Oral Hygiene Educational Protocol Manual

Introduction

The UBC Geriatric Dentistry Program has been delivering community dental services since 2007. The program now offers services to the residential care populations of several hospitals, and at UBC Clinics for independent older adults. In addition to dental service, the program is also committed to education and research. The model of care is based on fee-for-service delivery of dental care, although education and research are also mandated as outlined in the ELDERS manual “Oral Health Care for persons in residential care”. We hope to develop a model of care that can be available to other health regions within the province and elsewhere.

Today, the Geriatric Dentistry Program operates in 27 facilities with a team of dentists, dental hygienist, certified dental assistants, and supported by a specialized team of administrative personnel at UBC.

Purpose

The purpose of this document is to help improve the oral care of resident in long term care by engaging all of stakeholders who share in the care of the resident.

Oral Health

The Canadian Dental Association has published a position statement about the oral health of residents in long term care.

“Staff of long-term care facilities, dentists and other oral health care providers should work cooperatively, individually and collectively to develop constructive relationships and processes to advocate for and to enable the provision of appropriate care for the oral health needs of the residents.”

The Geriatric Dentistry Program recognizes we can make a significant contribution to the oral health of residents in long term care. Accordingly, to help care staff improve and maintain the oral health of the residents in long term care, The Geriatric Dentistry Program has developed the following educational goals.

Our Team

Working with the Geriatric Dentistry Program

Long term care facilities working with the Geriatric Dentistry Program offer their residents improved access to oral health services from daily mouth care, to dental hygiene and dentistry. The GDP dental hygienist educators help nursing staff develop oral care plans, and emphasize the importance of daily mouth care.

Long term care facilities under the GDP are compliant with the Community Care and Assisted Living Act (Appendix 1).

Dental Examination

Should be performed by a dentist upon the admission of the resident, then annually thereafter. Every resident should receive an annual examination regardless of whether or not they have teeth.

Dental examinations use the CODE (Clinical Oral Disorder in Elders). CODE serves as a clinical component to a comprehensive assessment of oral health in old age, which includes an assessment of gingival and periodontal health.

Dental Hygiene

During the oral examination, the dentist will recommend dental hygiene therapy based upon the resident’s need. The frequency of the dental hygiene therapy will then be assessed by the dental hygienist and will refer the resident to the dental as required. The dental hygienists will recommend the best care practice and oral care products for the resident.

The dental hygienist may be available to consult with care staff about a resident’s specific oral concern provided the resident or family has given consent to the GDP.

Community Care and Assisted Living Act, Residential Care Regulation (effective October 1, 2009)

General health and hygiene

54.

  1. A licensee must establish a program to instruct, if necessary, and assist persons in care in maintaining health and hygiene.
  2. A licensee must
    A) assist persons in care to obtain health services as required, and
    B) ensure that a medical practitioner or nurse practitioner can be contacted in an emergency.
  3. A licensee must
    A) encourage persons in care to be examined by a dental health care professional at least once every year, and
    B) assist persons in care to
    I. maintain daily oral health,
    II. obtain professional dental services as required, and
    III. follow a recommendation or order for dental treatment made by a dental health care professional.
  4. For the purposes of subsection (3), “dental health care professional” means a person who is a member of
    A) the College of Dental Surgeons of British Columbia,
    B) the College of Dental Hygienists of British Columbia, or
    C) the College of Denturists of British Columbia.

Supporting Daily Mouth Care

In order to support residents’ mouth care, nursing care teams can help by:

  • Sharing mouth care information with residents and their families.
  • Holding regular in service education sessions concerning mouth care, both teaching and hands-on for facility care staff.
  • Ensuring recommended oral care supplies are available for residents.
  • Orient new staff to daily mouth care.
  • Providing each resident with mouth care twice daily, in the morning and at bedtime, or more often as needed. Mouth care should be performed or supervised by the care staff.
  • Changing toothbrushes every 3 months and after an upper respiratory infection, or if contaminated. (dropped on the floor or an unsanitary surface)
  • Having dentures labeled. Upon examination, the dentist will recommend that the resident’s dentures are labeled. Labeling is done by the dental laboratory after consent is obtained from the family.
  • Changing denture brushes and denture storage containers every 3 months and after an upper respiratory infection, or if contaminated. (dropped on the floor or an unsanitary surface)

Daily Mouth Care Practice Guidelines 

The mouth care practice guidelines provide facilities with best-practice guidance for their residents. Created by the UBC Geriatric Dentistry Program, these guidelines are appropriate to be used by all long term care facilities.

Dentistry will be available for all residents who are registered with the UBC Geriatric Dentistry Program, (upon consent from family) however, through educational activities and in services, all of the residents in the facility will benefit from the program.

Residents with teeth

Supplies: Extra soft toothbrush and fluoride toothpaste.
Directions: Moisten toothbrush with warm water. Use a pea sized amount of fluoridated toothpaste and brush teeth, tongue, and lining of mouth 2 times a day, morning and night.

Residents with teeth and dentures/partial

Supplies: Extra soft toothbrush and fluoride toothpaste.
Denture brush and denture cup. Liquid hand soap for denture care.
Directions: Moisten toothbrush with warm water. Use a pea sized amount of fluoridated toothpaste and brush teeth, tongue, and lining of mouth 2 times a day, morning and night.
Brush denture/partial with water and liquid soap 2 times a day, morning and night. Remove denture/partial at night and leave them in a dry storage cup overnight.
Moisten with warm water before inserting.

Residents without teeth or dentures

Supplies: Extra soft toothbrush.
Directions: Moisten toothbrush with warm water, brush tongue and lining of mouth 2 times a day, morning and night.

Residents who are tube-fed or unable to swallow

Supplies: Extra soft toothbrush. May also select fluoride mouth rinse.
Directions: Moisten toothbrush with warm water, or fluoride mouth rinse. Dab on paper towel to remove extra moisture. With toothbrush, scoop out secretions. Brush teeth, tongue, and lining of mouth 2 times a day, morning and night.

Residents who have tracheostomy tubes

Supplies: Extra soft toothbrush. May also select fluoride mouth rinse. If equipped, use suction toothbrush.
Directions: Moisten toothbrush with warm water, or fluoride mouth rinse. Dab on paper towel to remove extra moisture. With toothbrush, scoop/suction out secretions. Brush teeth, tongue, and lining of mouth 2 times a day, morning and night.

Additional supplies to be available as per individualized care plans 

Mouth props Water soluble lubricant for lips
Dental floss Fluoride mouth rinse (0.05% or 0.2%)
Proxa-brushes Chlorhexidine (with prescription)
End tuft brushes Biotene products

Use of Mouth Care Cards 

Based on the assessment information, a mouth care card will be created for the resident by the facility care team.

It is recommended that the coded mouth care cards be created for each resident and posted in the resident’s bathroom or adjacent to their ADL sheet.

For ease of use, it is recommended that mouth care cards be copied onto the suggested coloured paper.

Mouth care cards and colour suggestions:

Teeth: Yellow
No Teeth Full Dentures: Blue
Teeth and Dentures: Green
Unable to Swallow/Tube Fed: Red
No Teeth no Dentures: Orange
Tracheostomy: White

Ability to provide mouth care

Independent – indicates the resident is able to brush all tooth surfaces, gum line areas, tongue and vestibule by himself/herself adequately with minimal to no plaque remaining.  This is very rare in long term care due to dexterity, visual and other physical limitations.

Assistance – indicates the resident may need hand over hand technique of tooth brushing or be able to partially brush his or her own teeth with assistance from caregiver in hard to reach or difficult areas, but cannot be relied upon to achieve adequate plaque control.

Dependent – indicates the resident requires full assistance from a caregiver for proper daily tooth brushing to take place.

Whenever a resident wishes to retain control, it should be respected and encouraged however, care staff should be available to provide support.

Mouth Care Cards – PDF Download

Routine Mouth Care Protocol – PDF Download

Tracheostomy for airway obstructed patients in extended care

Implications of tracheostomy

  • Use of suction to clear mouth of mucous/phlegm/saliva
  • No natural filtering of nose breathing, hence changes in oral and nasal bacterial microbiota
  • Increased risk of infection in stoma hole
  • May also be tube fed, but not necessarily so
  • Xerostomia
  • High risk for Aspiration Pneumonia

Mouth care in the Tracheostomy patient

  • If the patient is not equipped with a suction/compressor then follow mouth care directions for a high aspiration risk patient.
  • If the patient does have a suction/compressor and suction toothbrush supplied:
  • Kit may include suction toothbrush, cleansing solution (Sodium bicarbonate, Hydrogen peroxide, or Chlorhexidine Gluconate based), and oral lubricant.
  • Turn on compressor. Before starting it is important to use the suction catheter to clear the vestibule and oral cavity of any fluid/secretions from the patient so as to not permit too much fluid buildup during mouth care. Lubricate patient’s lips for comfort.
  • Dispense the cleansing solution provided by bursting the solution bag in the kit so as to saturate the brush head bristles while tipping the brush end downward.
  • Remove the saturated toothbrush and attach the hose to the opening of the toothbrush and secure in place.
  • Operator position between 7-9 or 3-5 o’clock.
  • Gently brush all cervical (gum line) areas, and teeth surfaces, and tongue to remove biofilm and food debris while depressing the thumb port (hole) periodically to activate the suction.
  • Clear the vestibule of any residual cleansing solution and or fluid accumulation.
  • Turn off compressor and lubricate patient’s lips again if needed.
  • If an automatic toothbrush is provided, use suction catheter at all times during procedure.

Goals

  • Provide staff with knowledge and ability to provide daily mouth care for their residents.
  • Provide staff with information that will help them value daily mouth care.
  • Inform staff about systemic health conditions and medications that may impact oral health.
  • Train staff on how to use a toothbrush, mouth prop and other mouth care aides.
  • Empower staff to feel comfortable in their ability to provide daily oral care to all residents regardless of complex health issues.

Daily Mouth Care In-Service Education

In-service education sessions will teach the purpose of daily mouth care and appropriate products for residents.  Education will also include identification and special care of conditions such as xerostomia, dysphagia, and oral lesions. It will also focus on systemic health conditions and medication pertaining to oral health.

Hands on education will teach the best practice methods for providing mouth care for all residents, including residents with dementia, aggression, and special oral conditions.

Staff will be given opportunity to demonstrate mouth care for residents during hands on in service and they will have the opportunity to ask questions and request guidance.

Education Format Information Presented Time Frame Annual Time Allotment

Didactic information presented by power point and use of educational materials. Use of: Dentaforms, Dentures, Toothbrush to demonstrate best practice.

 

 

  1. Oral Disease
  2. Daily Mouth Care
  3. Special Mouth Care
  4. Dentures, partials and their care
  5. Mouth Care Decisions
  6. Systemic health and medications.
  7. Oral health products
Approximately 45 minutes for each session. 4 hours. Often delivered in 2 or 3 back to back sessions to reach both day and afternoon, or afternoon and evening staff in one visit.
Hands On Demonstrations
  • Mouth Screening
  • Oral Care and Tooth brushing techniques
  • Denture Care
  • dfs
Approximately 10-15 minutes per resident. 2 hours. Best delivered between 9:30 AM and 11:30 AM

In-Service Outline

Participants will be asked to sign in. Sign in sheet will remain with administrators.

Care staff will be informed of a hands on in-service to be scheduled. In preparation for the hands on in-service, names of some of the more challenging residents can be collected and given to the RN supervisor.

Education Topics

Oral Disease

How plaque causes gum disease, as well as disease of bone that supports the teeth and how plaque causes tooth decay.

Daily Mouth Care

How to identify disease in the mouth caused by plaque. Why do gums bleed or why is there bad breath.

Cleaning the Mouth

How to effectively use a toothbrush to clean the teeth and mouth.

Special Mouth Care

Use of mouth props, care for dry mouth, care for residents who cannot swallow or are tube fed, residents with dementia and/or resistant to care.

Removal dentures, partial dentures and their Care

How to safely and effectively clean a removable denture or a partial denture, and how to best clean the resident’s mouth after denture or partial has been removed. What to do if a denture is not labeled.

Mouth Care Decisions

Identification of presence of oral lesions and correct process of care. (See mouth care decisions flow chart)

Systemic Health Conditions

How systemic health conditions affect oral health and how medications affect oral health.

Daily Mouth Care Products (Brushes / Floss / Rinses)

How to choose the best products based on specific oral conditions.

Care staff will be left with information about how to access BCDA care sheets and web address for Online Educational Resources for Seniors’ Oral Care.

Hands-on In Service Online

Ideally, this in service should be provided during the day, and not during a shift change.

A supervisor, such as the RN educator or care coordinator, can have a list of names of residents who are challenging to provide daily mouth care. The supervisor should accompany the dental hygienist educator during the entire hands on in service.

A plan to visit all of the residents on the list should be coordinated between the dental hygienist educator and the RN educator/care coordinator.

Plan to use the mouth care supplies that a resident has on hand for his/her own care. If there are no supplies on hand, or are not appropriate (worn/incorrect) recommendations will be made for appropriate supplies.

Ensure that oral care supplies are stored appropriately. Ideally in a kidney basin. Oral care supplies should not be stored with other personal hygiene supplies such as hair brushes or razors.

After providing educational and hands on in services, an email will be sent to the administrators summarizing the important points and questions.

It is also important to gather the names of care team members who attended both the didactic and hands on education, as they will be recognized for their participation with a UBC GDP certificate.

UBC Geriatric Dentistry Program Mouth Care Product Recommendations

Product Supplier Contact Information

Toothbrush: Compact head, long handle toothbrush #221PC

End Tuft toothbrush: Long handle, very small head 3 rows of tufted, beveled bristles
#308

Post Operative toothbrush: Narrow, long head, extra soft bristles
#317

Distributed by SunStar Gum

1-800-265-8353

Liz Stone

liz.stone@ca.sunstar.com

604-812-8395

Denture Toothbrushes- Butler #201 RYB Denture Brushes Distributed by SunStar Gum

1-800-265-8353

Liz Stone

liz.stone@ca.sunstar.com

604-812-8395

Toothpaste – Crest Cavity Protection Oral B

1-855-248 5352

 

Toothpaste – Colgate Cavity Protection Colgate Palmolive Catherine Tucker
778-896-3461
Open Wide mouth props Specialized Oral Care Co. Inc

1-800-722-7375

www.specializedmouthcare.com

Biotene Samples

Dry mouth lubrication

GlaxoSmithKlien/Sensodyne

Linda Germaine

1-800-268-5747

Oro NaF Fluoride Rinse

0.05% Sodium Fluoride Rinse

Germiphine

Tiffany Sturch

tsturch@germiphene.com

604- 961- 7717

X-Pur Opti Rinse:

0.05% Sodium Fluoride Rinse with Xylitol.

0.2% Sodium Fluoride Rinse with Xylitol

Oral Science

Karen Treadgold

k.treadgold@oralscience.com

604-765-4653

 Certificates and Forms – PDF Download