By: Dr. Brooke Fukuoka

A beautiful ninety-year-old woman was brought into our dental office. Her hair neatly combed, her outfit elegant, her nails painted and her lipstick perfect. However, when she opened her mouth, I could smell her breath and saw an impressive amount of debris. After gently wiping away debris, a minefield of inflamed gingiva, rampant caries and root tips were revealed.

Sadly, this story had become too familiar and the more I witnessed it the more I felt compelled to do something.

I developed a plan to visit long-term care facilities and teach caregivers customized oral hygiene for all residents. I  planned to dedicate an entire day to the venture. While I knew it would take time, it would be worth it, because I genuinely believed education was the main issue. I envisioned these patients coming back to me with improved oral health because of the difference I made…Nope.

This is how it actually went. When I arrived, the facility was down three staff members. The group I was scheduled to train had gone from the entire team to a single staff member who was simultaneously working on the floor. I felt dismissed and disrespected. However, since she was eager to learn and I had planned the training, I decided to commit all my energy to this lone team member. So, we set off to visit our first resident, who thankfully agreed to a teeth cleaning. We gathered his supplies and were ready to start when—beep, beep, beep—off went the caregiver’s pager. She said we had to check in with someone then we could return. We went to check on the resident who paged her, she was fine, only needing help changing the television channel and went back to our original resident. As we began to brush his teeth – beep, beep, beep – the pager went off again. At this point, I began to develop a strong dislike for that pager. It felt like we were running line sprints between residents. It broke my spirit when we returned to finish the cleaning, and we saw the resident had decided to eat crackers. I left for the day thinking of how few people we were able to see and realizing there was way more to overcoming oral health care challenges in elderly populations than simply an education problem. What made me feel that my time was still productive was that I transformed that caregiver into an educated advocate for oral health. However, a few days later she found employment elsewhere. There must be a better way.

When discussing the challenges of oral health care in long-term care facilities, we are quick to point out the lack of education and perceived importance, but we rarely discuss the reality of caregiver time constraints. While I didn’t realize it at the time, the day I spent training in that facility was not lost time but rather a learning experience for myself. Experiencing the barriers firsthand taught me this issue is more complex than I originally thought. Here are
some of the complexities and what we as oral healthcare providers do can to overcome them.

It is not just two minutes. The time it takes to clean someone’s teeth in assisted living is approximately 15-20 minutes. You can’t simply walk into someone’s room, stick a toothbrush in their mouth and begin brushing. Time needs to be included for social pleasantries, proper infection control, PPE, and locating their toothbrush- which can be a challenge with memory care patients.

Caregivers are being pulled in many directions. This was a difficult puzzle to solve. Oral care is one of many important responsibilities assigned to caregivers. When their pager goes off, they don’t know if a resident wants their TV channel changed or if they have fallen. While providers can increase efficiency with customized plans, unique equipment, and well thought out storage options, there will always be other demands pulling caregivers away from completing oral hygiene.

Our team devised a solution to send a member of the dental team to the long-term care facility once a week. With this tactic, oral hygiene would have undivided attention at least once per week. The expectation is still to have caregivers give their best attempt to help residents with basic oral hygiene daily. However, having a dental team member there weekly also had the unintended effect of keeping dental health top of mind for the care team.

Care is expensive. Performing oral care is a one-on-one activity (sometimes a two-on-one for more severe cases) and it takes about 15-20 minutes per person per session. This creates a challenge to find someone suitable for the role. Dental hygiene students have been ideal since they have baseline oral health knowledge and professionalism. Plus, they gain valuable experience during their time with this patient population. It is priceless to watch them grow from being nervous students to dental health professionals training other students. When it comes to geriatric oral care, by the time they graduate, these students could rival many of their more experienced colleagues. The students also develop deep relationships with the residents which provide an entirely new dimension of healthcare empathy and a deep understanding of the challenges this population faces. The professional development gained makes up for the unfortunate wage limitations.

The service was undefined. The program also faced naming challenges. Simply calling it “brushing and flossing” devalued the service and made it seem like a given. While naming it “professional hygiene services” gave the impression that unlicensed providers were practicing dentistry. After much wordsmithing, the program was titled, “assisted oral hygiene.” Assisted oral hygiene is defined 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.”

Essentially, it is brushing and flossing someone else’s teeth but acknowledging that there is a lot more involved when doing it for another person. While not an officially recognized term, it is used to facilitate communication and education.

Dr. Brooke Fukuoka works full-time with Family Health Services of Idaho where she has developed their Advanced Delivery Dental Clinic for patients with special healthcare needs. In her part-time practice, Your Special Smiles, she practices portable dentistry, hospital dentistry and teledentistry.

IMPORTANT ACKNOWLEDGMENTS
Assisted Oral Hygiene Term Coined by workgroup consisting of members from Your Special Smiles PLLC (Jingjing Qian, RDH-EA, Brooke MO Fukuoka DMD, FSCD), 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). HRSA grant funding was utilized in the development of this program.

Concepts mentioned in this presentation were developed with support by HRSA/HHS as part of a financial assistance award totaling $567,317 with 60% funded by HRSA/HHS and $167,317(40%) funded by non-government source(s). “The contents are those of the author(s) and do not necessarily represent the official view of, nor an endorsement, by HRSA/HHS, or the U.S. Government.” We are only a small part of this award.