In Nursing Homes, an Epidemic of Poor Dental Hygiene
By CATHERINE SAINT LOUIS AUGUST 4, 2013, 2:30 PM 207 Comments
Jennifer Whitney for The New York Times
Dr. Sarah Dirks, right, a dentist who treats nursing home residents in San Antonio, said she would be “surprised if oral care was even on the radar of the medical directors” at nursing homes
Katherine Ford visited her father, Dean Piercy, a World War II veteran with dementia, at a nursing home in Roanoke, Va., for months before she noticed the dust on his electric toothbrush. His teeth, she found, had not been brushed recently, so she began doing it herself after their lunches together.
But after he complained of a severe, unrelenting headache, she said, she badgered the staff to make an appointment for him with his dentist. The dentist found that a tooth had broken in two, and he showed Ms. Ford the part that had lodged in the roof of her father’s mouth.
“I was livid,” said Ms. Ford, 57, a court reporter. “I’m there every day, pointing out he’s in pain — and he had dental insurance. So there’s no reason this wasn’t addressed.”
In nursing homes across the country, residents like Mr. Piercy are plagued by cavities, gum disease and cracked teeth, in part because their mouths are not kept clean. While residents now require more dental care than in the past, nursing home employees are rarely prepared to provide it. Aides are swamped with other tasks, and when older charges must be helped to the toilet, fed or repositioned in bed, brushing their teeth often falls to the bottom of the to-do list.
Even when care is available, few staff members are trained to cope with the rising numbers of residents with dementia who resist routine dental hygiene.
Jennifer Whitney for The New York Times
Dentures are easier for nursing home staff to clean.
“I always say you can measure quality in a nursing home by looking in people’s mouths, because it’s one of the last things to be taken care of,” said Dr. Judith A. Jones, chairwoman of the department of general dentistry at Boston University. “Aides change someone’s Depends, change a catheter or turn somebody every few hours, but teeth often don’t get brushed twice a day.”
The neglect can lead to terrible pain for the residents. Worse, new studies suggest that this problem may be contributing to another: pneumonia, a leading killer of institutionalized older people.
The lack of daily oral care in nursing facilities is “an epidemic that’s almost universally overlooked,” said Dr. Sarah J. Dirks, a dentist who treats nursing home residents in San Antonio.
There are no current national assessments of oral health in nursing homes, but since 2011, at least seven states have evaluated residents using a survey developed by the Association of State and Territorial Dental Directors. One was Kansas, where dental hygienists examined 540 older residents in 20 long-term-care facilities. Nearly 30 percent of the residents had “substantial oral debris on at least two-thirds of their teeth,” according to a report issued by the Kansas Bureau of Oral Health. More than one-third had untreated decay.
The screeners saw plenty of fillings and crowns but concluded that “regular dental care has become a thing of the past” for many of the residents.
In Wisconsin, nearly 1,100 residents from 24 homes were examined. About 31 percent had teeth broken to the gums, with visible roots; 35 percent had substantial oral debris.
The problem has been graphically documented in state and federal inspections of nursing homes. In Texas, inspectors noted one resident with memory problems in too much pain to eat, her lower gums red, swollen and packed with food debris.
A 2006 study of five facilities in upstate New York found only 16 percent of residents received any oral care at all. Among those who did, average tooth brushing time was 16 seconds. Supplies like toothbrushes were scarce, the report said.
At the Raleigh Court Health and Rehabilitation Center in Roanoke, where Mr. Piercy was a resident, the administrator, Mark Tubbs, said in a statement that he could not discuss Mr. Piercy’s case because of federal privacy laws, and he could not corroborate Ms. Ford’s account. “All patients receive medically necessary, high-quality care, including oral care and hygiene,” Mr. Tubbs said.
Just as nursing home workers are expected to help residents bathe or reposition them to avoid bed sores, they are supposed to brush the teeth of residents who cannot do it themselves. So important is this task that it was federally mandated in the Omnibus Budget Reconciliation Act of 1987, which set new standards for nursing homes.
“They should be getting their care, but a lot of people don’t,” acknowledged Dr. David Gifford, the senior vice president of quality at the American Health Care Association, a trade group representing two-thirds of nursing homes nationwide.
Some residents decline help, he noted, and nursing home employees can do little about it. “It’s a very personal thing to have someone else brush your teeth,” Dr. Gifford said. “A lot of residents don’t want it, don’t like it and will ask not to have it.”
Many arrive at nursing homes with poor teeth, he added, after long periods without seeing a dentist.
Certainly, oral care can be a vexing challenge for nursing homes. Older Americans are more likely than ever to retain their natural teeth. Edentulism, total tooth loss, in older people declined from 1988 to 2004, according to data from the National Health and Nutrition Examination Surveys.
“Before, they came in with dentures,” said Barbara J. Smith, the manager of geriatric and special-needs populations at the American Dental Association. “Now it’s a whole different ballgame.” Dentures are easier for nursing home staff to clean.
Nearly two-thirds of those who stay in a nursing home long term have dementia, and many resist oral care, clenching their mouth shut or even trying to hit aides. The National Institutes of Health is financing research to address such resistance among nursing home residents with dementia.
Many prescription drugs — including some antidepressants, medications for high blood pressure and anti-seizure medications — can reduce saliva and dry out the mouth. Without daily oral care, older people taking such drugs are especially prone to “a relatively rapid deterioration,” said Dr. Ira Lamster, a dentist and a professor of health policy at the Mailman School of Public Health at Columbia.
The consequences are not limited to cavities and gum disease. Since 2004, when researchers first linked oral bacteria to the occurrence of hospital-acquired pneumonia in older people, a series of studies has shown that oral care — from regular brushing to professional dental care — might reduce the risk. Roughly one in 10 cases of deaths from pneumonia in nursing homes could be prevented by improving oral hygiene, according to a 2008 systematic review published in The Journal of the American Geriatrics Society.
But even when residents and their families know that better oral care is needed, paying for it can be a challenge. Medicare does not cover routine dental care like cleanings and fillings. Most states provide at least some dental services to adults on Medicaid, but coverage varies widely, and finding a local dentist who accepts Medicaid payments can be difficult.
More than 30 states allow dental hygienists to provide some treatment without specific authorization from a dentist, according to the American Dental Hygienists Association. But medical directors at nursing facilities do not necessarily see the value of having a dental hygienist on contract or on staff, said Shirley Gutkowski, a dental hygienist of 27 years who educates nursing-home workers in Wisconsin.
Dr. Dirks, the Texas dentist, said she would be “surprised if oral care was even on the radar of the medical directors” at nursing homes. Indeed, her group practice used to contract with 62 nursing homes, but now works only with 24 that make oral health a priority. For change to occur, she said, “every nursing home needs an oral care champion.”