Rita A. Jablonski

The Role of Biobehavioral, Environmental, and Social Forces on Oral Health Disparities in Frail and Functionally Dependent Nursing Home Elders

The purpose of this article is to review the literature on and discuss how interactions between bio-behavioral aging, nursing home environments, and social forces shaping current health care policies have contributed to oral health disparities in frail and functionally dependent elders who reside in nursing homes. Emerging empirical evidence suggests links between poor oral health with dental plaque deposition and systemic disease, such as nursing home-acquired pneumonia. The majority of nursing home residents lack either the functional ability or the mental capacity to perform their own mouth care and therefore must rely on others to perform mouth care for them. Certified nursing assistants (CNAs), who provide the majority of care activities, were unsure how to provide care to residents who engaged in care-resistive behaviors. The nurses who supervise the CNAs have limited knowledge regarding the provision of mouth care in general, and they specifically lack knowledge regarding the provision of mouth care to elders exhibiting care-resistant behavior. Elders in nursing homes have limited options when paying for dental care; Medicare does not generally cover routine dental care. Medicaid coverage varies widely between individual states; even when coverage exists, low Medicaid reimbursements discourage dentists from accepting Medicaid patients. The strategies needed to reduce these oral health disparities are complicated but not unrealistic. Investigators willing to embrace this cause will have no shortage of opportunities to test methods to improve the delivery of oral care as well as to monitor and reassess these methods.

Mouth Care in Nursing Homes: Knowledge, Beliefs, and Practices of Nursing Assistants

UNLABELLED The purpose of this study was to examine the knowledge, beliefs, and practices of nursing assistants (NAs) providing oral hygiene care to frail elders in nursing homes, with the intent of developing an educational program for NAs. METHODS The study occurred in two economically and geographically diverse nursing homes. From a sample size of 202 NAs, 106 returned the 19-item Oral Care Survey. RESULTS The NAs reported satisfactory knowledge regarding the tasks associated with providing mouth care. The NAs believed that tooth loss was a natural consequence of aging. They reported that they provided mouth care less frequently than is optimal but cited challenges such as caring for persons exhibiting care-resistive behaviors, fear of causing pain, and lack of supplies. CONCLUSION Nurses are in a powerful position to support NAs in providing mouth care by ensuring that they have adequate supplies and knowledge to respond to resistive behaviors.

An intervention to reduce care‐resistant behavior in persons with dementia during oral hygiene: a pilot study

The primary purpose of this pilot study was to test the feasibility of an intervention designed to reduce care-resistant behaviors (CRBs) in persons with moderate-to-severe dementia during oral hygiene activities. The intervention, Managing Oral Hygiene Using Threat Reduction (MOUTh), combined best oral hygiene practices with CRB reduction techniques. Oral health was operationalized as the total score obtained from the Oral Health Assessment Tool (OHAT). CRB was measured using a refinement of the Resistiveness to Care Scale. Seven nursing home residents with dementia received twice daily mouth care for 14 days. The baseline OHAT mean score of 7.29 (SD = 1.25) improved to 1.00 (SD = 1.26, p < .001); CRB improved from 2.43 CRBs/minute (SD = 4.26) to 1.09 CRBs/minute (SD = 1.56, t = 1.97, df 41, p= .06). The findings from this pilot study suggest that the MOUTh intervention is feasible and reduced CRBs, thus allowing more effective oral care.

Oral Health Measurement in Nursing Research: State of the Science

Oral health can impact general health and systemic disease. Changes in dental plaque, oral microbial flora, and local oral immunity may be important in the development or exacerbation of disease in critically ill patients, trauma patients, adults with chronic obstructive pulmonary disease, and frail elderly. Inasmuch as oral health potentially can be influenced by nursing interventions, nursing research in this area can contribute greatly to improved patient outcomes in these diverse populations. The authors’ research teams have conducted several federally funded projects focused on oral health and have developed synergy in research methods. A unifying theme for these research projects is the measurement of oral health. Standardized measures of components of oral health are available and applicable across populations, and their uses and relationship to nursing research and patient outcomes will be discussed.

Enhanced care assistant training to address the workforce crisis in home care: changes related to job satisfaction and career commitment.

Changes in job satisfaction and career commitment were observed as a consequence of a geriatric case management training program focusing on skills development among personal care attendants in home care. A comparison of pretraining and posttraining scores uncovered a statistically significant increase in Intrinsic Job Satisfaction scores for participants 18–39 years of age, whereas levels declined among the group of middle aged participants and no change was observed among participants age 52 and older. On the other hand, a statistically significant decline in Extrinsic Job Satisfaction was documented over all participants, but this was found to be primarily due to declines among participants 40–51 years of age. When contacted 6–12 months after the training series had concluded, participants indicated that the training substantially increased the likelihood that they would stay in their current jobs and improved their job satisfaction to some extent. A comparison of pretraining and posttraining scores among participants providing follow-up data revealed a statistically significant improvement in levels of Career Resilience. These results are discussed as they relate to similar training models and national data sets, and recommendations are offered for targeting future educational programs designed to address the long-term care workforce shortage.

Reducing care-resistant behaviors during oral hygiene in persons with dementia

BackgroundNursing home residents with dementia are often dependent on others for mouth care, yet will react with care-resistant behavior when receiving assistance. The oral health of these elders deteriorates in the absence of daily oral hygiene, predisposing them to harmful systemic problems such as pneumonia, hyperglycemia, cardiac disease, and cerebral vascular accidents. The purpose of this study is to determine whether care-resistant behaviors can be reduced, and oral health improved, through the application of an intervention based on the neurobiological principles of threat perception and fear response. The intervention, called Managing Oral Hygiene Using Threat Reduction, combines best mouth care practices with a constellation of behavioral techniques that reduce threat perception and thereby prevent or de-escalate care-resistant behaviors.Methods/DesignUsing a randomized repeated measures design, 80 elders with dementia from 5 different nursing homes will be randomized at the individual level to the experimental group, which will receive the intervention, or to the control group, which will receive standard mouth care from research team members who receive training in the proper methods for providing mouth care but no training in resistance recognition or prevention/mediation. Oral health assessments and care-resistant behavior measurements will be obtained during a 7-day observation period and a 21-day intervention period. Individual growth models using multilevel analysis will be used to estimate the efficacy of the intervention for reducing care-resistant behaviors in persons with dementia, and to estimate the overall efficacy of the intervention using oral health outcomes. Activity-based costing methods will be used to determine the cost of the proposed intervention.DiscussionAt the conclusion of this study, the research team anticipates having a proven intervention that prevents and reduces care-resistant within the context of mouth care. Long-term objectives include testing the effect of the intervention on systemic illnesses among persons with dementia; examining the transferability of this intervention to other activities of daily living; and disseminating threat reduction interventions to nursing home staff, which may radically change the manner in which care is provided to persons with dementia.Trial RegistrationClinicalTrials.gov: NCT01363258

Measuring the oral health of nursing home elders.

The primary purposes of this descriptive and prospective pilot study was to test the feasibility of a nursing and dental hygiene team to measure specific oral health indices in a sample of older adults residing in nursing homes (NHs). The secondary purpose was to determine the relationship between plaque and dentate status. Oral health indicators, functional status scores, and behavioral scores were collected and analyzed from 38 female NH residents from two geographically, organizationally, and economically diverse NHs. Persons with dentures had significantly lower plaque scores than those with natural dentition. Rural NH residents and African American NH residents had fewer filled teeth, indicating a potential lack of access to dental care. Oral health indicators were collected safely and efficiently from NH residents using a nursing and dental hygiene collaborative approach. Nursing and dental hygiene collaborations hold promise for improving the oral health in institutionalized elders.

No more fighting and biting during mouth care: applying the theoretical constructs of threat perception to clinical practice.

The purpose of this article is to describe how the neurobiological principles of threat perception and fear response can support clinical approaches to prevent and reduce care-resistant behaviors during mouth care. Nursing home residents who exhibit care-resistant behavior are at risk for poor oral health because daily oral hygiene may not be consistently provided. Poor oral health predisposes these older people to systemic problems such as pneumonia, cerebral vascular accidents, and hyperglycemia. Care-resistant behavior is a fear-evoked response to nurses’ unintentionally threatening behavior during mouth care. Nurses can safely and effectively provide mouth care to persons with dementia who resist care by using personalized combinations of 15 threat reduction strategies.

Oral Health and Hygiene Content in Nursing Fundamentals Textbooks

The purpose of this paper is to describe the quantity and quality of oral hygiene content in a representative sample of before-licensure nursing fundamentals textbooks. Seven textbooks were examined. Quantity was operationalized as the actual page count and percentage of content devoted to oral health and hygiene. Quality of content was operationalized as congruency with best mouth care practices. Best mouth care practices included evidence-based and consensus-based practices as published primarily by the American Dental Association and supported by both published nursing research and review articles specific to mouth care and published dental research and review articles specific to mouth care. Content devoted to oral health and hygiene averaged 0.6%. Although the quality of the content was highly variable, nearly every textbook contained some erroneous or outdated information. The most common areas for inaccuracy included the use of foam sponges for mouth care in dentate persons instead of soft toothbrushes and improper denture removal.

Mouth care to reduce ventilator-associated pneumonia.

Overview Despite the well-established association between good oral hygiene and the prevention of ventilator-associated pneumonia (VAP), the importance of mouth care in infection control is seldom recognized. The authors discuss the pathophysiology of VAP and why oral care is crucial to its prevention. They also provide an evidence-based, step-by-step guide to providing optimal oral care for intubated patients.