Is brushing your patients’ teeth really that important?

Many times, there are activities of daily living that are not necessarily the most pleasant but the importance should be over stressed.  After all nutrition as we know all begins in the mouth.  A clean mouth and good oral are important to begin being healthy.

Many medications can cause dry mouth and the patient may lose the good taste of food to enjoy as well as the desire to eat or drink.  A dirty mouth is not appetizing at all plus gives the patient bad breath, gum disease and causes tooth loss. 

We learn from an early age the important of brushing after meals and especially before going to bed.  The importance of flossing the teeth, brushing and a good oral rinse should be included in good oral hygiene.

Sadly, due to negligence, lack of staff, staff not interested or not enough time, teeth often can be “overlooked” and “forgotten”.  The patient can develop painful sores, terrible breath and rotten teeth which eventually leads to tooth loss.  

Nursing staff have been trained to provide activities of daily living including oral hygiene and not to provide this care is a deviation in their standards.

As a result of this neglect, there is a need to see a dentist. Seeing a dentist through out our lives has been important and must be followed through while a person is in the facility.  This is true no matter what type of facility the patient is in.  

Remember in facilities, if a dentist is needed to see the patients / residents, this service must be available and provided. 

Daily oral care and oral hygiene are necessary to maintain a quality of life and sadly in too many long term care facilities, this care can be poor to never occurring.  This also means the providers are not in compliance with the guidelines and protocols.[1]

Providing this oral hygiene can be a challenge if the patient / resident has dementia and does not understand what is being done, does not open the mouth and refuses to cooperative with this care.    Dementia patients often bit down on the toothbrush, will not rinse and spit out the oral rinse and can be agitated with care is provided, by hitting and kicking.  Yet just having a diagnosis of dementia does not mean oral care will not be nor cannot be provided.

Yet, the standard of nursing care requirements the care be provided for quality of life and healthy.  There are different types of toothpaste, brushes, and toot Hettes that can be used for the care on a regular basis.  The type of oral rinse or just plain water can be used if the patient just swallows after brushing and unable to swish and spit. 

The outcome of not brushing can be devastating.  A case I reviewed reflected the daily oral hygiene was never provided.  This 50 year old gentleman had been a professional, high profile in his community, dignified man in his working life.  His personal hygiene was always immaculate and the brushing of his teeth was down twice a day per his wife. 

Upon admission to the long term care facility, he had all his teeth and the teeth were in good condition and repair.

Prior to admission to the facility, this gentleman had appropriate healthcare and also saw his dentist on a regular basis for cleaning and oral needs.   Sadly, he was a victim of a stoke while working, hospitalized and later placed in a long term care facility.  His family was not able to provide and meet his personal needs at home.

While a resident in a long term care facility, the oral hygiene was not provided.  His wife even wrote notes to the staff / administration and spoke to the staff to “Please brush his teeth daily”.    Unfortunately, the brushing of his teeth did not occur, his teeth became rotten, gum disease occurred and all of the teeth had to be pulled. 

 Due to the loss of income and now on Medicaid for the facility payment of “care”, the pulling of his teeth was paid by Medicaid, but providing the resident with false teeth was not covered.  His family was unable to pay the cost of false teeth and he was left with only his gums to start the process of “chewing” his food.

As we all know, texture of our food is important for us to enjoy and be able to eat.  The gentlemen did not like having only liquid and pureed foods (paste like texture).   This resulted in often refusing his meals after all of his teeth were pulled.

Sadly, this man wasted away, weight loss and refusing to eat.   He suffered an early demise all because of negligence[2] by the staff and not having his teeth brushed.  Unfortunately, and additionally, the nursing staff did not honor / ignored the wife’s request of “Please brush his teeth daily”  and the nursing standard of care was ignored. 

 Brushing of his teeth should have been provided if the facility had sufficient and knowledgeable nursing staff to meet their resident’s needs.

“Neglect” means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

Per 42 CFR 483.25 Activities of Daily Living, “The facility must provide based on the comprehensive assessment and care plan and preferences of each resident, an ongoing program to support residents in their choice of activities…..”.   

In this case, the basic oral care was not provided and the nursing standard of care was violated. [3]

[1] https://pubmed.ncbi.nlm.nih.gov/23290098/

[2]https://qsep.cms.gov/data/107/AbuseNeglectExploitation.pdf

[3] 42CFR.25 quality of Care (a)(3) a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene.