Proper oral care for every individual including dependent seniors seems pretty obvious as part of their daily routine, but what if dependent seniors with lack of dexterity cannot perform oral care properly and efficiently?

Lack of dexterity can come alongside a disability. This can be caused by tremors and the inability to latch on to a device/material (Oral care for dependent seniors, 2019). The dexterity level should be assessed each continual care to monitor for not only early disease stages, but also how the client is adapting to using a device (Oral care for dependent seniors, 2019). During the client assessment phase during their routine dental visits, the dental hygienist (as well as their caregivers) can assess for their clients’ (Darby and Walsh, 2014):

• Range of motion – The client (if able to) is reaching for their oral cavity with their arms and hands. This can determine the length the device needs to be depending on the client’s ability to reach the mouth (Darby and Walsh, 2014).

• Grip strength – Some dependent seniors with a disability, such as those with arthritis or neuromuscular disorders, may have difficulty holding certain devices because of how narrow or small they may be. Their grip strength is assessed by having the client hold on to various size of devices. This can also be done by having the hygienist (or caregiver) grip the clients’ hands gently and ask them to squeeze with as much force as possible for 1 minute – this will help determine the strength needed to be able to latch on to the device for a given time that they present with. If they are unable to hold for 1 minute, a universal cuff (such as a Velcro strap) may be recommended in order to hold the device for the needed amount of time (Darby and Walsh, 2014).

• Skill level – The clients are observed by the hygienist or caregiver on how they are self-performing oral care for their own oral cavity. During this step, the ones observing will be able to assess any areas that are unable to be reached or are being missed and if they are brushing the tongue (Darby and Walsh, 2014).

For those dependent seniors with limited dexterity, there are a number of oral self-care aids that are available/recommended if needed. These devices may be motivating for the clients to try on their own or with the help of their caregivers (Darby and Walsh, 2014):

• Plastic rulers and rods – attached to the toothbrushes and floss holders with heavy electrical tape to avoid from coming apart (Darby and Walsh, 2014).
• A toothbrush with a compact head size to better fit intra-orally (Darby and Walsh, 2014).
• The plastic manual toothbrush handle may be bent by placing it above a flame or running the handle under hot water – this will help to angle the brush bristles against the curve of the arches of the teeth (Darby and Walsh, 2014).
• Built-up (wider) device handles with different materials to better accommodate those with a weaker grip strength – such as bicycle grips, Styrofoam molds, and arts-and-crafts materials. These materials can be used with their toothbrushes and floss holders and changed when necessary (Darby and Walsh, 2014).
• Power toothbrushes are also recommended for poor dexterity (Darby and Walsh, 2014).
• A universal cuff (Velcro strap) can be attached around the arm or wrist to help with stabilization (Darby and Walsh, 2014).
• Oral care foam stick dipped in povidone-iodine mouthwash – for about 1 minute to remove food and plaque remaining on the teeth (Oral care for the dependent elderly, n.d.).
• Spatula-shaped brush with light scrubbing to clean the tongue (Oral care for the dependent elderly, n.d.).
• Caregivers may assist in cleaning their dentures daily, as recommended (Oral care for the dependent elderly, n.d.).

The dependent seniors positioning may also need accommodating. Those with neuromuscular disorders may need a stabilization device to avoid them from moving away from their upright and secure positioning by providing materials such as backrests, headrests, seatbelts, chest straps, lateral trunk supports and hip guides (Darby and Walsh, 2014).

For the individuals who are prone to having seizures, immobilization devices should be used with caution – should be removed in the event of a seizure (Darby and Walsh, 2014).

For caregivers, some assisting recommendations can be to have the senior sit down, stand beside the senior (not directly in front of them), wrap their arms around the seniors’ head to support their chin/head using their hands (Oral care for dependent seniors, 2019). Continue with gentle oral care. If the senior is unable to open their mouth, the caregiver must do their best to brush anything they can access (Oral care for dependent seniors, 2019). Even if they are only able to brush the anterior part of their teeth and the sides of their teeth facing their cheeks, this will still improve their oral health by an increasing amount (Oral care for dependent seniors, 2019).

Every dependent senior should be assessed for their level of dexterity in order for them to receive the most optimal self oral care as possible, preventing any risks of oral disease (Oral care for dependent seniors, 2019).

JE

References:

Darby and Walsh, 2014. Dental Hygiene: Theory and Practice (4th Edition) [Texidium version]. Retrieved from http://texidium.com

Don’t Let Hand Pain Prevent Proper Dental Hygiene. (2017). Retrieved from Dentistry of the carolinas: https://dentistryofthecarolinas.com/2017/02/23/hand-pain-dental-care/

Oral care for dependent seniors. (2019, May 31). Retrieved from Queen of dental hygiene: https://queenofdentalhygiene.net/2015/06/oral-care-for-dependant-seniors/

Oral care for the dependent elderly. (n.d.). Retrieved from National Center for Geriatrics and Gerontology: https://www.ncgg.go.jp/hospital/english/clinics/documents/oralcavitycare_en1.pdf

Utensil Holder. (n.d.). Retrieved from Boomer store: http://www.boomerstore.biz/utensilholder.aspx

What are activities of daily living? (n.d.). Retrieved from Liberty Healthcare Corporation of North Carolina: https://nc-pcs.com/activities-of-daily-living/

Saliva is a critical component when it comes to optimal oral health and comfort. Unfortunately, there is 20-50% of the population that suffers from lack of saliva resulting in a dry mouth (Hemalatha, 2019). The deficiency in saliva is a concern for professionals as it increases the chances of dental decay and periodontal disease while decreasing the protective components found in saliva (Huang, 2015).

   There are two diagnostic categories for low saliva flow: salivary gland hypofunction and xerostomia (Hemalatha, 2019). Xerostomia is a term that is use when the saliva flow is decreased and the patient expresses symptoms of dry mouth, whereas salivary gland hypofunction is an asymptomatic decrease in saliva. Both are names for a decrease in saliva, the difference being one is symptomatic (xerostomia) and the other is not (SGH) (Hemalatha, 2019).

   There are several reasons for one to experience SGH or xerostomia, the following is a list of some potential causes: medications, radiation, age, dentures, chronic disease, etc (Huang, 2015). The most common form of xerostomia or SGH that professionals encounter is a side effect of medication(s). With  80% of all prescription medication having this side effect, and more than 75% of the people aged 65+ taking prescription medication concludes that the xerostomia and/or SGH has a high rate of occurrence in the elderly population (Hemalatha, 2019.

• 

    Radiation of the head and neck is another cause of xerostomia or SGH, this is due to the radiation causing damage to the salivary glands which produce saliva (Hemalatha, 2019). The damage that occurs to the gland will result in fibrosis (comparable to scar tissue) of the gland which prevents it from being able to secrete an adequate amount of saliva (Huang, 2015). Generally, clients will initially notice more viscous saliva in their mouth, followed by a complete loss of any salivary production (Huang, 2015). The amount of damage caused to the salivary glands depends highly on the (Science, 2018)amount of radiation delivered to that site. The more radiation, the more fibrotic the gland will become (W.Little, 2017). 

    Medications are a large contributing factor to elderly’s experiencing salivary dysfunction; however, it is certainly not the only reason for dry mouth in this population (W.Little, 2017). Recently, there was a study done on a group of seniors in a nursing home in Taiwan to elaborate on this topic (Huang, 2017). There were two divisions of this nursing home – one side is for the ‘nursing’ side (more psychological and more debilitating situations) and the others is the ‘seniors’ side (more self-sufficient but still in need of assistance). The study was done to try and categorize which seniors require more dental care due to their dry mouth condition. The conclusion of the study was that the senior side which required less staffing/help with daily oral care are suffering much more than those on the nursing side which have a practitioner close by most of the time (Huang, 2017). Other contributing factors were the lack of professional dental visits and dentures (not being able to properly clean/care for their dentures and/or tissue below(Huang, 2017).

There are four suggested methods to aid in managing this disease. They are as follows (Hemalatha, 2019).:
1. Palliative measures
2. Saliva Substitutes
3. Drug Switching
4. Drug Therapy

    Palliative measures consist of treating any symptoms and being proactive in terms of disease prevention (Hemalatha, 2019). Methods used for this treatment is focused on homecare regimens: proper brushing/flossing, removing any plaque/food debris that saliva would generally clear, reducing intake of highly acidic food, reduce frequency of acid attacks in the mouth (not snacking all day), use of at home fluoride rinses and pastes (Hemalatha, 2019)..

    Second management option is the use of salivary substitutes and/or lubricants (Hemalatha, 2019).. There are saliva substitutes that are sold over the counter that consist of all the same components regular saliva consists of. This is a highly recommended method as the salivary substitute consists of the same chemical/physical components of saliva (Hemalatha, 2019). Therefore, it has the ability to demineralize teeth after an acid attack, break down any harmful bacteria/build up in the mouth, and protect the structures inside the oral cavity to aid in disease prevention(Hemalatha, 2019).

    Now let’s review the use of drugs to help manage SGH/xerostomia. Ideally, medical professionals would recommended drugs without this side effect or find an alternative with less chance of this side effect (Hemalatha, 2019). However, that is not realistic and the control of systemic disease takes priority. It is always an option to consult a medical professional if one is experiencing complications with dry mouth to explore alternative options (W. Little, 2017).

    Lastly, the use of drugs to help stimulate salivary flow: Pilocarpine Hydrochloride (Hemalatha, 2019). This is a medication that stimulates salivary flow by mimicking the body’s natural pathway of creating saliva. The drug works on the brain that sends signals to the salivary glands to release more saliva (Hemalatha, 2019). There are different types and dosage depending on the client. This is a medication that is generally needed to be taken consecutively for optimal results (Hemalatha, 2019).. Like all medication, there are side effects to pilocarpine hydrochloride and it is advised that one consults their medical professional to ensure this medication is appropriate for them (Hemalatha, 2019).

How to manage SGH or Xerostomia (Huang, 2017)
-Regular professional dental visits
-Appropriate preventative care (fluorides, counselling, debridement, etc)
-Use of sugar free gum and/or salivary substitutes
-Keep hydrated
-Use fluoride tooth paste/mouth wash
-Ensure proper homecare is being done (with assistance if needed)

To conclude, when one is diagnosed with SGH and xerostomia it will affect many aspects of their life and it truly does result in a decrease in quality of life. Saliva aids in speech, eating and comfort which are part of our everyday tasks (Huang, 2017). Although this disease may be inevitable for some, there are certainly ways to manage it so that one can enjoy their life while maintaining health and comfort.

In summary, the following are list taken from the Oral Science website to aid is understanding and managing salivary gland hypofunction or xerostomia (Science, 2018):

CLINICAL SIGNS OF XEROSTOMIA (SCIENCE, 2018)

-Burning sensation
-Food sticks to mucosa 
-Oral health problems / Tissue alterations
-Angular chellitis (corner of lip sores/inflammation
-Candidiasis (fungal infections)
-Caries (Cavities)
-Halitosis (Bad breath)
-Loss of filiform papillae on tongue (Shining appearance of tongue)
-Mucositis (Inflamed, sore tissues in the mouth)
-Oral lesions
-Pain
-Periodontal disease (Gum disease)
-Redness of the tongue
-Taste alteration 
-Tooth sensitivity

FUNCTION OF SALIVA (Science, 2018):

-Acting as a buffer to neutralize acidic challenge
-Aiding in immune response with the presence of proteins, cytokines, hormones and mucins
-Aiding in proper speech and articulation
-Delivering calcium, phosphate and fluoride
-Performing as a lubricating agent
-Playing an active role in elimination of food and bacteria
-Protecting exposed root surfaces

CLINICAL SIGNS OF XEROSTOMIA (SCIENCE, 2018)
-Burning sensation
-Food sticks to mucosa 
-Oral health problems / Tissue alterations
-Angular chellitis (corner of lip sores/inflammation
-Candidiasis (fungal infections)
-Caries (Cavities)
-Halitosis (Bad breath)
-Loss of filiform papillae on tongue (Shining appearance of tongue)
-Mucositis (Inflamed, sore tissues in the mouth)
-Oral lesions
-Pain
-Periodontal disease (Gum disease)
-Redness of the tongue
-Taste alteration 
-Tooth sensitivity

ADVICE WITH XEROSTOMIC PATIENTS (SCIENCE, 2018):
-Changing or modification of the medications’ dosage
-Drink milk while eating 
-Frequent dental exams
-Frequent hydration (sip water regularly) unless there’s cause not to: Severe restrictions from cardiac and renal problems
-Humidification of the bedroom
-If no risk of choking: sucking on ice cubes or frozen juice bars
-Mash, humid food with light touch of citrus
-Rigorous dental hygiene

TO AVOID WITH XEROSTOMIC PATIENTS (SCIENCE, 2018):
-Alcohol
-Coffee
-Highly acidic food
-Sweet food
-Tobacco

TH

References

Hemalatha, V. T., Julius, A., Kumar, S. P. K., Periyasamy, T. T., & Sundar, N. M. (2019). Xerostomia: A current update for practitioners. Drug Invention Today, 12(3), 388–392. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=135900216&site=ed

Huang, Y.-C., Chu, C.-L., Ho, C.-S., Lan, S.-J., Chen, W.-Y., Liang, Y.-W., & Hsieh, Y.-P. (2015). Factors affecting institutionalized older peoples’ self-perceived dry mouth. Quality of Life Research, 24(3), 685–691. https://doi.org/10.1007/s11136-014-0792-7

James W. Little, Donald Falace, Craig Miller, Nelson L. Rhodus. (2017). Dental Management of the Medically Compromised Patient (9th Edition) [Texidium version]. Retrieved from http://texidium.com

Science, O. (2018). Google. Retrieved 06 17, 2019, from Oral Science: https://www.oralscience.com/en/protocols/xerostomia/

As we know, many dependent seniors wear dentures. What are dentures? A denture is an artificial material that mimics teeth and gums as a replacement (What are dentures?, 2019).  

Dentures are considered to restore oral functions (including missing teeth and bone resorption) and to restore the facial features around the mouth (Darby, & Walsh, 2014, p.1006).

There are different types of dentures made in a laboratory to meet the needs of individual seniors as listed below:

• Partial denture -> replaces only some and not all missing teeth and gums. Can be removed and placed back into the mouth by the client. The partial denture rests on metal framework (retainer clasps) and is supported by natural teeth when placed inside the mouth (Darby, & Walsh, 2014, p. 1007).
• Full/complete denture -> replaces all teeth and gums of either the upper or lower arch. Can be removed and placed back into the mouth by the client (Darby, & Walsh, 2014, p. 1008).

Caring for the denture includes removing the denture to clean after eating and before bed. Brushing the denture with a cleaning solution and a denture brush daily will avoid microorganisms from harvesting on to the denture and remaining inside the oral cavity. Soaking the dentures before bed time in water with a mild overnight cleanser will remove the bacteria (which also removes the odour) and the moisture will stabilize the shape of the denture. (Proper Denture Care and Maintenance, 2019)

 (Dental Use and Care Instructions, n.d.)

 (Dental Use and Care Instructions, n.d.)

The advantages for dependent seniors with dentures are the following:

• Seniors will have a full functioning set of teeth to assist with smiling, speaking and chewing solid foods (What are the benefits of dentures?, n.d.)
• Have them look and feel much better about their overall appearance (without the ‘sunken cheek’ appearance) (What are the benefits of dentures?, n.d.)
• Can last for a long time only if taken care properly – around 5-10 years (Dentures: Their Advantages and Disadvantages, 2019)

Although dentures can be a huge advantage to many, there are many disadvantages to consider, as listed below:

• Dentures tend to move around in the mouth, which can become irritable when chewing or speaking (will need some getting used too) (What are the benefits of dentures?, n.d.)
• Denture care needs to be addressed as important as caring for natural teeth to avoid any bacteria build up (What are the benefits of dentures?, n.d.)
• Masticatory stress (pressure in the mouth from the denture) can result in continuing alterations to the gums and oral cavity (Darby, & Walsh, 2014, p. 1010).
• There are risks of having inflammation and lesions in the mouth, if not removed and cleaned properly (Darby, & Walsh, 2014, p. 1010).
• Bacteria left on denture built up can cause periodontal disease – first signs being tartar at the base of the teeth, which then lead to tissues of the teeth and gums being destroyed (Oral Care for the Elderly, n.d.)

Dependent seniors may not be caring for their dentures as often or adequately as they should be and that can be due to many reasons; such as the family member or caregiver is unable to care for the senior adequately and/or regular dental visits for them decrease or cease over time (Our health system neglects the oral health of dependent seniors with tragic consequences, 2017).

When caregivers and/or family members are providing the care for others, it requires a skill with the responsibility and resources to do the care regularly and properly (Our health system neglects the oral health of dependent seniors with tragic consequences, 2017). While the registered nurses of Ontario have a guideline called “Oral Health Nursing Best Practice Guidelines” that they follow to ensure proper daily oral care is being performed for the dependent seniors, it is important that the seniors and family members understand the importance and are as well educated on the concerns (Our health system neglects the oral health of dependent seniors with tragic consequences, 2017).

The following listed below must be taken into consideration for the caregiver and family member in order to avoid any problems in oral cavity of the dependent senior:

• Dental visits regularly (Caring for Dentures tips for Seniors and Caregivers, n.d.)
• Encouraging the seniors to remove and clean on their own with support if needed (Caring for Dentures tips for Seniors and Caregivers, n.d.)
• Avoid cross-contamination by wearing gloves (Caring for Dentures tips for Seniors and Caregivers, n.d.)
• First remove the lower by holding the front teeth between the thumb and index finger and then lifting it out. Next remove the upper denture by lifting the lip and using fingers to tip the front teeth (rocking the denture back and forth may help remove the seal) (Caring for Dentures tips for Seniors and Caregivers, n.d.)
• Carefully remove partial dentures by using fingers and gently pulling the metal clasps away from the teeth (either downward or upward motion) (Caring for Dentures tips for Seniors and Caregivers, n.d.)
• Remember to inspect the mouth for any sore spots that do not heal in a few days, white or red patches, or any changes of colour in the mouth. These concerns may need to be addressed to a dentist (Tips for Caregivers, 2019).
• Assist with proper denture cleaning performed as listed before and clean any natural teeth if any are remaining (Caring for Dentures tips for Seniors and Caregivers, n.d.)
• Clean by massaging the inside of seniors’ mouth using a damp cloth or a soft toothbrush (Tips for Caregivers, 2019)
• Encourage the senior to reinsert the denture or assist if help is needed (Caring for Dentures tips for Seniors and Caregivers, n.d.)

By doing these important necessary steps, this will reduce the risks of any concerns, the seniors will feel more confident and will keep smiling!

JE

References

Caring for Dentures tips for Seniors and Caregivers. (n.d.). Retrieved from Your dental health: http://www.yourdentalhealth.ca/Assets/Caring%20for%20Dentures_YDH.pdf

Darby, & Walsh (2014). Dental Hygiene: Theory and Practice 4th Edition. St. Louis: Elsevier Canada

Dental Care Tips for Seniors. (n.d.). Retrieved from Smile of Bellevue: https://www.smilesofbellevue.com/2016/01/20/dental-care-tips-for-seniors/

Dental Use and Care Instructions. (n.d.). Retrieved from Ivory Dental Clinic: http://ivorydentalclinic.co.in/patient-info/post-treatment-info/denture-use-and-care-instructions/

Dentures: Their Advantages and Disadvantages. (2019). Retrieved from Really Smile: https://www.reallysmile.com/blog/dentures-their-advantages-and-disadvantages/

Oral Care for the Elderly. (n.d.). Retrieved from Nha Khoa Nhan Tam Dental Clinic: https://www.nhakhoanhantam.com/blogs/oral-care-for-dependent-elderly/oral-health-care-for-the-elderly

Our health system neglects the oral health of dependent seniors with tragic consequences. (2017, July). Retrieved from Ottawalife: http://www.ottawalife.com/article/our-health-system-neglects-the-oral-health-of-dependent-seniors-with-tragic-consequences

Proper Denture Care and Maintenance. (2019). Retrieved from Millwoods Denture Clinic: https://www.millwoodsdentureclinic.com/b/proper-denture-care-and-maintenance

Tips for Caregivers. (2019). Retrieved from Canadian Dental Association: https://www.cda-adc.ca/en/oral_health/cfyt/dental_care_seniors/tips.asp

Types of Prosthodontic Prostheses. (2014). In &. W. Darby, Dental hygiene: theory and practice 4th edition (p. 1007).

What are dentures? (2019). Retrieved from Colgate: https://www.colgate.com/en-us/oral-health/cosmetic-dentistry/dentures/what-are-dentures

What are the benefits of dentures? (n.d.). Retrieved from Medic8: http://www.medic8.com/cosmetic-dentistry/dentures/benefits-dentures.html