Ending the Silence in Long-Term Care Facilites - Let's Talk About It!

You're listening to The Dr. Phil Klein Dental Podcast Welcome to the show. I'm Dr. Phil Klein. Many older adults living in long-term care facilities suffer in silence from poor oral health. Today's podcast will address this concerning issue. Our guest is Sonya Dunbar, a registered dental hygienist for 30 years and known as the geriatric tooth fairy. She is an oral health educator on a mission to reduce the health risks of diseases and morbidity among seniors due to poor oral care. Before we get started, I'd like to mention that Sonya’s webinar, titled End the Silence, the State of Long-Term Care Facilities and Oral Health Care, is now available as an on-demand webinar on VivaLearning.com. Simply type in the search field Dunbar, D-U-N-B-A-R, and you'll see it. It's an excellent webinar for the entire dental team. Sonya, it's a pleasure to have you on Dental Talk. Thank you for having me. This is a topic that we really have no information on on our network as far as our podcast program. We have not interviewed anybody that's kind of an expert on long-term care facilities, and I know there's issues with oral care in these facilities, and we certainly want to get your insight on that today. So let me begin with this question. Tell us about your concern and passion for older adults that live in long-term care facilities. Thank you for asking. My passion is huge for older adults that reside in long-term care facilities. Many of them do not even get the basic oral care of having their teeth brushed daily. And it's so sad. And oftentimes they suffer in silence because the nurses or the CNAs do not go in their mouths. Oftentimes, they have low self-esteem because they feel ashamed of their mouth. And people believe when they're in long-term care facilities that people don't have a life. But they have a very active social life. And a lot of them withdraw. They go in their rooms. They do not interact with bingo, outside activities. And it appeals on the quality of their life. So if they have an active social life, they're not bedridden or they're not disabled to the point. where they won't be able to take care of their own mouth, why can't they brush their own teeth if they're active playing bingo and doing these activities in these kinds of facilities? Well, a lot of them had dexterity problems. A lot of them, they can't hold the toothbrush because they have arthritis or they have Parkinson's disease and they shake and they can't hold the toothbrush any longer or even hurts for them to hold a toothbrush. Sometimes they don't remember to brush their teeth. And their bingo may not be the same bingo that we're used to. You know, a lot of them have dementia and they just don't remember how to brush their teeth. I had one man today and he had an electric wheelchair, very bright. Well, he told me, he said, nothing is old on me but my body. My brain is very sharp. And he was 89 years old. And he came in and get his upper denture cleaned and his lower teeth. And he was pushing the electric wheelchair with one finger because he couldn't move his arms. So wait, this patient came into your office or you visited the facility to treat him? We go into the facility. So he rolled into what we set up in the facility. We usually set up in a room they give us or the beauty salon. He rolled this electric chair and he used to be an engineer. And he rolled his chair in and I, you know, I cleaned his teeth. I gave him a little kick. This was my first visit. He asked me, could I give him an electric brush so that the CNA could help him brush his teeth? And I said, how often do they help you? He said, they help me on my shower days. I get shower days two days a week. What does CNA stand for? Certified nursing assistants. Those are the people that care for the residents and do the daily activities of them. What state are you in? I'm in Florida, Georgia, and North Carolina. That's where we practice our dental offices at. Are you in a mobile situation where you actually, every day you go to a different facility or how does that work? We do pop up. So we don't have a van because I don't feel comfortable taking an older person that cannot walk well out of the nursing home. And a lot of times they're scared to go out because they can't even, oftentimes they can't get in a wheelchair on their own. They usually get lifted in the wheelchair by a hoarder. So a lot of times they don't like leaving the facility. That's just safe-hated. So we take everything into the facility. Everything that you have in the dental office, x-ray units, cavatrons, you know, high-speed, low -speed, we take all that in and it's portable. How long does that take you to set up? We have a team that sets up. It takes maybe 10 minutes. How often does that patient that you treated recently or today in that healthcare facility... see you as a hygienist? Now that he's on the program, the first visit is always with the dentist and the hygienist. So today the dentist did an exam, x-rays, and we did a cleaning. I will see him every month. Now that he's on our program, I will go in there every month. We did a basic prophy today. When we come back, we did a debridement with the cabotron. When we come back, we'll do some silver diamond fluoride. And we'll use varnish. And that's what we do. And we will apply it every month. We'll clean his teeth. We'll clean their tongue. Oftentimes their tongue is really dirty. It's because their medicines are crushed. They don't, a lot of times they have dry mouth because of the diabetes medicine, the depression medicine, not blood pressure medicine. Doc, you know the different medicines that cause. So they can't swallow their medicine. So their medicine is crushed and put in pudding. and it gets stuck on their tongue. What are the three top oral care problems that you encounter when you treat these patients in these long-term care facilities? The three top problems that we occur mostly is gum, gingival problems, gingivitis, periodontitis because of the plaque buildup, root caries because of the plaque sticking at the gum line, and denture repairs and denture cleanings. So the first two problems, would be almost obviated if they had regular brushing. And I'm not even talking about flossing, but regular brushing and maybe rinsing with a good antibacterial rinse. That would definitely reduce the amount of biofilm at the gingival area and at least keep the patient somewhat stable until you saw them the following month where they would get care again. Absolutely. So do you talk to the facility people about this? When you go there, maybe there should be somebody that can help them brush on a daily basis? Doc, you're preaching to the choir. This is why so many dental hygienists are screaming to have autonomy. Do you mind if I explain this a little bit right here? Can I open this up? Sure. Okay. First of all, most of the people in long-term care facilities, they have Medicaid. It does not pay a lot. So it's difficult for a dentist to want to go in there and work because of the Medicaid price of it. So it's good for a hygienist to go in. That's why tele-dentistry comes in or telehealth. Now, you would say, why wouldn't the CNAs, the certified nursing assistants or the nurses do it? First of all, the nurses are not going to do it because they're busy doing medications and prescriptions. So it's stuck to the CNAs. The CNAs are overworked and underpaid. The average CNA is between the ages of 18 to 36 years old. In many states, they're not even required to have a high school diploma, and they get anywhere between, I would say, 75 to 150 hours of training before they are certified to go on the floor. That's three to five days of training. Oral care is pushed into maybe a two-hour training, and it's right in there with nail polishing and combing the hair. Everybody that's working there gets almost no training at all in oral care. Not everyone, because nurses get training. The nurses get thorough, RNs get thorough training and so does LPNs. And I don't want anyone to feel that I'm throwing an RN or LPN or CNA under the bus. That's by no means that I'm doing that because anybody who takes care of a whole adult, I take my hat off to them. But I do know that these young women and men, they usually have ratio of one to 20. To every one CNA, they usually have up to 20 patients and they have to get up in the morning, get them dressed. comb their hair and get them ready for breathics or appointments. So if you have someone with dementia who fights you or bites you and you're getting them dressed to get to breathics and you have to get 20 people dressed between the hours of six and eight and bathe them and change their diaper, that's a whole lot. Yeah, no, no question about it. So when you do treat them and thank God that someone like you who is so dedicated to doing this goes to these facilities and treats these people that, You just mentioned his brain is as sharp as it was when he was 20, but his body's maybe not in as great shape at 89. And he's well aware of everything that's going on. And these people have pride in themselves still. And you want to keep that self-esteem at a level that keeps them happy and content and able to socialize with the other people in these facilities. Oral care and their teeth, of course, are very important. So tell us. Some of the things you do during that visit, let's say that patient had that initial visit and now they're on that regular re-care program that you have once a month. What do you do for that patient? What products do you use that work really well under the circumstances that we're facing here? I always use Remin Pro toothpaste on all of my patients. They like the way it tastes. It's cool and it is good for the biofilm. Is Remin Pro available retail or does that have to be prescribed? It's what a dentist can buy. Only a dentist can buy that. Okay. So your hygiene company, your hygiene organization has that in your inventory when you visit these facilities. Absolutely. We don't go in without it. Okay. And that's ReminPro and that's available through VOCO, I believe. What are some of the other things you use that you find effective based on the situations that we're facing? We always do silver diamond fluoride on root caries. Yeah. Tell us about that. Who makes that? And how is that applied? Elevate makes it. Okay. Elevate oral care. And all we have to do, and I love it because it's quick and easy. All we have to do is dry off the tooth, isolate it, and then just dab it on. And now they've come out with a gel. And we put that on and we seal it with a varnish and it works. And every time, and that arrests the decay. Because if you have an 89-year -old woman, I had an 89-year-old woman with three root tips. She had heart problems and dementia. And she was scared to leave the facility. And her family did not want her teeth extracted. The dentist didn't feel comfortable taking her off her blood thinners and doing an extraction. So we started treating her every month with Elevate, silver diamond fluoride, and varnish. And it worked. We cleaned it. We deplacked it every month. We use a silver diamond fluoride. We covered it up with the varnish and it worked. And it works all the time when we go in, when people that are compromised, what we're trying to do is give them a better quality of life and it does work. Yeah. Silver diamond fluoride is one of the fastest growing products in dentistry right now. And it's something that a lot of dentists didn't look too favorably upon earlier when, you know, there was some darkness associated with the, um placement of that material on the tooth some of the teeth would turn black oh it's nothing that we can do to stop it from turning black but for these people that are in compromised situations that they can't go out it's just the best thing for them and they love it they really love it and it works so yeah i think i think um sdi southern dental industries from australia they have a silver diamine fluoride product You can look into that too. I know Elevate sells it, but SDI also sells that. And I think they have a system where they could prevent the tooth from turning dark. Yeah, but I'm no expert on it. So after the silver diamond fluoride, what do you add? Some sort of fluoride varnish? After we do the silver diamond, we do pro fluoride. We apply that on everyone and it seals it in. And they love the taste. And they love, especially the caramel taste. They love the taste of it. And so that fluoride varnish basically seals the tooth until at least the next time you see them or even longer. Exactly. Now, some hygienists in some states can do glass arnomers, but I'm not in a state where hygienists can do that. But that really seals it. But not in Florida, Georgia or the Carolinas. We cannot do as a hygienist glass arnomers. You know, once the dentist does the exam, we're good for up to 18 months to go in and do. preventative care. But my dentists usually come in, the dentists that work in collaboration with me, my dentists usually come in every three months because by then we usually have a denture that needs a reline or adjustment and some simple extractions that need to be done or new people that need to do exams. So I usually get the dentists on board every three to four months. And when that dentist comes in, does he stay for a while? If he has to do a denture or require some lab work, does he get to stay for a few days or does he do? basically relines and they're out the door. Oh, no. No, he doesn't need to stay. He or she does not need to stay a few days. For example, we're going to a facility tomorrow. Tomorrow is going to be a hygiene day. The hygiene team is going to go in and we'll prep the people that's going to see the dentist the next day. So when the dentist comes in, we have the denture station set up with the drill. If he needs to do adjustment, he has his impression material, and he has the reline material. If she has to do extractions, we have the extraction stuff set up. So we have everything set. So when they come in, the dentist is usually not there over four to five hours. This toothpaste that you use, Reman Pro, do you give that tube to the patient, hoping they'll use it in between appointments? No. You know why I don't do that? We used to do that, but we started noticing that the staff was taking it. So that's something that we do not do. Now, what we can do, we've learned that the doctor can write a prescription of a chlorhexidine rinse. If the doctor writes a prescription of some chlorhexidine rinse, then it's on the nurse's cart. And the nurse can give it. So and they'll do that. But that's sometimes that's the best because the nurse is not going to brush their teeth, but they'll let them rinse with some chlorhexidine. So that's something they have a lot of periodontal involvement. We do that. But, you know, the nurse is not going to brush their teeth because they're passing medicines and they'll give them the pills and say rinse out with this, spit it out and they'll go on. Let me ask you this. So to our audience, you have a tremendous amount of experience working with patients that have. trouble dexterity-wise and other health issues that prevent them from doing adequate home care. And you go into these facilities and see what the results of that is. Now, in the case of a dentist who's working in a general dentist office and he has a patient come in and actually, you know, somebody drives that patient to the office, what would you recommend preventatively? similar to what you're doing in your facilities, but this patient is, but this patient is, of course, is ambulatory and able to get to the office. Would you be recommending Remin Pro for that person to use at home all the time and then have regular treatments of fluoride varnish and also silver diamine fluoride? Would all that be part of the treatment that you would recommend? I would definitely recommend the toothpaste. first thing i would do if someone's driving that patient in if the patient does not mind i would recommend if you could talk to the patient and the the responsible party is bringing them in because if someone's driving them to the appointment that's probably their caregiver and it's probably the person that's going to end up doing their long-term oral care so to educate that person would be great The toothpaste will be amazing. I wouldn't use silver diamond fluoride if you didn't have to. If they have root decay and they're in the dental office, if you can feel that feeling, do it. If they're able to come in, feel it and educate the patient about getting at those gum lines, oral care is important. If you can get them to use the Reming Pro toothpaste at that gum line and prevent that decay from getting there, that would be great. Well, thank you very much, Sandra. I think that's been a very insightful discussion about some of the issues we're certainly having. And like you said, there's kind of a silent suffering that these patients are undergoing that are in these facilities. And, you know, it's a tough situation because these patients are in Medicaid facilities and it's difficult to get the best care in the world. But you're doing an amazing job over there. And we really are grateful to you for your contributions to your community. And God bless you. Keep up the great work, Sandra. It was an honor to talk to you. Thank you so much for the opportunity. And something my grandmother used to always say, you know where you start off, but you don't know where you're going to end up. Most people don't expect to end up in a nursing home. And it's not only the Medicaid nursing homes that don't take care of the residents' teeth. I go to some pretty high-end ones. I read an article that said, you can always tell the quality of the nursing homes by the quality of the residents' oral care. Wow, that's a very good point. Yeah, that's a very good point. And that makes a lot of sense. Again, thank you very much, Sonya. Thank you so much for your insight. Thank you.