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The journey began many years ago at the Willows here in Saskatoon. At this meeting was many players in LTC , dental hygienist, dental therapists, dentists, SHCC representatives, U of S representation and Ministry of Health representation. The realization that the oral health of seniors in LTC was in need of better care and how does that happen was the theme of the discussions.
Parkridge had a dental therapist coming for dental care however Later into 2011 Parkridge a systematic dental cleaning and treatment program was implemented that co-ordinated with the U of S dental program. But this was not enough. A great start of awareness but how were we going to make the staff more aware of oral health importance and change the practice of minimal oral care to effective oral care between treatments.
. This is when we started implementing oral care into orientation of all new nursing staff.
In this training staff learned some of the concerns affecting the oral health of our residents
Also learned the process put simply of how tartar forms
Comparison pictures were shown
Also examples of teeth of LTC residents
However this also did not prove to be enough as we still saw: Dentures being brushed with toothpaste in hot water Residents with teeth had plaque buildup that turned to tarter Residents that had even the least amount of resistence were not approached again Foam swabs were used on teeth for plaque removal
Nov 2012, Canadian Nurse (explain what it is) came out with an Oral Care Protocol for LTC. The site was Deer Lodge Centre in Winnipeg. They experienced what many LTC Centres also experience. Oral Care for dependent residents in LTC consist of sponge swabs dipped in liquid mouth rinse and denture care with toothpaste and Polident.
The study sought to answer the questions: Are sponge swabs effective in cleaning the oral cavity? What oral Residents showed improvements, specifically Reductions: in plaque Swollen and bleeding gums Ulcerations Severe halitosis
Staff members were resistant to change until they saw the benefits of tooth brushing. The use of sponge swabs also declined.
At Parkridge we have many residents with high medical and behavioural needs. Many of these residents do no swish and spit. There was no way of getting foaming toothpaste out of the mouth therefore a foam swab dipped in mouth wash was the only care they were receiving.
Phoned Deer Lodge Centre, talked to authors of the article which were employees of the home. I was most interested in how they delivered the oral care of the high needs residents. Apparently they purchased soft small headed toothbrushes with large soft rubber barrelled handles which could be used as mouth props. Holding the mouth open as oral care was given. They also found a oral non-foaming antibacterial mouth gel named Perivex which did not contain fluoride was suitable for brushing those residents teeth that did not swish and spit. I also doubled as lip moisturizer. Also great for loosening the coating on the tougue.
They gave me a wealth of information about their suppliers and cost of the supplies.
This started many meetings with Leslie Topola and the staff of oral educators and SHR Material Management.
We finally received the products. The toothbrushes costing $0.50 , the tuft end toothbrush $0.52 and the Perivex $1.67 (115mls lastes 1 month) Toothbrushes changed every 3-6 months. During this time there were also many other projects with tighter timelines that our Staff Development Dept had to implement. Oral care became derailed numerous times, only prolonging the project.
Containers from Superstore dedicated for oral health products only completed the kit.
Collaboration with SHR Population and Public Health oral health. Supplied by SHR Population & Public Health, Oral Health Serves the purpose of periodic checks to track improvements, Would love to do every quarter but this proved impractical. Moved to q 6 monthly. Brightly colored serves as a visual for referral.
Process created for referral to jump the queue
Put in Dental Records of chart
Leslie and her staff also developed a Oral Health Care Plan in the form of a mirror cling
Oral care champions were chosen and trained to help do the assessments and care plans. These champions were also responsible for promotion and teaching the oral care to their collegues.
Performing an OHAT Work in pairs – one examiner, and one recorder (operator/resident safety, infection control and reduced examination time for resident)
-Selected residents with different behavioral issues and various dentitions Ie) CUD/CLD, edentulous, partial dentition
U of Manitoba website, in the Dentistry link had videos that were excellent for teaching techinques of implementing oral care to residents.
-One resident deceased since original assessments -two residents would not cooperate from PI score, an improvement from the last visit where 4 residents would not cooperate, one resident refused on both occasions -Of the 17 residents with natural teeth: there was an improvement in 4 resident PI scores There was no change in 5 resident PI scores Unable to determine change/improvement in 4 resident PI scores There was a slight decline in one resident PI score There was significant decline in two resident’s hard tissues There was a significant reduction supre and sub cal of one resident Combined PI Score for the entire facility – 2.34 out of 3 **Ideally for a facility average, I would like to see this number reduced to 1.5-1.8
-still seeing a disconnect with staff about the importance of daily oral care --any restorative treatment won’t hold up in the oral cavity if daily care is not being completed -champions, CNEs, care team managers and upper management must continue to promote daily oral care and stress the importance of mouth/overall body connection and maintaining residents dignity. -Paradigm shifts are slow, and we realize it will take time for all staff to buy in to the importance of providing daily oral care.
During this time with a lot of help from Leslie and her team of oral Health educators tow new Work Standards were developed.
Education has evolved.
Videos from University of Manitoba website as learning tools for staff.
Education has evolved to be more succinct and more meaningful to the nursing staff.
As well as practice on each other
Parkridge Dental Clinic passed on a message from a visiting dentist that he saw improvement in the oral health of several residents.
Went to her room to check on her teeth reddness gone.
ParkRidge Centre Oral Health Journey
T H E J O U R N E Y O F
I M P L E M E N T I N G A N
O R A L H E A L T H P R O G R A M A T
P A R K R I D G E C E N T R E
The Journey Begins
2010 – Meeting at the Willows, Saskatoon
Oral Health in Orientation to New Staff
Oral Health Education given to Existing
Oral Health Concerns in LTC:
Residents may have:
• Decreased saliva due to medications (dry
• Medications given with sweet sticky substances
(Jam, jelled juice, applesauce , pudding )
• Few raw fruits and vegetables (self-cleansing)
• Lack of proper daily mouth care
• Cognitive issues that prevent entry into their
How does poor oral health happen?
Plaque (bacteria) builds up in the mouth on teeth, gums,
cheeks and tongue.
Approximately 40% of the tooth surface is “hidden”
between the teeth, and can’t be reached by a toothbrush.
Plaque is a thin sticky layer that can be brushed and flossed
away. Plaque is full of hundreds of types of bacteria.
When plaque hardens it becomes “tartar”. Tartar can form deep below the
gum line. Tartar needs to be removed by professional dental cleaning at
least once yearly. Brush at the gum line.
ORAL HEALTH CARE
At a glance
INITIAL VISIT TO PARKRIDGE
April & May 2014
In one Parkridge Centre neighborhood, Saskatoon Health Region – Oral Health
Program dental health educators* (DHE’s) provided:
Initial oral health assessments using the Oral Health Assessment Tool (OHAT)
Plaque index scores for baseline data to determine an improvement or decline
in oral health
Individualized daily oral care plans for each resident who had an OHAT
Hands-on instruction/demonstration of how to provide daily oral care for various
Referral and follow up of oral lesions or any untreated oral conditions
Referral to U of S DDS students for exams, complete treatment plans, hygiene,
restorative procedures, extractions and recall/follow up
DHEs trained Clinical Nurse Educators (CNE) and one Speech
Language Pathologist (SLP) on how to perform the OHAT and daily
Provided hands-on demonstration of daily oral care on the
neighborhood with a variety of residents with varying dentitions
CNEs and neighborhood champions then trained Continuing Care
Aides (CCAs) on how to provide daily oral care.
Clinical Nurse Educators used a mannequin with teeth
and tongue to educate the staff and champions of each
6 MONTH FOLLOW-UP VISIT
Residents who were assessed in April/May received their 6
month OHAT follow-up by dental health educators and the
Plaque indices for comparison data were completed on all
residents with natural teeth.
Any reported lesion for follow-up/observation was re-assessed
for resolution and re-referred if resolution had not occurred.
6 MONTH FOLLOW-UP VISIT
October 2014 – continued
All individual oral care plans were updated and tooth
brushes and Perivex were replaced if required.
Any resident who did not have a daily oral care plan on
their mirror was provided with one.
Any toothettes or mouthwash found in resident’s oral kits
Any resident requiring follow-up for an oral lesion was
referred to CNE and Care Team Manager on the NBHD.
Continuous adjustments are being made to policy,
processes, training and resources as required,
until everything flows well.
CNEs continued adding new neighborhoods and
training front-line staff, until daily oral care was
fully implemented at Parkridge Centre.
Each neighborhood has two or more dedicated
oral health champions depending on the number
of residents residing in each neighborhood.
WORK STANDARDS DEVELOPED
(BY PRC STAFF DEVELOPMENT AND SHR DENTAL
1. Oral Care Routine Assessment:
Basic assessment process
2. Proper Oral Health in LTC:
Basic oral care for natural teeth
Basic oral care for the Edentulous resident
Oral care for a resident with dysphagia
PROPER ORAL HEALTH IN LTC:
Wheelchair oral care
Lying down oral care
Oral care to Uncooperative residents
How to avoid being bitten
Dry Mouth treatments
Appropriate and Inappropriate Foam Swab
Lip Lubricant guidelines
Oral care for the unconscious resident
PRESENTLY AT PRC:
Oral care has now been implemented on
all NBHD’s, staff are practicing oral care
techniques. Education is ongoing.
Products have been assigned SKU numbers
and can been ordered through our SHR
Mat. Management (Stores) by the NBHD
PRESENTLY AT PRC:
Staff are doing the care adequately,
consistency is a problem.
Re-assessments must be done, just in the
process of implementing this plan.
4th year Nursing Students from U of S for doing
follow-up education in Sept 2015 as part of
their health promotion practicum.
Changing practice is a slow process
Have Managers and Nurses on Board:
Have a nurse (RN, RPN LPN) within the
Old Habits Die Hard!
Increased education and practice
Auditing/surveillance has to happen:
Check in with staff one month after initial
implementation / education.
Check kits in rooms (for mouth care only)
after one month.
Check resident’s teeth, communicate to staff
your findings. Takes a while to become a
Emphasize foam “toothettes” not for
Post bouquets and reminders
Re-educate if needed
Have the champions report any issues