ast week, I had a meeting with a nursing home attorney to outline a strategy to defend a long-term care facility against a negligence and wrongful death lawsuit. It seems the resident had lost 25 percent of his usual body weight in a four-month period. He also suffered the usual clinical consequences that accompany significant involuntary weight loss (IWL). As we dissected the medical record, we noticed that the gentleman in question had been receiving a regular diet for many months and then was downgraded to a mechanical soft diet. Shortly thereafter, the mechanical soft diet was further downgraded to a pureed consistency.
It was clear from the weight and meal intake logs that the IWL began as soon as the diet texture was modified. So we began looking for a chart entry to explain why the regular diet was changed to pureed. We inspected every physician, nursing, nutrition, therapy, and social service note. In the end, the only comment we could find to shed some light on the situation was on a monthly nursing summary. It simply said, "chewing problem noted." I felt my stomach twist into a knot because I then knew the facility was in trouble.
The link between nutritional and dental status is often overlooked. According to a study published in the American Journal of Alzheimer's Disease, pain resulting from tooth decay and other dental problems often remains undetected in nursing home residents suffering from dementia.1 The reality is that many of our nursing home residents, even those without dementia, often have dental problems that are undetected or undertreated. Since most long-term care facilities do not have a dentist on the premises, it is up to the multidisciplinary care team to provide routine mouth and dental care and advocate for dental consultations as needed. So open wide and acquaint yourself with some common nutrition and dental health problems.
Dental History and Oral Assessment
The physician completes the medical history. The nurse completes the nursing assessment. The dietitian completes the nutritional assessment. But who completes the dental history and oral assessment? The dental history should include questions about the last time the resident visited a dentist, any changes in the mouth or teeth, any loose or sensitive teeth, and any pain or bleeding in the teeth or gums. Questions should also be asked about chewing and swallowing difficulties, taste and flavor problems, dry mouth, and mouth sores. Additional questions about denture fit and alignment must be documented for residents with dentures or partial dentures. Table 1 lists the steps for performing an oral assessment. The findings from both the history and oral assessment must be thoroughly documented in the medical record upon assessment and updated periodically.
The Case of the Missing Dentures
In most facilities, the nursing assessment form has a series of check-off boxes that look like this:
Dentures
_Full Upper _Full Lower
_Partial Upper _Partial Lower
If any of these boxes are checked, it is interpreted as indicating that the resident has dentures and wears those same dentures. On countless occasions, I have visited residents who greet me with a gummy smile and are clearly edentulous. The nursing assessment, just as clearly, has a check mark in the box indicating that the resident does wear dentures. When I inquire as to the status of the missing dentures, the reply is, "Oh yes, I do have dentures but I never wear them. They are in the night stand, dear." Situations like this cause unnecessary confusion and require careful documentation. A detailed chart note explaining that a resident owns dentures but does not wear the dentures is needed. The practitioner should also determine why the dentures are not worn and chart the reason as well as what solutions were offered.
A second case of missing dentures occurs when a resident arrives with dentures but then loses them in the facility. This frequently transpires because the removable denture or bridge was wrapped in a tissue and inadvertently discarded. Dentures must not be left on meal trays, bedside tables, or in pockets. Proper storage containers should be available to each resident and labeled with the name and room number of the resident. If dentures are lost, the medical record must be updated promptly.
Denture Fit
Many cases of missing dentures are due to ill fitting dentures that cause discomfort. The importance of well-fitting dentures should never be underestimated. A good set of dentures preserves the appearance, makes adequate nutrition with a regular diet possible, and enables proper enunciation thereby facilitating social interaction.2 One of the most common complaints of denture wearers is that the dentures have become loose. Loose or ill-fitting dentures may be identified by a "clicking" sound that can be heard when the wearer is talking or eating. Many people believe that once they have lost all their natural teeth and have full dentures, they no longer need to visit a dentist. This is a myth. The bone under the gum, which supports the denture, is gradually reduced in size and continues to undergo remodeling, which leads to a poor fit.2 Fit is also affected by weight changes as little as ten pounds. For these reasons, it is important to have periodic visits to refit the dentures.
Mouth Care
Twice-daily mouth care is essential for all residents. Better dental care may even reduce the risk of pneumonia in elderly residents. Several anaerobic bacteria from the periodontal pockets have been isolated in the lungs.3 The mechanism of infection may be the aspiration into the lungs of oral pathogens that are capable of causing pneumonia. To minimize this risk, teeth and dentures should be brushed in the morning, as well as in the evening. Table 2 lists guidelines for brushing teeth properly.
Daily flossing and rinsing with mouthwash can further eliminate bacteria. Alcohol-free mouthwash is the best choice because it does not dry out the oral cavity. Many residents may already have problems with saliva production and dry mouth as a side effect of medications. Mouthwash containing alcohol may exacerbate this dry mouth condition, called xerostomia.
Morning is usually the most hectic time of day in a long-term care facility. Morning mouth care is very often overlooked because it is not visible to the casual observer. This may be especially true in residents with dementia who may resist mouth care or become combative. Gentle communication and patient reassurance to these residents is helpful to enhance cooperation. Table 3 lists some communication techniques that may be useful when providing mouth care to residents with dementia.
Even with proper daily mouth care, a professional cleaning is recommended at least annually. It is important to communicate the importance of yearly professional dental visits to the resident and family members and document these education sessions.
The Nutritional Link
The provision of optimal nutrition for our residents is a difficult challenge even under the best of circumstances. When a resident is suffering from ill-fitting or missing dentures, dry mouth, mouth pain from bacterial colonies, or any other oral problem, the meal process can be even more frustrating for both the caregiver and the resident. It is up to the entire healthcare team to recognize the major role dental health plays in the maintenance of proper nutritional status. Now that is something to really chew on! |
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