Interdisciplinary Care for Individuals in Residential Nursing Facilities
A multi-disciplinary approach should be employed for effective oral care in patients with dementia. Dentists, dental hygienists, dental assistants, physicians, nurses, nursing assistants, and familial and other caregivers each have a unique role in providing oral health care to these patients.
Dental healthcare providers play a central role in creating a customized, long-term dental care plan for a patient that has been newly diagnosed with dementia.125 The dentist should attempt to make a plan that includes patient-specific information and involve the individual with dementia and their family while he or she is in the early stages of dementia.126 This may allow for increased buy-in and autonomy in treatment decisions from the patient who may then be more open to treatment and more engaged in making decisions. The plan should concentrate on eliminating pain, managing infection, and preventing new disease.127
Education of nurses, nursing assistants, and caretakers is critical to ensure the success of proper oral care in patients with dementia.128 Dental prostheses are growing increasingly diverse, including natural teeth, fixed bridges, dental implants, and removable prostheses.11,129 Natural teeth require brushing and interdental cleaning,117 while dentures need to be removed to be cleaned.116 Dental implants also require thorough preventative care to prevent inflammation and bone loss.116 Many nurses, CNAs, and other caretakers lack training in the complex care required different dental prostheses.128 In addition, CRBs exhibited by patients with dementia are a major obstacle to providing effective oral care.16 Offering strategies to improve oral hygiene delivery to front-line care providers is crucial as they are the primary individuals delivering oral care.16 Strategies offered may include MOUTh interventions (Managing Oral Hygiene Using Threat Reduction).16 MOUTh intervention is a nonpharmacologic, relationship-based intervention.16 Some tactics include forming a connection by approaching the patient at or below eye level, using a friendly and calm attitude, and using brief, one-step commands.16,119 Care providers may have a better chance of completing mouth-care activities if they are aware of different approaches that reduce CRBs in patients with dementia.16
Due to the progressive nature of dementia, verbal communication between the patient and the healthcare provider or caretaker may decrease as the disease progresses.127 Consequently, verbal communication may no longer be the best way to recognize health problems, such as tooth pain. Healthcare professionals and caretakers should be aware of non-verbal cues of dental discomfort.129 These include avoiding meals and being disinterested in eating, chewing of the lip, tongue or hands, “pulling” at the face, not wearing dentures, and aggression (particularly during activities of daily living, including oral hygiene).129
Healthcare professionals and caretakers should also consider their patient’s progression and stage of dementia. The different stages of dementia can affect how a patient will cope with dental treatments and interventions.129 Healthcare professionals and caretakers must be aware that strategies that are effective in one patient, may not be for others.129 Furthermore, a strategy that may be effective for a patient one day, may not work the next week for that same patient.133 Healthcare professionals and caretakers should recognize that treatment plans may need to change over time as the patient’s disease state changes.129
Oral hygiene must be seen as an integral part of a patient with dementia’s overall wellness and healthcare. An interdisciplinary approach allows the benefits of effective oral health to be achieved through delivery of regular oral hygiene and regular evaluation of oral health. Benefits of an increased focus on oral health may include decreased tooth loss, improved oral cancer detection, and decreased oral pain and infections. Patients with dementia may also see improvements in nutrition, decreased agitation associated with discomfort, overall health, and appearance with improved oral health.