Nursing Home Lesson Plan Outline

The Importance of Meticulous Oral Hygiene in the LTC Setting

Site:
Accura Healthcare
Family Room

Friday, February 17, 2017

1:45
Program Length: Approx. 25-30 min

Presenter: Emily Hummel

 Nursing Home Dental Hygiene Lesson

Title: The Importance of Meticulous Oral Hygiene in the LTC Setting

Assessment: Accura Healthcare can accommodate 54 residents. At

this time only 47 residents reside here. The majority of the residents
are elderly, but there are half a dozen residents between the ages of
30 and 40 years old. At least fifty percent of the residents need hands
on oral care assistance. If they wear dentures that automatically puts
them in that category. The more independent residents are asked daily
if they have carried out there mandatory oral care. Accura utilizes
Point of Care, which is a computer system that helps document
nutrition, hygiene, and a lot more. CNAs and nurses are available as
oral care resources. It is there job to take care of the oral hygiene for
residents who need assistance and help anyone else who may need it.
During intake of new patients, a quick once over is done through the
mouth, checking for any swelling, redness, and missing teeth. They
also make sure the patient has no pain in the oral cavity. Accura
Healthcare has partnered with Senior Dental. Senior Dental comes on
site to perform cleanings and simple extractions. They make it in 1 to
2 times a month. If something is too serious to perform on site they
will take the residents where they need to go to get the help they
need. The denture protocol is for the CNA to take out the denture at
night, brush the denture and soak the denture over night. In the
morning the denture is to be brushed again and rinsed before being
placed in the patients mouth for the day. Tammy hopes this in-service
oral health education will help the staff understand how important
proper oral hygiene is, and how important it is to keep the oral cavity
healthy. She feels like the overall attitude towards oral care in the big
picture is underestimated. The simplest thing such as bad oral hygiene
leading to pain which leads to the patient not eating is also something
she stresses to her staff. There has not been an oral care presentation
at this nursing home yet. The residents have many health services
available to them. A dietician and physical therapist is just a couple of
the services they have available. If the resident needs it Accura
Healthcare will provide it. In-service training is usually carried out in
the family room. The presentation is scheduled during a shift change
so both the staff that is leaving and the staff that is arriving can
participate. A projector is not available so poster boards will be
utilized.

Statement of Purpose: The purpose of teaching nursing home staff

proper oral care is to ensure that the residents have a healthy, pain
free life. Not only is a healthy mouth good for eating, drinking, tasting,
and speaking, it helps keep the rest of the body healthy as well. The
oral cavity really is the window to the rest of the body. So, for
individuals who cannot perform hygiene for them selves, a well-taught
provider is crucial to their wellbeing.

Goals and Objectives:

Goal 1: Staff will understand the major health complications that are
linked to poor oral hygiene and the importance of regular oral
screenings and what to look for while screening.
Objective 1.1: 90% of the staff will be able to name the correct
answer of pathology shown to them.
Objective 1.2: 100% of the staff will be able to name the three
major health link covered today
Goal 2: Staff will understand the importance of proper oral hygiene of
residents with natural teeth and residents with dentures and the
appropriate techniques complete these tasks.
Objective 2.1: Staff will be able to demonstrate back to me the
C shape flossing technique with 95% accuracy.
 Objective 2.2: Staff will be able to tell me the steps on denture
care at night and in the morning with 90% accuracy
Objective 2.3: Staff will be able to tell me at least two things
that should be avoided with dentures.
Goal 3: Staff will recognize other possible approaches to complete oral
hygiene on difficult patients
Objectives 3.1: Staff will be able to repeat at lest two ways to
help make a resident feel more comfortable.

Introduction: Hi everyone I am Emily Hummel a dental hygiene

student from DMACC! Today I am here to talk about the importance of
daily oral care for the elderly. Not only do the majority of your
residents suffer from age related ailments but as you all know and
have probably seen their oral hygiene also deteriorates. Some may
not be able to complete any oral care on their own, some may need a
little help, and some may just need a reminder. Either way proper
technique should be used and carried out daily. A couple of the
benefits of good oral hygiene for your residents
-Residents mouths will smell better, making it more pleasant for
everyone to interact with them
-There will be fewer residents who silently suffer or act out because of
undetected infection
-Residents with healthy mouths will be more confident to smile,
socialize, and eat without pain or embarrassment.
I know everyone here cares a lot about the residents they work with
and I am sure you have grown personal relationships with each and
every one of them. So this will all also benefit you.
So today what I really want to hit hard is overall health complications
that are linked to poor oral hygiene, what to look for when assessing
the oral cavity, proper oral care for residents with their natural teeth,
residents with dentures, and some tips and tricks for those patients
who may be a little more difficult. Whether you have those patients
now or possibly in the future.

Lesson Body:
1) What Im going to start with is the health complications we run
into with poor oral hygiene in the elderly. The link between poor
oral hygiene and diabetes is a common health complication to
run into and not just in the elderly. Not only does diabetes
increase the risk of getting periodontal disease but also
periodontal disease increases the risk of getting diabetes. So we
need to constantly be preventing infection from forming.
Periodontal infections can affect control of blood glucose levels
by increasing insulin resistance. Inadequate dental biofilm
control contributes to more severe tissue response because of
decreased resistance.
So poorly controlled periodontal health may alter blood glucose
levels and infections affect insulin requirements and may lead to
unstable diabetes.

Aspiration pneumonia is the leading cause of death in personal

care homes. Aspiration of oral and throat secretions are the
main cause of pneumonia. A correlation has been shown
between aspiration pneumonia and:
-Periodontal disease
-Poor dental plaque control
-Dry mouth
-Having natural teeth (especially with untreated dental caries)
-Uncooperative behavior during oral hygiene care
-Wearing dentures during sleep
-Trouble swallowing
Persistent daily oral hygiene in elderly living in nursing homes
was found to improve swallowing function by increasing time of
swallow and increasing salivary secretions. So to think that the
oral hygiene that we can control everyday for these residents,
 may actually save there life, is a real eye opener. Just by
thoroughly removing and reducing the germs and bacteria on the
teeth that gets into the lungs significantly reduces the risk of
aspiration pneumonia.

Poor oral hygiene can create a bactermia in the blood stream

that if left untreated can affect cardio vascular diseases resulting
in death. Infective endocarditis is one of those cardiovascular
diseases that is caused by the formation of bacteremia in the
blood stream (microorganisms in the blood). The bacteria form
growths on the heart valves or endocardial lining. If untreated
infective endocarditis is usually fatal, but with proper antibiotics
recovery is possible. (What makes someone prone?) What makes
someone prone to IE is previous history of IE, artificial heart
valves, or serious congenital heart conditions, and heart
transplant patients who develop a problem with a heart valve.
You want to identify high-risk residents by looking at their health
history and questioning them. These residents need help
maintaining optimal oral health and biofilm control to minimize
the chance for self-induced bacteremia. Encourage this resident
to maintain continued care visits with their dentist. A
preventative antibiotic is administered 1 hour before these visits
so optimal blood levels are established reducing the risk of
creating a bacteremia.

2) What to look for

-Oral cancer: With any painless lesion that doesnt heal in
two weeks it should be checked by a doc.
Squamous cell carcinoma: (epidermoid carcinoma) Is
the most common primary malignancy of the oral cavity. It can
metastasize or move to lymph nodes of the head and neck and
then to more distant sites such as the lungs and liver. They can
be seen as an ulcerative mass that is white, red, or a mixture of
white and red. They can occur anywhere in the oral cavity but
most arise on the floor of the mouth, laterals of the tongue, soft
palate, and tonsillar pillars.
Malignant Melanomas: Should be considered when
assessing pigmented lesions of the skin or mucosa. Lesions that
show these characteristics should be further evaluated to rule
out melanoma.
Asymmetric (that is one half being different from the other)
Borders (lesions with irregular borders)
Color (lesions in which the color varies from black to tan
and possibly red or blue)
Diameter (greater than 6mm)
Evolving (changing in size, shape, or color)

-Candida albicans (oral candidiasis): D1089 Most common

fungal infection in humans. It is caused by an imbalance in oral
flora and host immunity. It can be seen as a white cottage
cheese-like mass that wipes off with red inflamed tissue and
bleeding underneath (pseudomembranous Candidiasis
As a red lesion usually on the hard palate and dorsal surface of
the tongue called erythematous candidiasis
And as elevated white-yellow patches that cannot be wiped off
chronic hyperplastic candidiasis
Prevention for all of these is the same; Routine oral care, daily
denture care, dentures out every night, mouth moisturizer if dry
mouth is present.

-Denture stomatitis: Is an inflammation of the oral mucosa

that contacts a complete or partial denture. It is the most
common inflammation of the removable denture happening in up
to 65% of older adults who wear complete maxillary dentures
(Wilkins 1011). This is seen as generalized redness of the
mucosa contacting the denture; it has a velvet like appearance,
and pain and burning sensation in that area.
-Papillary hyperplasia is also something to keep an eye out for
in denture wearing residents. You will find red granular papillary
projections described as looking like cobblestone. The cause is
associated with poor denture hygiene, ill-fitting dentures, and
Candida Albicans. If severe enough may have to be resolved
with surgery, anti fungal agents, but can be cleared up with strict
oral hygiene measures.

-Xerostomia: A lot of medications taken by elderly cause

reduced salivary production. Anticholinergics, diuretics,
anticonvulsants, antidepressants, antibiotics, and the list goes
on. Oxygen has also been shown to have a drying effect on the
mucosa. Saliva is essential for keeping oral infections at bay. It
has protective, antibacterial properties that maintain a healthy
balance of resident bacteria, and also helps to wash away debris
and food particles. Inflammation and infection can occur as a
result of reduced saliva production. Debris sticks to the teeth
forming plaque at the gum line, which leads to gingivitis, decay,
or periodontal disease. When a resident is suffering with severe
xerostomia you want to moisten the lips then the inside of the
oral cavity every time before you do oral hygiene care on the
patient. Going in a dry mouth with a dry toothbrush can really
do damage. It will also make the resident a lot more comfortable
moistening the oral cavity. You can moisten the oral cavity with a
dry mouth rinse on a little sponge and swab it around. Or even
water if that is all you have on hand.

-Angular cheilitis: Is seen as fissuring at the corners of the

mouth, with cracks, ulcerations, and redness. It is either moist
with saliva or dry with a crust. It can be caused by lack of
support of the corners of the mouth because ill fitting dentures.
Riboflavin deficiency can cause this as well as an infection by
 candidia albicans. A prescription antifungal medication may be
indicated in that case.

-Dental Caries: Everyone probably knows as cavities. It is an

infectious and actually a transmissible disease caused by
bacteria and fermentable carbohydrates. There are many factors
that can make a person more susceptible such as tooth anatomy,
saliva, fluoride use, diet, and oral hygiene. In elderly the most
common place to find cavities is on the tooth root. Root
exposure is common because of gingival recession in the elderly.
The cementum, which covers the root, is a lot less dense than
the enamel covering the crown so cavities can form very easily
on the root. Of course cavities can be found anywhere on the
teeth, so we just want to keep an eye out for these so they dont
progress and lead to pain, tooth loss, or a root canal.

-Calculus: is oral biofilm that has been mineralized by the

saliva. Everyone accumulates calculus just some people more
than others. Although calculus doesnt harm the teeth it enables
the attachment and retention of plaque biofilm, which can irritate
the gums. So if you are seeing a lot of calculus in the mouth its
probably time to get a hygienist to clean their teeth.

3) For a resident who has their natural teeth flossing and brushing
with a soft toothbrush twice a day is key. The bass technique is
the most efficient way to clean the teeth and gums. This is
positioning the toothbrush at a 45-degree angle towards the
gums and using short back and forth strokes for atleast two
minutes. This cleanses both the teeth and ensures bacteria
disruption under the gums. If bacteria has time to sit and
colonize underneath the gums, infection and disease is likely to
form. Even the bass technique cant reach all the areas we need
to hit so that is where we bring out the floss. The easiest way to
 floss someone elses teeth is to wrap the floss around your two
middle fingers and only using two fingers in the mouth at a time,
either two pointer fingers, two thumbs, or a pointer finger and
thumb. This makes it easier to access the back teeth and the
patient doesnt feel like they have so much in their mouth. When
flossing the teeth you want to wrap the floss around the tooth in
a c shape and gently move it up and down to help access
under the gums and prevent floss cuts. If you repeatedly push
the floss straight down between the teeth it will cause floss cuts
and can create gingival clefts. Weather you use floss picks or the
floss with the long handle you still should make sure to wrap the
floss towards each tooth surface.
For patients who have trouble swallowing or spitting a suction
toothbrush may really come in handy. It helps keeps the saliva
build up down when brushing.
An electric toothbrush also makes brushing residents teeth
easier. All you have to do is place the toothbrush in the 45-
degree angle and gently guide it around the mouth. It is also
easier for the patients who can brush their own teeth but may
have arthritis and cant handle a thin toothbrush handle anymore.
The thicker handle makes it easier and more comfortable for
these patients. The small brush head attachments make it
easier to reach those tough to reach spots as well.

4) For a resident with dentures you want to be sure to remove the

denture every night, no exceptions. It is important to clean both
the denture and soft tissues in the mouth daily. After eating
meals throughout the day the denture should be removed and
cleansed by rinsing under water to ensure no food is trapped
underneath causing irritation. When removing for the night,
gently remove the denture, and rinse away saliva and loose
 debris, and in the case of a complete denture remove any
adhesive material used. Then use a denture brush to remove
accumulations on the inner impression and outer polished
surfaces. Again rinse the denture and brush under water.
Inspect the denture for any remaining biofilm or food debris then
place prosthesis in assigned denture cup with cleanser over
night. On removal of the denture from the mouth, with a soft
toothbrush or a soft cloth use long strokes from the back to the
front to clean the edentulous mucosa and tongue and vestibules.
In the morning before insertion of the denture the oral cavity
should be cleansed again. The denture should be removed from
the cleanser and brushed and rinsed thoroughly again then
placed in the oral cavity. The cleanser should be changed daily.
When dealing with dentures be sure to avoid
-Abrasive cleaning material (stiff brushes or harsh toothpastes
such as whitening toothpastes that may damage the denture)
-Bleach containing products (this may weaken dentures and
change their color. DO NOT soak dentures with metal
attachments in solutions that contain chlorine because it can
tarnish and corrode the metal)
-Hot water (to hot of water can warp your dentures)

5) How to handle the difficult or reluctant resident. Dental care can

be scary to some people so making sure they are in a
comfortable relaxed atmosphere may help calm there nerves.
The tell-show-do approach helps deal with this natural reaction.
Tell the clients about each step before you do it, show them how
youre going to do each step before you do it, and then do the
steps in the same way that youve explained to them. Be patient
as your resident builds trust with you working in and around their
mouth cause it may take some time to adjust. Let them know
you care and always give positive feedback. Use the same
techniques, at the same time and place every day. Making it
 routine can help soothe fears or help eliminate problem behavior.
Allowing the resident to hold a special item for comfort, playing
their favorite music, or making oral care a game are some ideas
to help with difficult residents. Individualized approaches will
have to be determined. If getting in the residents mouth for
more than a minute is a problem then hitting every area in the
mouth is probably an issue. Using a 3-sided brush gives you
complete tooth coverage and easier access to all surfaces of the
teeth in a shorter amount of time. This DenTrust toothbrush
applies the bass brushing technique automatically. Just apply
toothpaste to the bristles and use short back and forth strokes.
The back of the toothbrush head has a tongue cleaner. Just flip
the toothbrush over resting the cleaning ridges on the tongue
and pull forward.

All right we are going do a little activity. Im going to show you

different pathologies that you might see in the mouth and out of
these pathologies I have written down I want you to tell me which
one it is.

Evaluation:
Goal 1: Staff will understand the major health complications that are
linked to poor oral hygiene and the importance of regular oral
screenings and what to look for while screening.
Objective 1.1: 90% of the staff was able to name the correct
answer of pathology shown to them.
Objective 1.2: 100% of the staff named the three major health
link covered
Goal 2: Staff will understand the importance of proper oral hygiene of
residents with natural teeth and residents with dentures and the
appropriate techniques complete these tasks.
Objective 2.1: Staff was able to demonstrate back to me the
C shape flossing technique with 95% accuracy.
Objective 2.2: Staff was able to tell me the steps on denture
care at night and in the morning with 90% accuracy
Objective 2.3: Staff was able to tell me at least two things that
should be avoided with dentures.
Goal 3: Staff will recognize other possible approaches to complete oral
hygiene on difficult patients
Objectives 3.1: Staff repeated two ways to help make a
resident feel more comfortable.
Materials List/ Teaching Aid
a) Pamphlet (attached)
b) Pictures of oral pathology
c) Pictures of oral care products and proper techniques
d) Products to be utilized (sensodyne, dry mouth rinse, denture
cleaner, denture brush, denture container, 3 sided toothbrush,
super floss, etc.)
e) Mouth model
f) Smoking, diabetes, and cancer handouts.