‘Disgusting, frustrating, upsetting’: When dental hygiene in a nursing home doesn’t go as planned

Editor’s note: Amy Ericks, RDH, BSDH, is in the process of pursuing a career in collaborative practice outside the dental practice. You can follow her journey beginning here.

The process of visualizing a goal, setting a timeline, carrying out needed tasks is exciting. When all of the hard work culminates and the goal is accomplished, there is an emotional and physical sigh as the goal is realized. At this point, there is a choice—set another goal or continue to proceed with the accomplished goal, forging ahead. Some days I feel that this is where I am at. Do I set another goal or do I proceed along the same path of the goal I just accomplished?

If you recall, from previous articles, I wanted to be in a facility caring for residents within two years. It has only been one year since I started on this journey, and I’m already seeing residents, caring for them, attempting to advocate for them. I should be excited, proud, content in my progress and should carry it along as long as I can. Right? I struggle with this from day to day. Yes, I most certainly want to continue on with this process, continue to perfect it, continue to expand it.

But I have to be honest. The way that this program is being carried out in this facility is not entirely what I had envisioned. OK—it’s not really a problem, and it is to be expected that it has some areas that can be improved upon. I have already made what feels like hundreds of changes to everything from paperwork, to documentation, to the actual care process. What I struggle the most with is that I can’t seem to let go of the idea that the oral health of these residents will be magically changed for the better simply by receiving my care. Oh, how naive of me. This never happens to any of my patients in clinical practice, who mostly have their own physical and mental abilities to help them carry out my home care instructions. Why should I think that it would happen here?

I would like to talk about one resident in particular, just to give you an idea of why I feel frustrated with my program’s performance. This resident (we’ll call him Fred) at this time was able to be transferred from the wheelchair to my dental chair, which allowed for a fairly comfortable session for both Fred and me. I was told by the staff, “Good luck, Fred never lets anyone in his mouth!” I had seen Fred for an oral health review, had taken some intraoral photos using my amazing MouthWatch equipment, and completed a simple brushing and flossing for him. Yes, several reminders to open and requests for him to turn towards me occurred, but other than that, I’d have to say I had no issues completing any of those tasks. Due to time constraints, I did not intend to provide a prophy for Fred on this particular day.

On a side note, I have heard the “good luck” statement more than once, and I have decided to simply ignore it. I am not sure if it is a way for the staff to justify their discomfort in caring for the residents’ oral health, to excuse the residents’ oral condition, or if it truly is a forewarning that the resident may be uncooperative. In any case, I do not want to have a preconceived notion on what to expect because I find that this can be misleading. I have not had one single resident that has been uncooperative to the point of being unable to provide care.

Back to Fred. The next time I had scheduled to see him, I had coordinated with my supervising dentist to be able to complete a live video feed exam, again using MouthWatch. At this session Fred was not able to be transferred to the dental chair due to a recent injury, so the treatment was completed in his wheelchair. Again, he was cooperative, needing several reminders but was in no way denying me to complete treatment. He had heavy marginal plaque and food debris and heavy generalized calculus, which was the case during the first session as well, when I only completed a brush and floss.

To be honest, it did not look like much brushing effort had been attempted in the past two months since that initial session. In the time I had with him, I completed the lower arch only; because he was in a wheelchair, this was the most comfortable arch to treat for both of us. At the end of the hour, he had had enough of me, so we decided to complete the upper arch at my next visit.

Fast forward six weeks until my next scheduled day at the facility, and I find Fred to complete the remainder of the prophy for the upper arch. The injury requiring him to stay in the wheelchair has resolved; however, again he stays in the wheelchair for treatment. This is due to another issue, which I will touch on later in a future article. Today though, Fred is nowhere near the same level of alert as previous sessions and basically sleeps the entire time, possibly due to medication. His head falls forward, as this is not a reclining wheelchair, and I am attempting to treat the upper arch. I am sure you can imagine the ergonomic nightmare this was, but that’s not even my concern at this point.

When he is somewhat alert, I get some more intraoral pictures, and I have to say I was devastated. I thought that the oral home care, or lack of it, that I was seeing at the two previous sessions was bad, but I was not prepared for today. Not only was there heavy plaque along the margins, but the entire buccal surface of every tooth had at least a 1–2mm thick veneer of plaque. If you were to have looked in his mouth you would have questioned that anything had been done 6 weeks ago to the lower arch. It was disgusting, it was frustrating, and I was upset—to put it mildly.

I truly wanted to find a staff member that could adequately explain to me how Fred was uncooperative for his recommended oral home care. He was sleeping in the wheelchair while I am cleaning his teeth! I could not wrap my head around any explanation that I could imagine, and it really bothered me. Why, why is Fred not being provided with the extremely important oral home care that he needs? Am I the only one that is seeing that this is an aspiration pneumonia nightmare waiting to happen?

I calm myself down, and tell myself to just do the best I can. I finish the treatment on the upper arch to the best of my ergonomic abilities, and let’s be honest, I do repeat my work on the lower arch as well. How many of us could leave it like that? I return Fred to his wing and hand him off to the facility staff. I do not question them regarding the oral care procedures of this facility, as badly as I wanted to. I call it a day, finish up the rest of the related work, and seriously ponder whether or not I am making a difference.

Thank you for sharing in my victories and my frustrations. Please don’t hesitate to reach out with any questions or comments. You can reach me by email at [email protected] or you can find me on Facebook and message me there.

After 6 years of full-time clinical practice, Amy Ericks, RDH, BSDH, decided to pursue a journey to bring dental hygiene services to a long-term care facility. This often-neglected population has been on her mind for some time, and she is humbled to be able to be making a difference in their care. Here she walks us through her journey as she navigates this exciting new career path, stumbling blocks and all. She is also currently the president-elect of the South Dakota Dental Hygiene Association and is hopeful and encouraged about the impact she may have within her state.