Oral Health Assessment for Assisted Living Residents

In this episode, Deborah Dowd, RDH, MS, speaks about her team’s research on oral health assessments and reassessments for assisted living residents, including the rules and regulations in 12 western states, and the importance of specifying oral self-care performance as part of the activities of daily living (ADL) assessment.

Additional Resource:

Deborah Dowd, RDH, MS, is a dental hygienist and an adjunct instructor at Utah Valley University and Fortis College (Alpine, Utah).



Jessica Bard: Hello everyone. And welcome to another installment of Podcast 360, your go-to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant360 Specialty Network.

Oral health is essential for promoting good overall health in vulnerable older adults. Deborah Dowd is here to speak with us today about her team's research on oral health assessments for assisted living residents. Deborah is a dental hygienist and an adjunct professor at Utah Valley University and Fortis College in the Salt Lake City, Utah area. Thank you for joining us today. Can you please give us an overview of your research?

Deborah Dowd: Yes. The purpose of our study was to describe and compare the resident intake admission assessment process and the reassessment process among 12 western states for assisted living facilities related to the resident's oral health and their ability to provide oral self-care. The design investigated the similarities and differences among assisted living facilities of those 12 states. Each respective state's department, or division of health agency website, and the legislator's website were searched to determine state laws and regulations for assisted living facilities.

Verification occurred that the data collected were consistent with the rules and regulations of those individual states and the government relayed as being accurate and current by a person within the governmental agency responsible for the oversight of assisted living facilities. The state admission assessment rules and regulations, along with the state required oral health assessment tools were evaluated to answer each research question.

Jessica Bard: How did this research topic come about?

Deborah Dowd: So, this research topic came about as a result of my thesis research at Idaho State University. I had been involved in a pilot study where a group of dental hygienists went into an assisted living facility and set up portable equipment to provide dental health services, including an oral evaluation, dental x-rays, intraoral photos, oral education, and cleanings for the residents.

The oral conditions of the residents we saw that day were very poor. Each of them had moderate to heavy plaque bacteria on their teeth and some level of gum or gingival disease ranging from gingivitis to periodontal disease. And in addition, there were multiple teeth with cavities present. It was very saddening to see the condition of these residents oral cavity. And from this experience, I wondered if assisted living caregivers helped residents care for their teeth and provided assistance with brushing with their teeth or dentures.

So as a research team, we questioned what emphasis was placed on oral health. So we considered the methodology of evaluating 12 western states’ rules and regulations for assisted facilities. We discovered assisted living facilities are licensed by states, which established rules and regulations facilities must follow. These requirements include an initial assessment at admission and a reassessment at periodical intervals. Assessment data are used for care planning and determining need services.

However, little was known about state requirements for assessing residents’ oral health status and their ability to perform daily oral self-care. So, our first research question that came about was, what the resident admission assessment process are for determining oral health status and the ability to provide oral self-care in assisted living facilities. For our second question, then it went on into the residents' reassessment process and how they went ahead and determined their oral health status and their ability to provide oral self-care in the assisted living facilities.

Jessica Bard: Can you elaborate on the results of your study and did those findings surprise you?

Deborah Dowd: So, an important point that I'd like to consider before I get into the results is that understanding that oral health is an integral part of our overall health and therefore oral health care is an essential component of a comprehensive health care. So in addition to systemic links, evidence shows a correlation between poor oral health and quality of life related to eating, speaking, overall appearance, and wellbeing. Current research shows there's a systemic connection between many chronic diseases and periodontal disease. Some of the conditions include diabetes, heart disease, Alzheimer's and dementia. Those individuals with a chronic disease are at higher risk for getting periodontal disease and in turn, the periodontal disease impacts the chronic disease. Some of the results that we found with our research revealed that assessment for oral health status and oral self-care lacks a consistency and completeness across the states.

To determine the oral health status of assisted living residents, the assessment forms may only have a single question about whether they have dentures, or an additional question associated with chewing or swallowing problems. And then these questions are asked to residents or family members. So overall we found that oral health is not valued at the level it may need to be. And that there's little value placed on evaluating that oral health among some of the nursing, maybe medical staff or administrators of the residential facilities.

Along with that, none of the state admission requirements included an actual oral health evaluation or actual exam of the teeth, whether they were loose, natural or decayed, the gums, the tongue, lips, or oral cleanliness. So the one interesting finding, however, among those individuals, anyone that was covered by Medicaid were required to have a limited evaluation of their oral status using a minimum data set, which is a federal government-required assessment tool used for care planning and reimbursement for those assisted living facilities.

And so among the dental section of that minimum data set tool, they do assess their toothbrushing ability and evaluate the activity of daily living that residents and the level of their personal hygiene and ability to brush their teeth. So along with, to explain some of the activities of daily living, those are just our daily self-care tasks necessary for an individual's wellbeing. And the definition includes eating, bathing, dressing, walking, toileting, mobility, transferring, grooming, and personal hygiene. And then personal hygiene is not always specific to oral hygiene. So of the 12 states, all of the 12 states perform an activity of daily assessment to identify the residents' ability to perform each of those activities of daily living, to determine the level of care and assistance the resident may need. And so dexterity is one of the things that becomes a problem amongst older adults. So evaluating their level of toothbrushing abilities becomes critical in maintaining their oral health.

And so only 5 states regulations address the assessment of daily oral care abilities for personal hygiene. And this assessment establishes a resident functional capabilities and ability to perform activities of daily living self-care in order to determine a personal assistance. And then again, that level of care that they need. And so among that also that all of the 12 states provide personal care services and assisting residents with those activities of daily living. However, only 4 states were specific about providing assistance with daily oral hygiene or denture care or reminding even the residents to perform oral care. So that was one kind of finding along those lines.

And then another finding was that among the research, it also shows that there's a level of oral health knowledge among the nurses and the CNAs and their ability to appropriately evaluate oral health conditions and possible treatment needs. And so their research has indicated that there needs to be an improvement in some of the nursing training and oral assessments and determining treatment needs of older adults.

And so with some of those findings there, overall, we were not too surprised with some of the findings because through our research and current evidence-based research shows the older adult population is one of the many underserved populations with a huge disparity in oral care. There are many barriers that come about that they aren't able to receive access to care. And so along that to other research studies that we also know, assisted living residents have poor oral health, and there is a higher rate of coronal and group cavities and an increase occurrence of periodontal disease and tooth loss.

So, in addition to residents having problems with those, they also can have problems with chewing or swallowing, having dry mouth that can also lead then to malnutrition. So this just further expound the problems that they may have in that evaluation and receiving more care. So in that regards, that part wasn't as surprising, just knowing that some of that research out there tells us that the oral care is pretty poor, but it was a little bit surprising in a sense to determine that oral health status had little value and was limited as an assessment category to be evaluated along with the general health evaluation and care planning and determining of those residents and the assistance that they needed.

Jessica Bard: In your opinion, how would you like to see these results impact standard practice?

Deborah Dowd: One area could be the value placed on oral health to have that be an additional emphasis in their assessment that is evaluated upon admission and a reassessment throughout the time that they are staying there in the facility. And with that evaluation to have a assessment tool that is common throughout, that would be used to help with assessing those individuals and their needs. So with that, then a policy on oral health that would help improve some of the oral care right now, too. We understand the overload and the care that the CNAs and the nurses provide for the residents that live there at this time.

And to be able to add toothbrushing care and oral health needs could be a little bit more burdensome for them in the things that they may need to do, but understanding that importance of their overall health is that simple part of helping with some toothbrushing can have a great impact on their overall health and what occurs with them and how they're able to live their lives and have that quality of life that they can have. A lot of the multiple medical conditions and complications that may arise among the residents. And so there are different things that can happen resulting in a decline in their function and their abilities as they reside in those care facilities. So a big thing would be to have some policy changes at the state levels and even among the individual care facilities to include that oral health and have that be an emphasis and an important part of their care to keep the residents healthy throughout their state.

And so, another big part of that would be right now with a lot of... A lot of the states, the rules and regulations allow dental hygienists to provide care in these facilities and come into their facility in one way or capacity, in a mobile setting, bringing in equipment to help provide some of that care for those residents. And so another thing would be reimbursement throughout the states that would be an equal reimbursement.

Just recently here in Utah, they changed some legislation where a dental hygienist is now considered a provider that could get some direct reimbursement from Medicaid. And so any individual that they may serve and have an opportunity to provide oral care services for in those facilities could get reimbursement directly from Medicaid for that. And so having an opportunity for more hygienists and dental professionals, to be able to collaborate with the health professionals there in the care facilities and have that interprofessional collaboration relationship in helping diagnose, help evaluate, help care for those residents would be a great thing that as far as a policy that could change to provide that care and hopefully lessen that burden that comes upon them and decrease that disparity that occurs among the older adult population. And hopefully then overall, this kind of improves their health, that they tend to have a decline in, and just have that access to care.

Jessica Bard: Were there any limitations to this study? And what's next for research on this topic?

Deborah Dowd: Being that I live here in Utah, I wanted to look into my surrounding states and keep my study smaller in the interest of time and kind of management control. So limitations then would be that the research was only limited to the Western region of the United States and therefore was not generalizable to all of the United States. And then even with the multiple attempts that we had to verify the accuracy of the data by directly contacting each state agency for clarification and obtaining updates to the rules and regulations, there was one state that we were not able to verify their state's information.

And then, so what's next for research on this topic? I think one direction could be to expand and research all 50 states and look at the requirements with state rules and regulations to find a model state that may incorporate and emphasize oral health in the assessment and reassessment process and provide daily oral self-care assistance among the residents. Another direction could be to have oral health professionals collaborate with state agencies to develop a policy model and effective assessment instruments to determine oral health status treatment needs, oral health-related quality of life and daily oral self-care, and then implement that policy and that model within some assisted living facilities and determine if that development of that assessment instrument would in fact, or does in fact maintain or improve assisted living residents oral health, and contribute to their comprehensive healthcare wellbeing and quality of life.

And then another thought would be to research and expand into also the nursing homes or skilled nursing facilities, and look at their rules and regulations to determine what their emphasis might be on oral health status and oral self-care, and also the assistance that they may provide to their residents.

Jessica Bard:

Deborah, thank you so much for your time today. Is there anything else that you'd like to add

Deborah Dowd: Just to kind of keep in mind, too, with this, the older population is increasing in number because we are living longer, statistics show that the baby boomer generation, they're getting older and there'll be a 25% of the population being 65 years and older by 2036. And so with that, there's going to be a lot of need in these care facilities. As our results have revealed that assessments for oral health status and oral self-care, where that lacks a little bit of consistency and completeness across the states, there needs to be a shift in a way that these facilities provide care for their residents and incorporate the value of oral care and oral health. Then also having some of these policies and programs in place now, or sooner than later, can help ready them for the impact of the increased number of individuals that would be in their care facilities.

And then I would just say, too, just the clinical examination of the mouth, having an opportunity to actually look in the mouth and determine the oral health status and to have that be implemented among assisted living residents. And then allowing that collaboration that I had mentioned before among dental hygienists and other health professionals to come in and be a part of some of the health assessments and even the reassessments, but then also providing care, implementing oral care programs into these facilities to help it be, maybe, in a way too less burdensome among the nurses and then some of that care can be put onto the dental care professionals.

And then another big thing where telehealth is becoming more popular. There's also what's called teledentistry. And so in that way we can come in as a dental professionals and provide care and communicate also with the other practitioners at a different location, we can use x-rays, radiographs, intraoral photographs, provide treatment plans, communicate with a doctor in another location, provide some diagnosis and treatment plan for residents.

And so I think that there's a lot that can be done, come the future, and incorporating some of this technology and care policies. One of the little examples that go along with that, even just recently, Idaho state put together what was called a guided oral health program, where the CNAs were in the assisted living facility directly communicating through live video with a dental hygienist as they were evaluating the resident's oral health and assisting them with brushing their teeth. And so the CNAs were able to have guidance from the hygienist in brushing properly, and also identifying areas of concern. Any of that type of little implementation that can occur in some of these facilities to increase the overall health of the residents could be... Just like an up-and-coming theme that helps incorporate both the dental health and overall health and help keep these residents living long and happy and having a good quality of life as they are residing in these facilities.

Jessica Bard: Well, thank you very much for your time and for your research on this. It was very interesting. I appreciate it.

Deborah Dowd: Yes. Thank you. I appreciate that you found my research even, and were interested and able to reach out to us to find out more information on this.