The importance of brushing your teeth is highly under-rated. In fact not brushing your teeth or maintaining good oral hygiene puts you at risk for serious health complications. This blog discusses the reasons why oral health is important as we age and why neglecting the oral health of older adults, especially in long term care homes (LTCH), can be considered a form of elder abuse.
Why is oral health care an important health issue in LTCH?
The #1 cause of death in LTCH residents is pneumonia and the link with oral health is well known (1;2)! Pneumonia can be acquired when bacteria laden secretions travel to the lungs. There is an accumulation of bacteria in the dental plaque and this bacteria sits in the mouth, teeth (including dentures), oral mucosa, and under the gums,. The bacteria can easily travel to the respiratory tract and can become pneumonia. There is also evidence that maintaining adequate oral hygiene can prevent pneumonia (3;4). Approximately one in 10 cases of death from pneumonia in LTCH residents may be prevented by improving oral hygiene (3). This clearly supports the belief of most dentists, dental hygienists, and other health professionals that brushing your teeth may indeed save lives!
But what if you are unable to brush your teeth? What if you are unable to do a proper cleaning for the recommended 'two minutes a day, twice a day, especially after meals'. This is the situation for many older adults, particularly those living in LTCH.
What is the scientific evidence linking oral care with good health?
Some estimates suggest that oral diseases affect over 95 percent of Canadian adults (5;6). Older adults are at particularly high risk for oral health problems, and poor oral health in seniors has been linked to general systemic health risks, such as cardiovascular disease, stroke, poor nutrition, glycemic control in people with diabetes and respiratory infection (7;8). Despite this growing body of evidence, the mouth seems to be forgotten and neglected. The oral cavity generally seems to be relegated to the realm of the dentist, and many residents living in LTCH typically never get seen by one or at the very best seen infrequently. The potential for creating additional health problems because of this lack of emphasis on oral care is significant.
Why is oral health an issue as we age?
As we age, we have greater changes in our teeth and gums which require more care rather than less (7). As well, older adults have greater challenges with:
- missing teeth,
- heavily restored teeth,
- higher rates of gum/periodontal disease,
- very high rates of root decay (relative to younger adults)
- higher rates of dry mouth
Typically many medications (over 400 types) can cause dry mouth; this problem is made worse in many older adults who may be on several medications.
As well, our teeth and mouth require more attention rather than less as we age. Unfortunately, this attention is not provided in most acute and long term care hospitals. Studies have shown (9) that there were missed nursing- care opportunities with regards to mouth care in acute care hospitals. The issue of oral care becomes a greater health problem in LTCH. Older adults are living in LTCH because they require greater assistance with personal care. Although the care providers in LTCH are tasked with performing many personal care activities, it seems that oral care tends to get neglected (8).
As a dentist who has spent over a decade visiting over 140 LTCH and acute care hospitals treating older adults, I have learned much about the degree of oral care provided. Surprisingly, little time is allotted to oral hygiene. I have often wondered if there is an examination and assessment of the oral cavity upon admission to the LTCH and who is responsible for this. When visiting seniors in LTCH, I look for the daily regimen and checklist that shows the degree of oral health care a resident is receiving. This checklist is often difficult to find or not well documented. From a dentist's perspective, this care plan is as critical and life-saving as delivering medications to prevent serious health problems, such as pneumonia.
Inconsistent oral care in LTCH is associated with the lack of:
- clear understanding as to who is responsible for assessment and care of the teeth and mouth
- training of nursing and other health care staff
- understanding of how medications may cause dry mouth
There are some challenges for staff and residents in LTCH in establishing consistent and adequate oral health care. Fear, perceived difficulty, lack of knowledge, uncooperative residents, lack of supplies, lack of time, and lack of staff are reported as barriers to oral care (8). The training for health care aids and for nursing staff, until recently, has been very limited with regards to oral care generally, but even less so for this care in the elderly (8;10). As a dentist, I often find that other health care professionals don't understand the adverse effects of medications on the oral cavity (or the severe consequences of dry mouth). Nor can they identify problems in the mouth or understand the effects that fractured/broken teeth can have on one's health.
A secondary problem is that there are limited preventative guidelines or referral guidelines for health care workers to follow when it comes to oral health. Currently, no extensively tested evidence-based oral care protocols exist for the institutionalized elderly (8). Moreover, even within the dental profession itself, practice guidelines have not been fully developed or implemented (8). Even if these guidelines existed, typically frontline staff (nurses and health care aides) may not have appropriate tools to examine or treat the mouth; nor are they trained in how to use these tools. The problem becomes more difficult with residents who have dementia. How do you help someone with brushing their teeth when they are resistant to care because of confusion or cognitive changes? A pilot study using the 'Managing Oral Hygiene using Threat Reduction (MOUTh)' approach has shown some promising results. The MOUTh approach gives those providing care a method to deliver oral hygiene in older adults who resist help (11). Nevertheless, health care providers in LTCH need clear guidance and documented plans to assist with these challenging situations.
A final problem is that residents in LTCH are often not evaluated by a dentist nor have their teeth cleaned by a hygienist on a regular basis. Dentists and dental hygienists, as experts in the care of the mouth and teeth, should be part of the healthcare team.
There is a problem of perception about the need for regular oral care
Many health care providers don't seem to link oral health with the serious risk for poor health outcomes. If health care workers are not trained in understanding issues related to oral health, they are not likely to prioritize it relative to other care activities. There also a need to stress the serious nature of some oral health problems. For example, most adults should recognize that healthy gums never bleed, and should seek dental care if they had this problem. Similarly, when health care providers see residents with bleeding gums, they should understand that this is a concerning health problem. If a doctor saw a cut or a wound on a patient that continued to bleed, they would surely seek to stop the bleeding. However, if a resident's gums continue to bleed, there seems to be a lack of understanding that this is equally serious.
There is also a tendency to forget to consider the mouth as a possible source for other care concerns. For example, if a resident is not eating, care providers may not consider evaluating the resident's mouth as a possible source of the problem. Perceptions become realities and there is a huge perception that residents, their caregivers and health care providers do not perceive dental care as a necessary part of daily care. Likely, the way in which caregivers prioritize dental care may be directly related to their own beliefs and culture. As a dentist, my message to residents, families, and health care providers is that oral care is a basic and necessary care for everyone and of every age, especially as we age. All of us need to 'brush up' on mouth care, as our health and life depend on it.
What is the relationship between neglect in oral care and elder abuse?
Thus far, we have seen that residents of LTCH may not receive adequate oral hygiene or dental care for a variety of reasons. For the residents to enjoy better health, comfort, confidence, quality of life and personal dignity good oral hygiene is essential. If it is neglected it leads to pain, eating problems, speech difficulties, bad breath and poor appearance. More importantly, we can see that it can also lead to serious health concerns and even death.
So how is this lack of oral hygiene and dental care related to elder abuse and neglect? We have defined dental elder abuse as 'when a person or a system prevents a person from receiving necessary basic oral care' (12;13). Until recently, there has been a lack of recognition and definition of elder abuse related to oral hygiene. Caregivers of older adults often neglect oral health and may inadvertently be exposing their loved ones to abuse.
Very little is known about the magnitude of this type of abuse because most have not linked oral health to neglect and abuse. For this reason we have started a new initiative to investigate this type of abuse (12;13). In the near future we hope to have more information about elder neglect and abuse in the context of oral hygiene.
What is the bottom line about oral care and health in older adults?
So how can I turn your frown upside down as you read this? We can decrease the risk of pneumonia and other health problems in LTCH by providing good oral hygiene. We need to increase awareness at all levels that providing daily and comprehensive oral care is a basic care necessity. Daily oral care regimens need to be adhered to and we need to assist front line staff by providing better training and including dentists and dental hygienists as part of the team.
Preventing neglect of oral health is not only a health issue but it is also an ethical issue. Neglect of a person's oral health can be considered elder abuse in some situations.