary Approach Page 13

Facility Policy for Oral Care Page 13

Assessment Page 14

Oral History on Admission Page 14

Regular Oral Assessment Page 14

Oral Care Plan Page 14

Education of Staff Page 15

Resources Page 15

Appendix A: Community Form Patient Information Record Page 17

Appendix B: Hospital Facility Patient Information Record Page 18

Appendix C: Oral Care Gap Analysis Page 19

Appendix D: Sample LTC Oral Care Policy Page 22

Appendix E: Sample Oral Hygiene History Page 26

Acknowledgements

The CDA’s Committee on Clinical and Scientific Affairs acknowledges the resources and

information available on the public websites of the following organizations:

American Dental Association www.ada.org

British Society for Disability and Oral Health www.bsdh.org.uk

Halton Region Health Department – Dental Health (Ontario) www.halton.ca

Regional Geriatric Program central (Ontario) www.rgpc.ca

Registered Nurses’ Association of Ontario www.rnao.org

University of British Columbia ELDERS Group www.elders.dentistry.ubc.ca

University of Manitoba’s Centre for Community Oral Health www.umanitoba.ca/dentistry/ccoh

Optimal Oral Health for Frail Older Adults:

Best Practices Along the Continuum of Care

INTRODUCTION

The Canadian Dental Association recognizes that oral health is directly linked to general health.

Older adults with complex health conditions are at greater risk for oral diseases, which can have a

profound impact on chewing, swallowing and nutrition; increase susceptibility to systemic

infectious diseases, especially pneumonia; cause pain; and affect quality of life issues such as self-

image, communication and social interaction. As elderly persons become more frail and dependent,

with increasing medical comorbidities, multiple medications, physical and/or cognitive

impairments, and require greater dependence on caregiver support, the risk for oral diseases

increases and the negative effect on general health and well-being accelerates.

Best dental and oral care practices for seniors are needed along the continuum of care, as more

seniors and government health agencies embrace an “aging at home” strategy. For aging patients in

private dental practice, a common sense or rational approach to oral health care may facilitate their

oral care and provide for better oral health in later stages of life, when they are partially or fully

dependent on others for daily personal care. Patients who are homebound and cannot attend the

dental office may have an increased need for care, yet do not have the level of assistance provided

in the long-term care setting. As for seniors residing in long-term care facilities, they are a diverse

group that requires initial and ongoing assessment as well as individual care plans based on

accepted best care practices. End-of-life or palliative oral care best practices may apply to patients

in any of these three settings.

The philosophy of rational provision of oral health services for the elderly extends across the

continuum of care, with care plans modified based on the unique circumstances of an individual

patient. Some of the resources provided in the section on long-term care may be equally useful in

private practice and home settings. For all patients, but especially elderly patients, an

interprofessional approach to care is important, with sharing of information and expertise among

dental providers, physicians, nurses, pharmacists, dieticians, social workers and others.

Access to care is an essential component of ensuring optimal oral health for frail older adults.

Canadians of all ages value fair and equal access to health care as a basic right. The Canadian

Dental Association supports this right. This resource was created to help ensure that the elderly

continue to have access to care, regardless of their health and living conditions. Inadequate oral

health care can have far-reaching consequences. It is important that oral care be viewed within the

broader context of health care, and that all care providers work together to promote and ensure the

general health and well-being of our aging population.

BEST PRACTICES FOR AGING ADULTS IN PRIVATE DENTAL PRACTICE

1. The Aging Population

• The population aged 65 years or older is significant (13%) and increasing. This group of

aging adults is a diverse and heterogeneous population with varying dental needs, medical

conditions and behavioural characteristics. Approximately 95% of people over the age of 65

live in the community. Of these, 5% are homebound and 17% have mobility limitations.

Over 70% can therefore still travel to a dentist. (Ettinger 2006)

• The majority of older adults are relatively healthy and mobile. These “independent older

adults” have treatment requirements no different from other adult patients. However, when

treating this population, the dentist should be cognizant of approaching older age, the

development of associated health issues (e.g., medical problems, use of more medications,

reduced dexterity, social issues) and increasing oral disease as older patients become more

frail, more dependent and more cognitively impaired. (Chalmers 2006a) Many frail older

adults still attend private dental practices but may require special transport and/or be

accompanied by a caregiver.

• Currently, no definitive, published, evidence-based clinical guidelines are available for this

aspect of dental practice. However, many useful articles and special reviews on the medical

and dental problems facing this population of patients provide advice on appropriate care

management.

2. The Importance of Prevention

• Changing and increasing caries patterns in aging dentate patients have created more

challenges for clinicians. Development of rampant caries is possible even while patients are

still living in the community. (Chalmers 2006a) As people live longer and retain more teeth

that are often already heavily restored, they will require significantly more complex

treatment.

• While the older dentate patient is still relatively healthy, considerable emphasis should be

placed on caries prevention education. This should be designed to ensure sound preventive

habits are established before problems develop and should include information on oral

disease, the importance of an appropriate diet (minimal consumption of fermentable dietary

sugars and carbohydrates, particularly between meals), patient-specific oral hygiene

methods and techniques, and the prescription of additional patient-specific measures to

increase tooth resistance (e.g., in-office fluoride varnish, home fluoride rinses or

chlorhexidine). A good preventive regime for the relatively independent older adult with

increasing caries risk involves 3 weeks use of 0.2% fluoride rinse nightly, alternating with 1

week of 0.12% chlorhexidine used twice daily. (Featherstone et al. 2003) In-office caries

prevention could also include the regular use of direct application of fluoride varnish on

teeth at risk. Sugar substitutes, particularly the use of xylitol (non-acidogenic) chewing gum,

can be effective.

• As elderly patients grow more frail, managing their oral care becomes more complex and

challenging, and treatment possibilities will depend on a number of modifying factors.

(Lindquist and Ettinger 2003)

3. Rational Dental Care for the Elderly

• The four key areas of dental need to be considered when treating frail elderly are function,

symptoms, pathology and esthetics. (Berkey et al. 1996) These areas will require pragmatic

modification based on fundamental issues such as illness and degree of functional and

cognitive impairment.

• The concept of “rational care” for medically compromised elderly patients, which can be

more appropriate than “technically idealized care”, was introduced in 1984. (Ettinger

1984) A key issue in rational dental care is the understanding of what is an acceptable oral

status for a particular patient, as opposed to a subjective estimate of need based on the

dentist’s own experience.

• “Oral impairment and disability are inevitable features of old age, but they do not

necessarily have a negative impact on one’s quality of life.” (MacEntee 2007)

• Rational dental care involves “individualized care with all modifying factors evaluated and

considered” (Ettinger 2006). Factors include the patient’s ability to tolerate the stress of

treatment, the possibility of reasonable and less extensive treatment alternatives, how the

patient’s dental problems affect his or her quality of life, as well as the patient’s ability to

maintain oral health independently. The idea that “nothing less than idealized dentistry is

secondhand, compromised care offered by bad dentists” has been strongly refuted.

• Treatment for the “biologically compromised” older dental patient should ideally take place

in shorter appointments in a comfortable, supportive and positive environment with capable

practitioners. Treatment plans may need to evolve over time as treatment progresses and the

patient’s situation changes. (Lindquist and Ettinger 2003)

• Caries in frail older patients or patients with early dementia may often need to be managed

by conventional hand instruments and a slow-speed handpiece. For anterior esthetic

restorations where moisture control is possible, a composite resin, glass ionomer or glass

ionomer/composite sandwich technique is appropriate. Where moisture control is less than

optimal, the material of choice will be glass ionomer — or even a temporary zinc oxide and

eugenol material. For posterior restorations where moisture control is less than optimal, the

material of choice will be amalgam or glass ionomer, especially for subgingival locations.

(Chalmers 2006b) Long-term temporary restorations using hard-setting zinc oxide and

eugenol can also be extremely useful in difficult management situations. Fractured teeth can

be maintained simply by smoothing any sharp edges to ensure patient comfort.

• For deep caries there is increasing evidence that the deepest layers of carious dentin in a

vital tooth may not require removal, or may be treated successfully through two-stage

(stepwise) restorative management. (Van Thompson et al. 2008) Although management of a

deep carious lesion would normally involve two-stage treatment using a temporary

restorative material, an expedient, safe and pragmatic technique for the biologically

compromised older patient is to place a permanent restorative material at the first visit,

leaving deeper caries in appropriate situations (Chalmers 2006b) Avoiding exposure of the

carious pulp will reduce the need for more invasive treatment such as endodontic therapy or

extraction.

• The rate of total edentulism has steadily decreased over the past 50 years due to a

combination of improved access to dental care, diet and prevention. However, the rate of

partial edentulism has increased, especially in the elderly. The demand for dental prostheses

to replace missing teeth is significant. For healthy older adults, fixed or removable partial

dentures or implant-supported crowns may be considered. For patients missing a limited

number of posterior teeth, especially a single posterior unit, the best option is often no

treatment. A shortened dental arch limited to a combination of two opposing bicuspids

and/or molars per side provides adequate function at any age. When considering tooth

replacement for frail older adults, the least intrusive and most cost-effective means should

be considered. A well-designed and constructed acrylic removable partial denture is often

the best solution. This prosthesis will require relining over time to compensate for residual

ridge resorption, but has the advantage of easy conversion to a complete denture if the

remaining teeth are lost. All dental prostheses require reassessment and maintenance over

time; the removable partial denture in particular tends to collect plaque on surfaces in

contact with teeth, making these teeth more susceptible to caries and gingivitis.

4. Medical Issues

Systemic diseases are more common in older adults, even among those who are functionally

independent. Dental professionals need to be aware of the medical status of older patients, the

medications they are taking and the possible effects of these drugs on treatment. Before the first

appointment, and every recall appointment thereafter, it is advisable to ask older patients or their

caregiver to bring a printed list of medications and dosages. A standardized referral form or

patient information form received before the first visit to the dental office may be helpful. Two

examples of patient information forms are available for use in Appendices A and B. These

documents can also be found in Word and PDF format on the CDA website at http://www.cda-

adc.ca/en/dental_profession/practising/best_practices_seniors/default.asp. The first appointment for an

elderly patient should be of sufficient length to allow for an unhurried medical history and oral

examination.

• Older people tend to be more sensitive to drugs and to invasive dental treatments. Dentists

should use local anesthesia whenever possible as the risks of general anesthesia are greater

in older patients than in younger patients. Local anesthetic used with recommended dosages

of epinephrine has no significant effect on cardiac arrhythmias in functionally independent

older patients. (Scully and Ettinger 2007)

• The 10 most common systemic diseases found in the aging population that influence oral

health care have been described by Scully and Ettinger (2007):

o Arthritis (reduced dexterity for oral hygiene, joint discomfort in the dental chair,

tendency to bleed, possible need for corticosteroid supplementation and antibiotic

coverage for joint prostheses).

o Head and neck cancer (need for oral health before cancer therapy, reduced salivary

flow after radiotherapy, management of oral ulceration, mucositis and candidiasis).

o Chronic obstructive pulmonary disease (management depends on extent of

dyspnea, medications include bronchodilators and/or corticosteroids, patient best

treated upright).

o Diabetes (risk of hypoglycemia is main concern during dental treatment, well-

controlled diabetics tolerate procedures well, poorly controlled will require referral

for invasive procedures; diabetics may be immunocompromised, more susceptible to

infections and may require more aggressive infection management).

o Ischemic heart disease (training in CPR and emergency procedures necessary, level

of stability of disease important, stress-reduction protocols, limiting of epinephrine,

knowledge of INR).

o Hypertension (control before treatment, avoidance of anxiety and pain).

o Mental health, cognitive impairment, Alzheimer disease (behavioural problems,

adverse drug reactions, increased oral disease, reduced cooperation as disease

advances).

o Osteoporosis (fractures, bisphosphonates).

o Parkinson disease (involuntary movements, COMT inhibitors may interact with

epinephrine, restorative care increasingly difficult).

o Stroke (confusion, mobility and/or communication problems, deterioration of oral

hygiene, defer elective care for 3 months, short sessions, treat patient upright).

The authors conclude that the dentist’s focus should always be on prevention of dental

disease, especially in people who have progressive debilitating systemic diseases.

• Saliva flow rate may be reduced in elderly people due to medications and various associated

medical conditions. Xerostomia (dry mouth) is the most common adverse drug-related

effect in the oral cavity and has been associated with over 500 medications. It is common in

patients being treated for hypertension or mental illness. Because of the synergistic effects

of multiple medications, dry mouth is a particularly common and significant problem for

elderly patients. (Porter et al. 2004) Lack of saliva often causes soreness, dryness of the

mucosa and lips, caries, candidiasis and intolerance to removable dentures. An increase in

the severity of xerostomia can lead to a greater risk of dysphagia, choking and nutritional

problems. (Madinier et al. 2009) Management includes general and local hydration, saliva

substitutes and lubricants, local agents to stimulate secretion (e.g. sugarless gum), antifungal

treatment, modification of the diet and nutritional supplementation. (Madinier et al. 2009)

Intense caries prevention is essential. Dialogue with the patient’s physician is recommended.

5. Palliative Dental Care

• For the frail, elderly, dependent adult still in the community and attending private dental

offices with a caregiver, the concept of palliative dental care is appropriate — particularly if

the patient has dementia. In such cases, care involves “regular hygiene to reduce bacterial

invasion of the lungs, relief of pain and ‘maintenance of dignity’.” (MacEntee, private

correspondence)

• Focusing on idealized dental care for the frail older patient with a failing dentition, without

recognizing the stress and expense involved and without taking into account the limited

therapeutic benefits, can exaggerate the need for treatment (MacEntee 2007) and lead to

pointless and unnecessary over-treatment.

• The average length of stay in a long-term care residence depends on the gender and age of

the resident, as well as the level of care required. Eighty-five percent of nursing home

residents are 75 years of age or older. The average expected length of stay for this age group

(for all levels of care) averages 3.9 to 4.5 years across regions of Manitoba. (DeCoster et al.

1995) Individuals needing lower levels of care stay, on average, much longer than

individuals needing higher levels. The average length of stay for Veterans Affairs Canada’s

in-patients in long-term care facilities (average age over 80 years) was less than 1.9 years for

2005-06. (Veterans Affairs Canada data, Dec 2006)

• The goal of palliative care for seniors who are either terminally ill or approaching the end

stage of life is not to focus on disease, but rather on quality of life and the relief of

discomfort and pain. Early identification and rational management of potential dental

problems play an important role in relieving suffering at this stage of life.

6. Educational Resources

As part of its Oral Longevity initiative, the American Dental Association has developed

educational resources to assist dentists in educating patients, consumers and health

professionals about oral care for the elderly.

7. References

Berkey DB, Berg RG, Ettinger RL, Mersal A, Mann J. The old-old dental patient: the

challenge of clinical decision-making. JADA 1996; 127:321-332.

Chalmers JM. Minimal intervention dentistry: part 1. Strategies for addressing the new

caries challenge in older patients. J Can Dent Assoc 2006a; 72(5):427-433.

Chalmers JM. Minimal intervention dentistry: part 2. Strategies for addressing restorative

challenges in older patients. J Can Dent Assoc 2006b; 72(5):435-440.

DeCoster C, Roos NP, Bogdanovic B. Utilization of nursing home resources. Medical Care

1995; 33(12):DS79-82.

Ettinger RL. Rational dental care: part 1. Has the concept changed in 20 years? J Can Dent

Assoc 2006; 72(5):441-445.

Ettinger RL. Clinical decision-making in the dental treatment of the elderly. Gerontology

1984; 3:157-165.

Featherstone JD, Adair SM, Anderson MH, Berkowitz RJ, Bird WF, Crall JJ, Den Besten

PK, Donly KJ, Glassman P, Milgrom P, Roth JR, Snow R, Stewart RE. Caries management

by risk assessment: consensus statement, April 2002. J Calif Dent Assoc 2003; 31(3):257-

69.

Friedlander AH, Norman DC, Mahler ME, Norman KM, Yagiela JA. Alzheimer’s disease:

psychopathology, medical management and dental implications. JADA 2006; 137:1240-

1251.

Lindquist TJ, Ettinger RL. The complexities involved with managing the care of an elderly

patient. JADA 2003; 134:593-600.

MacEntee MI. Quality of life as an indicator of oral health in older people. JADA 2007;

138:47S-52S.

Madinier I, Starita-Geribaldi M, Berthier F, Pesci-Bardon C, Brocker P. Detection of mild

hyposalivation in elderly people based on the chewing time of specifically designed disc

tests: Diagnostic accuracy. J Am Geriatr Soc 2009; 57:691-696.

Porter SR, Scully C, Hegarty AM. An update of the etiology and management of

xerostomia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004; 97:28-46.

Scully C, Ettinger RL. The influence of systemic diseases on oral health care in older adults.

JADA 2007; 138:7S-14S.

Van Thompson, Craig RG, Curro FA, Green WS, Ship JA. Treatment of deep carious

lesions by complete excavation or partial removal. A critical review. JADA 2008; 139:705-

711.

BEST PRACTICES FOR DENTAL CARE FOR THE HOMEBOUND

Dentists may want to visit patients in their own home, or may be called to do so. The British Society

for Disability and Oral Health has developed guidelines for the provision of at-home oral health

services for homebound patients. This resource offers practical advice about offering care in the

home setting environment, including infection control and other safety issues, and the planning and

provision of treatment.

BEST PRACTICES FOR ORAL CARE IN LONG- TERM CARE (LTC) FACILITIES

1. Organizational Support

For an oral health care program to be successful, there needs to be support at all levels within

the facility and a culture that values and promotes oral health as a basic right of residents that is

integral to their overall health and well-being. Champions within the facility should be

identified to oversee the program and liaise with all members of the team. As part of the

organization’s quality assurance program, the facility should monitor and evaluate its oral care

program and ensure its sustainability.

2. Multidisciplinary Approach

An interprofessional approach should be used for the design, implementation and evaluation of

the oral health care program. LTC administrators and champions should contact local dental

organizations to develop partnerships and for assistance in identifying dental professionals who

can work as part of the program team. Provincial associations and/or local dental societies

should identify facilities and health networks within their area to develop partnerships and

promote interprofessional capacity to support oral care programs in LTC facilities.

3. Facility Policy for Oral Care

All LTC facilities should develop policies regarding oral health best practices. New or existing

policies and procedures should be evaluated, so that gaps between current and best practices can

be identified and corrected. Ontario’s Regional Geriatric Program central (RGPc) has developed

a resource that facilitates the comparison of an LTC facility’s practices, policies and procedures

to those in the Registered Nurses Association of Ontario (RNAO) Oral Health Best Practice

Guideline (see Appendix C). A sample oral care policy for LTC facilities is included with this

document (see Appendix D).

4. Assessment

Entry into an LTC facility provides an opportunity for a thorough oral assessment of the patient,

identification of oral problems that require attention, and ongoing nursing assessment and oral

care. A dental examination or an oral assessment by a qualified dental health professional

should be completed or arranged shortly after admission and periodically thereafter. These

examinations should be supplemented by oral health assessments and screenings by nurses and

caregivers, as outlined below.

4.1. Oral History on Admission

Within 24 hours of admission, an oral health history should be taken in addition to the

Minimum Data Set (MDS), as part of the new resident’s admission history. The oral health

history should include information about oral health beliefs, oral care practices and current

state of oral health, as perceived by the resident or his or her caregiver. A sample oral

hygiene history questionnaire has been developed by the RNAO and is included with this

document (see Appendix E).

4.2. Regular Oral Assessment

Nursing assessment of oral health should be done within 24 hours of admission, at least

quarterly thereafter, and whenever the resident, a family member or caregiver identifies a

change in oral health status. Ontario’s Halton Region Health Department has developed an

oral health assessment tool for this purpose.

Oral Health Assessment Tool

Using the Oral Health Assessment Tool

5. Oral Care Plan

All residents, including those who do not have natural teeth (with or without dentures), should

have an individualized oral care plan. The oral care plan should be reviewed and modified as

needed after each oral assessment. An example of an oral hygiene care plan and a guide to

interventions for residents in LTC are available from Ontario’s Halton Region Health

Department.

Oral Hygiene Care Plan for LTC

Dementia Reference Tool

6. Education of Staff

LTC facilities, in collaboration with dental health professionals, should implement continuing

education opportunities for nurses and personal support workers that include appropriate oral

health knowledge and skills training. Samples of training materials are provided in the resources

section.

RESOURCES

1. Oral Care Best Practices Sources

Oral Health: Nursing Assessment and Interventions Best Practice Guideline

This guideline, developed by the RNAO as part of its evidence-based Nursing Best Practice

Guidelines Program, focuses on specific vulnerable populations (those who need assistance to

meet their oral hygiene needs).

Oral Health: Nursing Assessment and Interventions Recommendations

This is a summary of the recommendations from the RNAO Oral Health Best Practice

Guideline.

Best Practices Approach to Oral Care in Long-Term Care Homes

These materials were developed by the Ontario’s Regional Geriatric Program central, one of

five geriatric regional programs in Ontario.

2. Training Resources

The following resources were developed by the Halton Oral Health Outreach Program of the

Halton Ontario Region Health Department. They are designed to assist in the education of staff

in LTC facilities.

• Basic Oral Care - K.I.S.S

• Dysphagia: Oral Health Care Tips for Individuals That Have Difficulty Swallowing

• Palliative End Stage Care

• Dementia Care

• Dry Mouth: Managing Xerostomia (Hypo-salivation)

• Diabetes: Managing Oral Care for the Elderly Diabetic

• Oral Pathology Basics: Common Mouth Sores in the Elderly

• Tooth Abscess: Recognizing a Tooth Abscess

• Cancer Care: Mucositis

• Denture Care

• Oral Health Products and Tips

3. Oral Care for Patients With Dementia – DVD

Oral Hygiene: Managing Oral Care for Residents with Responsive Behaviours – This

instructional 16-minute video/DVD was developed by the RNAO as part of the evidence-based

best practice guideline Oral Health: Nursing Assessments and Interventions. It is designed to

assist caregivers in providing proper oral care for patients with dementia and is available from

www.rnao.org. (Cost is $15. The material may be replicated in its entirety for educational

purposes only, with appropriate credit or citation.)

4. Oral Health Promotion Fact Sheets for LTC

These Oral Health Promotion Fact Sheets for Long-term Care were developed by the Health

Promotion Unit, Centre for Community Oral Health - Faculty of Dentistry, University of

Manitoba.

University of Manitoba’s Centre for Community Oral Health

5. Oral Health Educational Material for LTC

These Oral Health Educational Materials for Long-term Care were developed by the University

of British Columbia ELDERS (Elders Link with Dental Education, Research and Service)

group.

University of British Columbia ELDERS Group

Appendix A

Community Form PATIENT INFORMATION RECORD

Please bring to dental appointment

NAME: _____________________________________________Ƒ Dr. Ƒ Ms Ƒ Mrs. Ƒ Miss Ƒ Mr.

Male_____ Female_______

BIRTH DATE ____ / ____ / ____

YEAR MONTH DAY

ADDRESS: ________________________________________________________________

TELEPHONE. No. _______________ PHYSICIAN: ___________________________

CONTACT __________________________ Relationship___________________________

HOME: (

____)_____________________ BUSINESS: (____)_______________________

MEDICATION LIST

(Please list ALL medications, including non prescription drugs)

1. ________________________________________

2. _______________________________________

3. ________________________________________

4. ________________________________________

5. ________________________________________

6. ________________________________________

7. ________________________________________

8. ________________________________________

ALLERGIES

:__________________________________________________

For patients on Warfarin (Coumadin): Most recent INR

Date:_______ Reading:__________

ADDITIONAL INFORMATION FOR PATIENTS WITH CAREGIVERS:

MOBILITY:

Does patient use: Wheelchair_____ Walker________

Able to transfer to dental chair:

YES

with minimal assistance

with 2 persons assisting

COGNITIVE/SENSORY STATUS:

Alert ___ Mildly confused _____ Moderately confused ____ Advanced cognitive impairment ____

Hard of hearing

YES mild ___ moderate ___ profound ___

Please answer the following questions:

REASON FOR VISIT________________________________________________________________

Last dental visit_____________________

Radiographs available__________________________

Optimal Health for Frail Older Adults

Appendix B

Hospital Facility PATIENT INFORMATION RECORD

Please fax to _________________________ prior to appointment date

NAME: _____________________________________________Ƒ Dr. Ƒ Ms Ƒ Mrs. Ƒ Miss Ƒ Mr.

Male_____ Female_______ BIRTH DATE ____ / ____ / ____

YEAR MONTH DAY

ADDRESS: _________________________________________

UNIT/FLOOR: _________ TELEPHONE. No. _________________

PHYSICIAN: _____________________ PRIMARY CARE NURSE: ________________________

SDM: _________________________________

HOME: (

____)____________ BUS: (____)_______________ CELL: (____)_______________

ALTERNATE CONTACT _______________________________

HOME: (

____)__________________ BUSINESS: (____)____________________

INSURANCE:

Ƒ NO Ƒ YES _____________________________________________

PERSON RESPONSIBLE FOR PAYMENT OF ACCOUNT: _________________________

ADDRESS:

REASON FOR REFERRAL/VISIT:

MEDICATION LIST (Please list ALL medications, including non prescription drugs OR attach MARS)

For patients on Warfarin (Coumadin): Most recent INR Date:_______ Reading:__________

ALLERGIES:

MOBILITY:

Does patient use: Wheelchair_____ Walker________

Able to transfer to dental chair:

Ƒ NO Ƒ YES Ƒ with minimal assistance Ƒ with 2 persons assisting

COGNITIVE/SENSORY STATUS:

Alert ___ Mildly confused _____ Moderately confused ____ Advanced cognitive impairment ____

Hard of hearing

Ƒ NO Ƒ YES mild ___ moderate ___ profound ___

Please answer the following questions:

1. Is patient in pain? Yes ___ No ____

2. Does patient have an acute infection? Yes ___ No ___If yes, describe location of pain/infection and

if pain is intermittent or constant, and duration of pain.

3. What treatment for pain relief/infection has been used?

Optimal Health for Frail Older Adults

Best Practices Approach to Oral Care in LTC Resource Kit March 2008

Oral Care Gap Analysis

Based on the RNAO Oral Health BPG Recommendations (2007).

Compare your LTC home’s practices, policies and procedures to those in the RNAO’s Oral Health

Best Practice Guideline.

Appendex C

Oral Care Gap Analysis

Optimal Health for Frail Older Adults

Best Practices Approach to Oral Care in LTC Resource Kit March 2008

Appendex C

Oral Care Gap Analysis

Optimal Health for Frail Older Adults

Best Practices Approach to Oral Care in LTC Resource Kit March 2008

Available for download on www.rgpc.ca

>> Long-Term Care Best Practices Resource Centre

Appendex C

Oral Care Gap Analysis

Optimal Health for Frail Older Adults

Appendex D

Sample LTC Oral Care Policy

Best Practices Approach to Oral Care in LTC Resource Kit March 2008

Oral Care

Policy

This is a SAMPLE LTC Oral Care policy and it can be used as a template.

LTC Home

SAMPLE ONLY- feel free to adapt to your LTC home

Nursing

Subject

Oral Care

POLICY:

1. An oral health history will be completed as part of the resident admission assessment and will

include oral hygiene beliefs, practices and current state of oral health.

2. Assessment of oral health will be included in all resident health assessments:

• Within 24 hours of admission

• At least quarterly and annually

• As oral health status changes

3. Residents’ oral health status will be assessed using the Oral Health Assessment Tool (OHAT)

for Long-Term Care.

• For LTC homes using MDS-RAI 2.0: complete Sections K and L , as necessary, complete

the OHAT to supplement the RAI with additional oral status information.

4. An individualized Oral Hygiene Care Plan (plan of care) will be determined and implemented

based on the completed oral assessment (OHAT), MDS Dental Care RAP, resident’s

preferences, functional ability, cognition and ability to cooperate and follow instructions.

5. Staff will provide, remind or cue oral care for residents at least twice daily. If possible, oral care

should be completed in the resident’s bathroom (i.e., due to the physical cues available).

6. Prior to initiating oral care, staff should review the oral hygiene care plan and be aware of the

resident’s cognitive status, their responsive behaviours, communication, sensory and functional

impairments, and dysphagia.

7. Encourage residents to be independent with oral care. Staff will complete any oral care that the

resident was not able to complete. Staff will provide or supervise the provision of oral care for

those residents at risk of aspiration.

8. Communicate with the resident at all times during oral care ensuring that the resident is aware

of the steps of the procedure and independent tasks required.

9. The “Approaches to Oral Care” tool can be used as a resource for staff in completing resident’s

oral care. Recommended interventions:

Optimal Health for Frail Older Adults

Appendex D

Sample LTC Oral Care Policy

Best Practices Approach to Oral Care in LTC Resource Kit March 2008 10

 Never use toothpaste or mouth rinses with residents who have swallowing difficulties. Only

use water.

 Never use lemon glycerine swabs with oral care.

 The resident should be properly positioned to receive oral care.

 For residents who are unable to keep their mouth open, use mouth propping devices

(ie. two toothbrush technique, wedges, etc.)

 Use a toothbrush with a small head, soft bristles and a larger handle with a rubberized grip.

 Use pea size amounts of toothpaste.

10. Interventions for care of dentures:

 Never use denture tablets for soaking dentures of residents with dementia. The ingestion

of tablets/solution is serious. Vinegar/water solution can be used as an alternate (mix ½

water and ½ vinegar).

 Remove dentures daily for at least three hours, for gums to rest.

 Clean dentures with denture paste, denture brush and soak in cool water.

 Brush the mouth tissues and tongue with soft bristle brush prior to applying the dentures.

Dentures should be thoroughly rinsed

11. Denture cups and toothbrushes will be labelled and replaced every 3 months and as required.

Replace toothbrushes after every oral infection.

12. The effectiveness of the oral care interventions will be evaluated at least quarterly. Additional

or alternate interventions will be added as necessary.

13. At the time of admission and throughout their stay, residents will have access to oral health

professionals including dentist, denturist and dental hygienist.

14. Based on the nursing assessment and in consultation with the resident and /or SDM, referrals

to an oral health professional (dentist, denturist, dental hygienist) will be made.

EDUCATION:

1. Orientation: New staff, Registered Nursing staff and Personal Support Workers / Health care

Aides (full and part-time) will receive oral hygiene care education and information during their

orientation.

2. Continuing Education: Staff education sessions regarding oral care hygiene will be provided

annually and additionally, as required.

QUALITY/ AUDITING MONITORING:

The LTCH Satisfaction Surveying process will include an annual evaluation of:

1. Residents’ satisfaction with oral hygiene care received

2. Family / SDM’s satisfaction with oral hygiene care provided.

Optimal Health for Frail Older Adults

Appendex D

Sample LTC Oral Care Policy

Best Practices Approach to Oral Care in LTC Resource Kit March 2008 11

Procedure

Denture Care

a) Introduction

• Plaque & tartar form on dentures just the same as they form on natural teeth

• Brush dentures (as you would natural teeth) at least twice daily

• Remove dentures daily for at least 3 hours for gums to rest, overnight is easiest

• Use a separate brush for any natural teeth

• Ask the resident to remove their dentures. Assist, if they can’t

• For upper dentures

• slide your index finger along the denture’s side then push gently

against the back of the denture to break the seal. Grasp it and remove

by rotating it. Grasp lower dentures at the front and rotate.

• For partial dentures

• place thumbnails over or under the clasps, apply pressure, being

careful to not bend the clasps and catch them on lips or gums.

b) Cleaning dentures:

• Wear gloves

• Line the sink with a towel. Fill it with some cool water just in case the dentures slip and

fall. Hot water can warp dentures.

• Rinse with cold water to remove food

• Scrub dentures using a denture brush and denture paste. Never use abrasive

cleansers or scouring powders

• Thoroughly brush all surfaces especially those that touch the gums. Rinse

well.

• At bedtime, place dentures in denture cup with cool water and vinegar (½ water and

½ vinegar)

• Only soaking them overnight with a cleansing table is not sufficient – it doesn’t clean

off the plaque

• NEVER use denture tablets for soaking dentures of residents with dementia -

ingestion of tablets/solution is serious

• Never use vinegar on dentures with any metal on them as this will cause the

metal to turn black.

Optimal Health for Frail Older Adults

Appendex D

Sample LTC Oral Care Policy

Best Practices Approach to Oral Care in LTC Resource Kit March 2008 12

Toothpastes

• Use pea-sized amounts of toothpaste, squeezing out a long strip of toothpaste is too

much

• Most toothpastes have a strong taste, many residents don’t like this, not appealing to

residents with Alzheimer’s Disease

• Foaming action of toothpaste increases saliva flow & will result in the resident wanting

to spit >> choke, gag

• DO NOT use toothpaste for residents who have dysphagia, who cannot swallow or

spit/rinse properly, have high level of dementia - there are oral cleansing gels available

Toothbrushes

o The best type of toothbrush to use for residents

 is one with a small head, soft bristles, larger handle with rubberized grip

 2-Toothbrush Technique:

 For residents who bite down during care, consider using 2 toothbrushes – one to

prop the mouth open and one for cleansing

o Replace toothbrush:

• every 3 months or after an infection

Available for download on www.rgpc.ca

>> Long-Term Care Best Practices Resource Centre

Optimal Health for Frail Older Adults

Appendex E

Sample Oral Hygiene History

Oral Health: Nursing Assessment and Interventions

Appendix D: Oral Hygiene History –

Sample Questions

Please Note: These are suggested questions to assist in taking an oral hygiene history. It is not a validated

tool for the assessment of the person’s oral health history.

Admission Oral Hygiene History Sample Questions

Hygiene Beliefs:

Which statement best describes your beliefs regarding your teeth:

a) I expect that with proper care my teeth will last me a lifetime.

b) No big deal if I lose my teeth, most people do when they get older.

c) If I lose my teeth I can always get dentures.

Where on a scale would you place your oral health?

1 3 5

Not Important Somewhat Important Very Important

Personal Practices:

1. Are your teeth your natural teeth? Do you have dentures? Do you have crowns?

If the client has dentures: Do you have partial or full dentures? Do they fit properly?

How long have you had the ones you are currently using?

2. Are you having any difficulty doing your oral care?

3. How often do you brush your teeth in a day?

4. What type of toothbrush do you use?

5. What type of toothpaste do you use?

6. How often do you replace your toothbrush?

7. Do you use mouthwash?

8. Do you floss regularly?

9. Have you used tobacco products within the last six months? If so, how many cigarettes/cigars/pipes

do you currently smoke a day or how much chewing tobacco do you use?

10. Do you drink caffeinated beverages?

11. How often do you visit the dentist?

12. When was the last visit to the dentist?

13. Does going to the dentist upset you?

14. Do you have difficulty chewing or swallowing?

15. Is there anything else that you do to keep your mouth healthy?

Current State of Oral Health:

1. Are you currently experiencing any problems in your mouth?

2. Are your teeth sensitive to hot or cold?

3. When was your last visit to a dentist?

4. Are you currently taking any medications?