Richard B. Liipfert , D.M.D. Dental Care in Long Term Nursing Facilities

1. Richard B. Liipfert, D.M.D. Dental Care in Long Term Nursing Facilities

2. Part I: ORAL HYGIENE

3. Importance of Dental Care Poor Oral Health Can Lead to Serious Health Complications Signs of Poor Oral Health • Mouth Pain • Bleeding Gums • Bad Breath • Red Swollen Gums • Visible Food Debris • Swollen Face • Heavy Plaque Buildup • Heavy Tartar Buildup • Dry Mouth • Badly Fitting Dentures • Broken Off Teeth • White Coating in Mouth • Pus at Gum line • Loose Teeth • Chipped Teeth

4. Importance of Dental Care Poor Oral Health Compromises Resident Comfort & Quality of Life • Everyone feels better when their mouths are clean, including our residents. • Their breath is fresher, food tastes better, their teeth look nicer, and they are much more comfortable. • They feel better about themselves and their family notices the excellent oral care they are receiving from you. • Also, patients with poor oral health are more susceptible to oral infections and dental abscesses. • These can result in dental emergencies and can create a life threatening situation for the more fragile resident. • Daily oral hygiene help from the nursing staff, along with regular professional treatment can reduce the incidence of dental emergencies in the facility.

5. Quality of Life Issues Poor Oral Health Dental Emergencies Poor Oral Health Compromises Resident Comfort & Quality of Life • Clean Mouths Feel Better • Food Tastes Better • Mouths Look Nicer • Residents Feel Better About Themselves Poor Oral Health Increases Risk of Dental Emergency • More susceptible to oral infections and dental abscesses. • Can create a life threatening situation for the more fragile resident. • Daily oral hygiene help from the nursing staff, along with regular professional treatment can reduce the incidence of dental emergencies in the facility.

6. Oral Hygiene Enforce Daily Oral Care! • My practice can provide the professional cleanings, fillings, etc. but this is not nearly enough to keep the mouths of your residents healthy. • We still see a rapid deterioration of dentation, even with us seeing them twice a year. • There must be consistent DAILY oral care that is appropriate to the specific needs level of the resident. When providing daily oral care, we must account for the level of physical and cognitive ability.

7. Why is Daily Oral Hygiene Lacking in Most Facilities? Enforce Daily Oral Care! • Uncooperative Residents • Lacking Education of Importance of Daily Oral Care • DMD is available for staff in-services upon request! • Facility is a Busy Place – Oral Care is not a High Priority • Mouth is Unpleasant Area

8. Daily Oral Care With dentures Without dentures Edentulous Residents • Remove and Rinse BID • Scrub with Denture Brush • Soak in Denture Cleaner Weekly • Inspect Mouth • Rinse After Meals to Remove Food Particles

9. Daily Oral Care No Physical Limitations No Cognitive impairment • Simply Remind them to Brush and Clean Dentures • Offer to Help them if Needed

10. Daily Oral Care Physical Limitations BEDBOUND • Bring Toothbrush, Toothpaste, Water, & Basin to Resident • Offer to Help them if Needed IMPAIRED MANUAL DEXTERITY • CNA Must Brush their Teeth for them • Rubber ball, Bike Handle Bar Grip • Include Brushing Teeth as a part of Physical Therapy

11. Daily Oral Care DEMENTIA PATIENT • If they Refuse, put Wet Toothbrush with Toothpaste to Lips I find that if you touch their lips with a wet toothbrush and not try to put the toothbrush in their mouth at first, often most dementia residents will remember what a toothbrush is and if you are patient, the resident will eventually let you brush their teeth.

12. Daily Oral Care COMATOSE PATIENT • These residents also need oral care • Mucous will buildup in throat and mouth • Mouth breathing causes mucous to thicken and many times harden, especially on the tongue • Brush TID, or more • Swab out mouth with Lemon Glycerin swab or wet 4x4 gauze • Difficult task for nursing staff

13. Daily Oral Care GASTRIC TUBE RESIDENT • Lacking Oral Hygiene • Staff assumes it is not necessary since they do not eat • Need Personal Suction Unit • Rinse mouth during the day with non alcoholic mouthwash or water • Brush teeth BID • Often has distinct mouth odor • Residents many times can not swallow own saliva – it pools in mouth and causes tremendous buildup of calculus • It takes Dentist and staff hours to remove this calculus buildup only to see it built back up at next visit because proper oral care is not being done.

14. Daily Oral Care Cerebral Palsy Resident • Often Uncooperative, Won’t Allow Dental Exam or Any Treatment • Daily Oral Hygiene is Impossible due to Behavior • Decay and Infections Result • Teeth are Making them Sick • Full Mouth Extractions Usually Recommended • Require Sedation in Hospital Setting/Oral Surgeon’s Office • MCG has a Residency Program that Accepts these Patients for Removal of All their Teeth

15. Examples of Poor Oral Health

16. Examples of Poor Oral Health

17. Examples of Poor Oral Health

18. Examples of Poor Oral Health

19. BOAGL (Broken Off at Gum Line) • Not Usually Painful • Recessed and Atrophic Pulp • Fibrotic Encapsulation of Retained Roots

20. Calculus Buildup on Denture

21. Placque Buildup on Denture

22. Calculus

23. Loose Teeth

24. Stains on Denture

25. Part II: Dental Tags

26. Top Things Regulators Tag For Lack of Daily Oral Hygiene • Even with a monthly dental company visiting your facility, daily oral care is required. • Do not think you will avoid dental tags simply because you have a dental company visiting your facility or a dentist on staff. • Staff must assist those residents who cannot perform daily oral hygiene.

27. Top Things Regulators Tag For Unidentified Tooth Brushes in Common Areas • When tooth brushes are stored in a common area be sure that they are properly labeled!

28. Top Things Regulators Tag For Unidentified Denture Brushes and Denture Cups • Always put patient name on denture brushes and cups.

29. Top Things Regulators Tag For Infection Control Issues with Toothbrushes, Denture Brushes, and Denture Cups • Avoid stagnant water and mold in denture cups

30. Top Things Regulators Tag For Residents are not given the Opportunity to Provide Daily Oral Care for themselves • Staff must aid residents that do not have mobility by bringing them their toothbrush, tooth paste, spit basin, and water.

31. Top Things Regulators Tag For Dental Emergencies not Handled and Documented in a Reasonable Time Frame • Dentist or Physician should be called within 24-48 hours depending on the severity of the problem. • If further attention is necessary, it also needs to be done in a reasonable time frame.

32. Top Things Regulators Tag For Documentation Issues • Annual reviews must include rational for the decision not to treat certain dental conditions. • Examples: • Advanced age • Health Considerations • Patient or Family Refusal • Asymptomatic, no inflammation, no infection present • Not completing annual reviews

33. Emergency Service True Dental Emergencies To Us: • Uncontrolled Pain • Uncontrolled Bleeding • Obvious Facial or Intraoral Swelling True Dental Emergency to You: • Resident Complaining • Surveyors in the Building • Family Member Complaining

34. Dental Emergencies Local Dentists Avoid Emergencies in Facilities Because: • Very Poor Reimbursement • Interrupts their Schedule • Lack of Proper Equipment • Lack of Expertise to Operate in this Environment Most do it as a favor. I have never had a local dentist complain when we covered their emergencies or dental needs. Sending Emergencies out to ER or Local Dentist Should be Avoided! If enrolled, Emergency Service is at no cost!!!

35. Federal Mandate, State MandateIt is the Law! • Regulatory Authorities have Not Been Enforcing Dental Care In the Long Term Care Facilities in the Past. • They Now See that Dynamic, and others can Provide Onsite Care at Nursing Facilities and are Becoming More Strict in their Surveys as it Pertains to Dental Care.

36. Federal Mandate, State MandateIt is the Law! • 42CFR 483.55(a) • Requires skilled nursing facilities to provide or obtain routine and 24-hour emergent dental care • 42CFR 483.20(b)(xi) • Requires the facility to conduct initial and period dental assessments • 42CFR 483.75(h) • Requires that if a dentist is not on staff, the facility arrange to have one under an agreement with the facility

37. “The Intent of this regulation is to ensure that the facility be responsible for assisting the resident in obtaining needed dental services, including routine dental services.” §483.55 Dental Services The facility must assist residents in obtaining routine and 24-hour emergency dental care. §483.55(a) Skilled Nursing Facilities A facility— (1) Must provide or obtain from an outside resource, in accordance with §483.75(h) of this part, routine and emergency dental services to meet the needs of each resident (2) May charge a Medicare resident an additional amount for routine and emergency dental services (3) Must if necessary assist the resident in making appointments; and by arranging for transportation to and from the dentist’s office (4) Promptly refer residents with lost or damaged dentures to a dentist. Intent §483.55

38. Help US, Help YOU! Our Goal is to Treat All the Residents in Your Facility • Most of your residents qualify for services at No Out of Pocket Cost! • We need your help identifying the residents not enrolled with dental needs. • All residents deserve quality dental care.

39. How is the Oral Hygiene In LTC? • In most facilities, daily oral care has room for improvement • We find dentures that have not been removed in weeks, or months • Granulation tissue will even grow on the appliance in extreme cases • We can provide professional cleanings every 6 months, but it is up to the staff to provide the daily oral care. • Also, take a look in your patients mouths and fill out referral forms for a dental screening

40. Conclusion • Overall Level of Care in Most Facilities is Excellent • Oral Care Needs Improvement • LTC Residents Deserve Our Respect and the Best Care we Together Can Provide

41. Questions? Richard B. Liipfert, D.M.D. Dynamic Mobile Dentistry 111 Grove Pointe Drive Macon, Georgia 31201 478-330-5038 office 478-719-4365 mobile www.dynamicmobiledentistry.com liipfertdmd@gmail.com