Literally writing a book on dental hygiene care at Nursing Homes

by Anne Nugent Guignon, RDH, MPH

Hygienists are concerned about access to care. Thousands of American citizens are not receiving necessary dental treatment. This is not an isolated problem. Hygienists all over the country address these issues via their state legislatures.

Texas hygienists had tried for years to convince the legislature to amend the practice act in order to provide much needed services directly to underserved populations. In the 2002 legislative session, the Texas Dental Hygienists' Association spearheaded these efforts, and Texas now has statutes that allow hygienists to provide services for nursing home residents.

It is one thing to have the statutes in place, but it is an entirely different situation to actually provide care for these residents. Last year, the dream of implementing a successful nursing home project became a reality for Lynne Durham, RDH.

Lynne is a recent graduate of the Texas Woman's University degree completion program. During her studies, she developed a nursing home project for a community dental health course. Lynne saw the recent changes in the dental practice act as a wonderful opportunity for her association to do something important in their community.

When Kim Hall, RDH, decided to join a new hygiene component of the Texas Dental Hygienists' Association, she looked for a niche. She decided to volunteer for the senior events committee. Lynne was the other member of the committee, as well as the president of that component. Lynne soon convinced Kim that the North Texas Dental Hygienists' Association could tackle a nursing home project.

These two pioneers took on the project with vigor. Nothing like this had ever been attempted in Texas. There were no templates. Yes, there were statutory guidelines, but there was no one person who could guide them through the maze of legalities and paperwork. Yes, they had mentors, hygienists who were very familiar with the needs of the geriatric population, but still they were blazing their own trail.

Instinctively, these two women knew that they would need the help of other hygienists. They concluded that they would need at least five hygienists to make the project successful, but first they needed to develop a project framework and a series of protocols.

Kim worried whether five hygienists could manage a fully capacitated nursing home. It seemed like too many patients. She put her faith in Lynne, who was the voice of experience, having developed another nursing home project. Kim sensed her dedication, compassion for the population, and willingness to make it work. Kim knew she was getting involved with something good — good for everyone involved.

Kim contacted the Texas Department of Health and Human Resources and found there are 13 nursing homes in their target area, Denton County. They sent a letter to the administrative director of each facility, describing the goals of the project. A questionnaire for the nursing home social worker was included with the letter. The hygienists requested the following information:
• Number of residents
• Range of resident level of care
• Whether audiovisual equipment would be available for in-service presentations
• Whether or not the facility could provide disposables such as gloves or masks for the project.

Half of the nursing homes responded. Lynne and Kim felt it was critical to interview the director of nursing and the social worker. They were able to set up four appointments.

According to Kim, Lynne really shined at these interviews. It was apparent to the nursing directors and the social workers that Lynne had an excellent understanding of the Dental Practice Act. She showed them how it should be followed and how this project would require extensive documentation as well as informed consents from the residents or their guardians. As a result of these meetings, the nursing home administration learned that oral health examinations as performed by dental hygienists, not only evaluate the entire mouth, but can also provide life-saving information.

Sorting through the paperwork

It was determined that a 60-bed facility would be a manageable task for this initial project. It was close to home and the staff was willing. These two important considerations were overshadowed by one special circumstance that really tipped the balance in favor of their final selection. Earlier in her career, the social worker had been a hygienist. Work-related injuries had sidelined her, but Kim and Lynne felt that Mary Walters, MSW, would surely understand and support their goals.

Kim and Lynne spent hours designing and redesigning the necessary forms for each resident. It was important to comply with the new Texas legislation and the governing regulations. Every resident of the facility was sent a request for services form and a permission slip. The nursing home's social worker received 30 completed slips signed by the resident or a guardian with power of attorney. Now the hygienists had a roster of 30 residents who would receive some type of service from the volunteers.

The two hygienists knew that it would be important to have a physician release for their dental hygiene services. This was their first stumbling block. They wanted the resident's' physicians to sign a health history that included standard dental questions, but the physicians did not know the residents' dental histories. They did not feel comfortable signing the release form designed by Lynne and Kim. Mary Walters verbally explained the project to the physicians, who then wrote orders for each patient requesting a dental hygiene oral assessment and preventive services, including orders for any needed premedication.

The hygienists concluded that the residents' medical histories would contain the necessary information, but they needed to gain access to the medical records. Since the nursing home's social worker was a former hygienist, she understood what the hygienists needed. As a result of her efforts, each hygiene volunteer signed a confidentiality agreement before opening the medical records.

In addition to gaining access to the medical records, the Texas statutes required written orders from each resident's dentist of record in order to provide dental hygiene services.

All 12 area dentists responded with signed orders, allowing the hygienists to proceed with the assessments. Dr. Norm Pomerance volunteered to see any resident who did not have a dentist of record. He wrote all premedication prescriptions for these patients.

The physician's orders for a dental hygiene assessment and preventive services for each resident contained information about whether a resident required pre-medication or not. The hygienists contacted the dentist of record for any patient who needed premedication, supplying the nursing home's triplicate prescription sheet. The prescription, written by the dentist, was then forwarded to the director of nursing who ordered the necessary antibiotics. The nursing staff dispensed the premedications prior to the hygiene visits.

Up to this point, Lynne and Kim had been the only hygienists involved. They knew that additional manpower was critical, so they began to spread the word at local component meetings and continuing education programs. Three other hygienists joined the project — Jan Schoen, Prudence Sanchez, and Annette Gentry. Five area dental assistants agreed to help with the project — Heather Bronkhorst, Sheila Denison, Kristi Lear, Candace Sauls, and Alexandra Smith.

Texas law requires that each hygiene volunteer have at least two years of clinical experience prior to treating nursing home residents. Before actual patient services began, the North Central Texas component contacted their insurance carrier. Additional coverage was not necessary as long as each hygiene volunteer had individual liability coverage.

A meeting was scheduled at Kim's house for the volunteer hygienists and assistants. They reviewed forms, shared contact information, and received a map of the facility. Each hygienist received a binder that contained the following information for every resident that they were assigned to see: oral screening authorization, physician's orders for a dental hygiene assessment, health history, initial dental hygiene orders from a dentist, dental hygiene assessment chart, progress notes form, and a report of findings.

Working through the logistics

Fridays turned out to be the best day for all of the volunteers. Kim coordinated everyone's schedules and contacted the social worker by e-mail at the beginning of each week with the details about which residents were to be seen and whether or not they would need premedication. It was important to order the medications ahead of time because the homes do not always have enough on site.

The home did not have a spare room for the hygienists, so they used a portion of the activity center. This gave them access to a sink, outlets for ultrasonic set-up, a table for supplies, and a linen closet. Towels were used in lieu of patient bibs and washcloths became bite blocks. The North Central Texas Dental Hygienists' Association component donated many of the supplies and materials needed for this project, but help was also secured from several companies that manufacture products that are easy to use in this type of challenging setting.

Lighting presented a serious problem. Most of the evaluations were done in the resident's own room, and often the only source of light was a tiny fluorescent light mounted above the bed. Sometimes there was a table lamp, but the illumination was not adequate. Volunteers resorted to wearing a tiny miner's light, but this did not supply adequate illumination either.

Toward the end of the project, a hygienist in another part of Texas heard about it and loaned the group an Orascoptic Walk About Headlight. This is a portable halogen headlight that runs off of a battery pack. The hygienists attached the Walk About to a visor shield and the battery pack to their waistband. Now they were in business! Once Orascoptic learned of their situation, they agreed to supply headlights for future projects.

Scaling presented another challenge. The hygienists knew that generally piezo units require less water than other types of power scaling. At the beginning of the project, the volunteers had to share one scaler; however, once the Satelec Company learned of their predicament, all of the volunteers were supplied with a piezo scaler.

NSK America makes a cordless polishing handpiece called the Taskall, a device perfectly suited for this type of project. Kim phoned the company and explained the project to them. Within days, the company had donated polishers for all volunteer hygienists.

Establishing the routine

Each hygienist's day started just before nine and ended well after four, seeing from four to eight patients per day. Residents with later stages of dementia were impossible to understand, and, at times, the hygienists were only able to perform a toothbrush prophy. The volunteers learned to accommodate residents with swallowing difficulties by working with the patient in a semi-supine position. Some residents were unable to respond to commands to open wide. This limited access to posterior teeth.

One nursing aide's comment stood out — "She is letting you clean her teeth? She won't even let us brush her hair."

The residents were assessed in their rooms, or they were taken to the activity center for privacy. Nursing aides assisted in transferring residents from their chairs to the beds for treatment. After hours of leaning over their beds, the hygienists' backs began to suffer. One volunteer had the resident sit in a recliner. The hygienist, seated in the resident's chair, wheeled it beside the recliner and began to work. Another resident was treated in a recliner while the hygienist knelt down on the floor.

Hygienists know how to make things work. The team of volunteer hygienists worked together.in harmony. These professionals were there to serve the patients.

Each resident was evaluated. The extent and type of service varied from one patient to another. The findings were recorded on a Resident Oral Health Needs Assessment Form and included the following observations:

• Acute needs — refer ASAP
• No apparent pathology
• Abscess — endo or perio
• Caries
• Fractured tooth/ filling
• Suspicious oral lesion — needs biopsy
• Oral yeast infection
• Denture care
• Prophylaxis

Each hygienist assessed six patients, conducted a prophylaxis, in as many visits as needed, cleaned and marked dentures, and provided oral hygiene instructions. The many dental needs of these residents included: multiple areas of decay, numerous fractured fillings, and several oral lesions that needed further evaluation.

Once volunteers completed their assessments and initial treatment, Lynne coordinated all of the findings. The necessary forms were inserted into the patient's medical record. The director of nursing and the social worker also received reports that detailed all of the hygienists' findings and services rendered. The personal dentist for each resident also received a letter that detailed any specific dental need.

Of the 30 patients that requested dental hygiene services, two patients died during the project. Not all patients could receive a prophylaxis, due to their health conditions. There were 18 dentate and 10 edentulous patients. Fourteen percent of all patients had acute oral health needs, which included obvious infection, pain, and/or risk of injury. Oral lesions, including denture sores, were found in almost one third of the residents. Nearly three quarters of the dentate patients had fractured teeth, and more than six out of ten had obvious caries.

In assessing the effectiveness of this project, Mary Walters, LSW, director of social services, noted that the facility staff was very impressed by the professionalism of the dental hygiene volunteers. They arrived at the home and went right to work. They were self-directed and self-motivated. These volunteers gave up their free time to participate in the project.

While some were initially a bit apprehensive, the end result was a win/win situation. Kindness, patience, and gentleness abounded as they went about their routine, and many of the residents who were unable or unwilling to see a dentist in the community were able to have their oral health assessed. The volunteers discovered how interesting and funny elderly patients can be. Family members continue to give positive feedback concerning the improvement in the level of the residents' oral hygiene.

Lynne had a dream and Kim bought into it.

They worked for countless hours until their project was successful. They proved that dental hygienists are the oral care specialists. They demonstrated that hygienists have a place in dependent care settings and can make a difference. They have provided the rest of us with a template.

Lynne and Kim did the ground-breaking. They wrote the first book on how to create a viable and effective access to care project in Texas. How many of you are willing to add to their legacy? Are we ready to follow in their footsteps, or will their efforts become a volume that doesn't have a second edition?

For further information, contact Lynne Durham, RDH, at [email protected] or Kim Hall, RDH, at [email protected]. For a copy of the project forms, please send a self-addressed, stamped ($1.25) large envelope to North Texas Dental Hygienists' Association, 1011 Timber Creek Dr. Lewisville, TX 75067.

Anne Nugent Guignon, RDH, MPH, practices clinical dental hygiene in Houston, Texas. She writes, speaks, and presents continuing- education courses on ergonomics and advanced ultrasonic instrumentation through her company, ErgoSonics (www.ergosonics.com). She can be reached by phone at (713) 974-4540 or by e-mail at [email protected].

• Use a saliva substitute with a brush to remove heavy, dry plaque. This facilitates the exam, moisturizes the mouth, and is appropriate for patients with swallowing difficulties.
• Keep visits short.
• The patient may not remember what you did at the last visit, so it may be necessary to reintroduce the procedures at each visit.
• Earn the respect of the nursing staff with your professionalism.
• Try not to get in the way of the nursing home staff. By doing so, you will foster a strong ally. From top left, clockwise, Plak-Vac, the Satlec P5, the Orascoptic WalkAbout, a Gomco suction unit, and the NSK America Taskall cordless handpiece.