Lori Abendroth knocked on the door and walked into the room. Five evenings a week, she visits around 40 residents at Good Samaritan Society in Moscow to clean their teeth.
"No one wants to talk to you anymore when you're old," a woman called out from a wheelchair, her back to the door. At the age of 95, she doesn't hesitate to say what's on her mind.
"Oh, that's not true," Abendroth replied, facing her patient and wheeling her to the center of the room.
After more words of assurance, Abendroth gets down to business, asking if she can clean the woman's dentures. Her spirits lifted, the woman obliged and the two chatted while Abendroth scrubbed and placed them in a cup for overnight soaking. As she worked, the conversation turned to a collection of apples on the woman's bedside table, then to events of the past.
Within 10 minutes, the woman's dentures were clean, and her mouth had been treated with an antibacterial rinse. Smiles and small talk had been exchanged; concerns and preferences were acknowledged; comfort was offered and received.
Who knew that cleaning someone's teeth could be so beautiful?
The effect of aging on oral health
When it comes to health and hygiene, aging brings a host of challenges, including potential changes in one's ability to care for their own oral health. The once-simple of task of daily brushing can be forgotten or become difficult, taking a backseat to more pressing needs or discomforts.
Dr. Rich Bailey of Pullman practiced dentistry in the Lewiston-Clarkston valley from 2008-15. During that time, he observed many older patients experience a sudden decline in oral health.
"They would be doing great the whole time, and then all of the sudden they'd show up for one appointment and have a dozen deep cavities," Bailey said. "It was a sharp drop-off."
The trend generally was connected to a shift in health or living situation, often as a person was sliding into dementia. People who had been fastidious about brushing and flossing were no longer able to provide thorough, consistent care for themselves.
Older adults have a number of added risk factors that contribute to a decline in oral health. Those with dementia don't always remember to remember to brush their teeth daily, Bailey said, and may resist help for this very personal task.
Finger and hand dexterity can be limited by arthritis or other conditions, Bailey said, so that even if individuals are willing to brush, they're not able to perform the task as effectively. And declining mobility can hamper a person's ability to get to a dentist for a regular cleaning and examination.
A dry mouth also contributes to oral health problems. Salivary glands don't work as well when a person ages, Bailey explained, and the condition can be compounded with certain types of medication.
High-sugar foods also can be a factor for some older people who lose interest in maintaining a nutritious diet. This can be especially true in a home or care facility where sweets are a constant option.
"There are a dozen variables that add to (a decline in oral health), and you only need two or three to cause a lot of trouble," Bailey said.
A declining number of care options
At a certain point, Bailey said, dental care becomes less about preserving teeth and more about supporting overall health and keeping patients' mouths clean and comfortable.
Teeth that are missing or in poor condition make it hard to enjoy certain foods and can cause embarrassment. But dentures aren't always a solution.
"Learning to use dentures is like learning to ride a bicycle, you have to be up for it," Bailey said. "I've had some patients tell me, 'I feel like I'm wearing a shoe in my mouth.' "
Usually by the time someone is no longer able to care for their oral health, the vitality in their teeth is gone, so decay doesn't cause pain. But as brittle teeth break, sharp edges develop. Since most patients at that stage prefer non-invasive solutions, Bailey said, filling a cavity or extracting a tooth isn't worth the discomfort and hassle for them. Instead these rough spots are typically filed down.
"The thing that bothers them the most is the rough edges," Bailey said.
Beyond basic comfort and aesthetics, poor oral health can lead to serious health complications. Infections and inflammation burden the immune system and can lead to an overall deterioration of health. Bailey said, and studies show a connection between oral health and heart health.
"The mouth is the gateway to the body," Bailey said.
The search for practical solutions
While it's easy to identify risk factors and obstacles to optimal oral health, it's tougher to come up with working solutions. Many older adults live alone. Among those who receive care at home or in a facility, oral care can be lost in the shuffle of urgent demands placed on caregivers. And some patients resist care.
So Bailey got busy. Four years ago, he began moving to a mobile practice, acquiring and developing equipment that could be loaded into a trailer and taken from site to site. He now works with a number of care facilities in the region, bringing dental care to residents.
"If they can't walk, they're done going to the dentist; it's a physical impossibility," Bailey said.
Unfortunately, by the time he is treating patients in a facility, it's often too late to do much. He recognized the need to develop a more comprehensive preventative care program to minimize decay and other problems.
"I tried all kinds of things," Bailey said.
He trained facility staff, he coached individual patients, he tried different toothbrushes and created lists of high-needs patients. None of these tactics worked. Asking overburdened facility staff to perform quality dental care is unrealistic, Bailey said, and with the high staff turnover many facilities experience, training had to be done too frequently to make it worthwhile.
But when Bailey went to Good Samaritan with his goal of providing excellent preventive care, administrator Jamie Berg agreed it was worth pursuing. She joined in the dialogue of finding ways to supplement care.
In her 26 years as an administrator, Berg said, Bailey was the first dentist who was willing to bring equipment to residents on site. Not only did his visits give residents easy access to dental care, but the arrangement allowed Bailey and Berg to discuss ways they might support what facility staff was already doing.
"We went back and forth with different ideas," Berg said. "We wanted to take it to the next level."
The Good Samaritan oral care pilot program
Bailey and Berg finally arrived at something they agreed might work: Rather than rely on facility staff to provide added levels of preventative oral care, Good Samaritan would hire dental assistants who worked for Bailey. These trained professionals would come in every evening to serve around 40 residents who were determined to benefit most from added care.
"We launched a six-month pilot program just to see what that would look like," Berg said.
Families of those eligible for the program, along with the residents themselves, were contacted for consent. No added fees accompanied the service; it was included in facility fees. Good Samaritan covered these added expenses out of pocket.
"We're always looking for ways to go above and beyond expectations," Berg said. "We wanted to know, would this even make a difference?"
That the program is still in place one year later attests to its value. Every month during the pilot program, Bailey took photos to document any changes he might see. Residents enrolled in the program were at various stages of aging and had been at Good Samaritan for different lengths of time. Improvement was minor for some. But for others with more advanced levels of oral health problems, the difference was noticeable even to the untrained eye, Bailey said. Within a few months, red, inflamed gums turned to a healthy shade of pink.
"It makes a difference," Berg said. "And it feels great that we can do that much more for our residents." She added that family response to the program has been positive.
While the program is going well and is expected to continue for the time being, Berg was careful to clarify that resident care is a complex issue and that various facilities might arrive at different care solutions.
"It's not a perfect solution, but this is something that works for us right now," Berg said.
Currently, it is the only program of its type that Bailey is aware of being used in care facilities in the area.
'Consistency is the key'
Having a dedicated, trained professional providing care ensures that residents that most need assistance are getting a high standard of regular care.
"Consistency is the key," Bailey said.
The preventive oral care program for residents that still have their own teeth utilizes a "three-part punch." The process begins with Peridex, an antibacterial rinse. Because many older adults needing additional oral health care can't comfortably use traditional toothpaste, this rinse is applied to a brush which is used to spread the rinse through the mouth and clean the teeth. Besides killing the bacteria that causes periodontal problems, Bailey said, an added benefit is that the chlorhexidine in the rinse also kills the bacteria that cause aspiration pneumonia.
Next in the process is Prevident, a prescription-strength fluoride rinse which strengthens the teeth. Then, the teeth are flossed and a prescription strength toothpaste gel is applied to the gum line.
Residents in the program who have dentures can have them cleaned every night and their mouth checked for sore spots that might indicate the denture is no longer fitting properly. The dental assistant can choose to do additional cleaning if it seems beneficial.
The time required to clean the mouth varies from person to person, though it generally takes one staff member about four hours to get to everyone. Before starting, Abendroth meets with the nursing staff to discuss any changes or specific needs of residents for that day.
By now, Abendroth knows the general evening routine for the residents she cares for, so she goes from room to room in order of who might prefer to be seen earlier in the evening and ending with those who don't settle into their rooms until later on.
Abendroth shares the cleaning tasks with one other staff member; she works five days a week, and the other covers the remaining two. She feels this consistency is especially valuable for the demographic they are serving.
"They start to trust you after a while, and I feel like that's important. It can be an invasive thing, and it's important to develop trust," Abendroth said.
The consistency also allows her to learn patient preferences, meet specific needs and figure out solutions. For example, she normally asks residents for permission right before providing care, but one couple always declined when she asked. Eventually she discovered they happily complied if she just announced that she was going to provide care. Learning these "tricks" and resident preferences makes it easier on everyone, she said.
The regular checks also allow her to catch any problems that begin to develop.
"When I look in their mouths five times a week, I can see changes," Abendroth said.
Abendroth recently noticed an ulceration that was developing in one resident. She let Bailey know, and the change was documented and checked.
Having a trained professional knowing what to look for makes a difference, she said. Sometimes residents don't notice changes themselves, and sometimes they lack the ability to say they have a problem.
"Anytime you let a dental problem go, it gets worse," Abendroth said.
The care factor
The visible improvement in oral health is the primary reason that Good Samaritan continues to use this high-quality oral health preventative program, but that's not the only reason.
"It's bigger than that," Berg said. "God's called us to take care of these people."
And sometimes care means taking the extra moment to share a smile, or listen to someone or ask about their day.
Abendroth gets paid only to clean teeth. But in the course of doing her job, she's sometimes called upon to lend a hand with other caregiving tasks, and she sees great value in the relational care she inadvertently provides along the way.
"People are people," Berg said, "and it's nice to have someone pay attention to you."
Schmidt can be reached at (208) 305-4578 or email@example.com.