The nursing home situation in the U.S. is very sad. Even the best nursing homes are depressing. Nurses and certified nursing assistants run from crying residents to beepers and buzzers. From problem to problem, they exhaust themselves, running to put out fire after fire.
It's no secret that the world of dentistry is often appalled at the condition of the mouth and teeth of these residents. Dental care providers don't understand the big deal about cleaning someone's teeth, mouth or dentures. It is a big deal for caregivers in the long-term care facilities. They have people dying on the wards. They have residents who won't eat, won't take their medications and are very upset at the lack of family contact. There isn't a good resolution yet about what to do with dependent elderly in this country. Dentistry can apply some answers to take the burden off workers in the realm of oral care.
The biggest problem in oral care for the elderly, or anyone else for that matter, is bacteria. The second is fungus. Between the two they are the instigators of dental disease. Decreasing the number of bacteria and fungus is a way to decrease the amount of mouth disease. Traditionally, we think of using a toothbrush first, which is a good idea, for sure. There is more. Research tells us that using xylitol lozenges or gum after meals decreases the amount of cavity-causing bacteria so much that the risk for tooth decay is substantially decreased.
Chewing gum has been used as a vehicle for delivering oral health care aids in research for a number of years. Today there are enough chewing gums containing xylitol to make this a happy part of daily oral cares in the facilities. One piece of gum after meals and once or twice more during the day has been very effective for decreasing yeasts and the bacteria that cause dental decay.
Xylitol works by tricking the bacteria; they prefer xylitol but cannot metabolize it, effectively starving themselves. Without metabolization of a sugar there is no acid to decay the teeth. For yeast, the xylitol inhibits the yeasts ability to attach itself, rendering it harmless. Gum chewing has been shown effective in increasing muscle tone in the face and increasing the ability to taste food. Dependent people in the long-term care facilities can gain a number of points on the "quality of life" scale by having chewing gum as part of their everyday routine.
The gum should be chewed for five minutes. Xylitol in the lozenge form is a little more technique sensitive. The longer they stay in the mouth the better; chewing clears the mouth too fast -- don't chew.
Fluoride is also very important in oral hygiene. On the one hand, it's important to decrease the bacterial load with a toothbrush to decrease the incidence of decay. On the other hand, teeth need to be given the elements necessary to build up areas that are broken down. Fluoride is one of those elements. It can be delivered a couple of ways. One is with municipal water supplies that have been supplemented with fluoride. Another is toothpaste. Residents shouldn't rinse the toothpaste off when they're done brushing. This keeps the fluoride on the teeth longer. Spitting excess toothpaste is still recommended.
Another way to incorporate fluoride onto the teeth is the use of a fluoride lozenge. Like a candy, a fluoride lozenge dissolves in the mouth providing this important element to the teeth.
You can see there is more to do for "Great Aunt Mary," grandmother, or even great grandfather than insisting that someone brush their teeth.
Many of the medications that people take today cause the mouth to become dry. Dry mouth, called xerostomia in the literature, is not a natural occurrence. It is a pathological condition stemming from medications, injury or a malfunctioning somewhere along the line. In any case, the lack of saliva does a couple of things: it doesn't dilute the acids produced by the bacteria; it doesn't supply the teeth with the healing molecules of calcium and phosphorus; and it can't buffer the acids that are formed.
So, the next best thing to do is to provide those things from the outside. Unfortunately, in this country, we do not have a saliva substitute that can reproduce all the components of human saliva -- so we have to build it. Recaldent® is an ingredient in Trident White® and Trident® For KidsTM that provides the calcium and phosphorus in a way that is useful to the teeth. Biotene® products by Laclede, are salivary substitutes that contain an enzyme that breaks down the walls of the bacteria. The two together make a great team for rebuilding teeth.
All in all, oral care for the dependent classes is difficult, especially if the only option is better tooth brushing. It's frustrating to brush as well as can be expected under the circumstances and still have problems with decay. Take heart. You can make a difference to your loved one by providing xylitol-sweetened gum, fluoride lozenges and saliva replacement products such as the Biotene line of products available from your pharmacist.
There are more reasons to clean the mouth than inevitable cavities. Dental biofilms (plaque) are known to harbor all the pathogens of the lungs and GI as well. Pneumonia incidence has been shown to decrease when oral care is increased in facilities where dependent elderly live. Oral care is wound care. Power brushes (like Sonicare®) are helpful in removing the biofilms in short order. Nursing assistants have a very difficult responsibility, and they are often the ones left to take care of the residents' teeth and mouth. Offering gum and lozenges can be a way to help the residents.
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