After more than 6 months, our journey across different life stages has come to an end. We have been discussing many interesting topics the past few months, from periodontal disease during pregnancy to caring for the elderly, and everything in between. In the last episode of our SUNSTAR CONVERSATIONS PRO series – aired on October 7, 2021 – we had the opportunity to discuss a special topic that concerns all life stages: caregivers. Together with Dr. Larisa Musić and Prof. Dr. Falk Schwendicke, we explored the supporting role oral care professionals can have for caregivers, to help improve oral health for those who need it most. Continue reading to learn more.
Larisa kicks off the conversation by defining caregivers: “They are individuals that care for people that have some sort of short- or long-term limitations that might be caused by an injury, an illness or any sort of disability. Usually, we classify them as formal or informal, where the former are usually being paid and trained (e.g., nurses) whereas the latter are not (e.g., people within the social circle of the patient in need, such as spouses, children or friends)”. She continues: “these individuals rarely receive the education for the tasks that they provide, which vary from daily activities such as eating, bathing, and going to the toilet to instrumental activities such as transportation, paying the bills and tending to the household. But they also offer companionship and emotional support”. When we talk about the care recipients, Larisa highlights that it’s important to realize not all of them are elderly: “they can be of any age, ranging from children and teenagers to young and older adults. This is important as the oral care needs are different depending on the age group”.
Falk then provides context to what caregivers are facing in terms of oral health in the population they care for, starting by highlighting the fact that they are facing a very heterogeneous group with quite complex needs, especially in comparison to 40 years ago: “for example, dental caries was mainly a disease of children and adolescents, followed by tooth loss in their thirties and forties, and by the age of 60-65, the vast majority of people didn’t have any teeth left. That has changed massively with all the preventive successes. We are seeing increasingly good oral health and tooth retention, in children, adolescents, adults and by now even in the first seniors. And an increasingly lower amount of people has full dentures. And that obviously has an impact on caregivers because a full denture is a completely different thing to care for. Dealing with own teeth is even more difficult”.
Oral health and general health
Falk continues on the topic of the link between oral and general health: “We really see that certain systemic diseases are linked to periodontal disease, like for example diabetes. We know that it’s hard to control diabetes if periodontal disease isn’t managed, and on the other hand if diabetes isn’t controlled then you won’t manage periodontal disease successfully. So, we really need joint care concepts, and caregivers have an important role here. Also, especially relevant for the group of very old people who need care and assistance is the link between oral hygiene, oral biofilm, and pneumonia, which is a deadly one. We know that poor oral hygiene doubles the risk of dying from pneumonia, and good plaque control can reduce that risk by 40-50%. These are two very good examples of where these patients need our assistance, and whereas we are usually very much focused on dealing with people who come to our practice, for the people we are talking about today, we need other solutions”. Larisa provides some additional context: “It’s important to raise awareness about these potential links, because especially in terms of caregiving, oral health is very low on the list of priorities, mainly because of the many other bodily issues, mobility issues, comorbidities, medication etc. But it’s up to us to work on these things and change it”. Falk agrees: “Showcasing the link between oral and systemic diseases puts the mouth where it belongs: into our body. And there are other examples, like quality of life, nutrition, weight; these are all established associations backed up by evidence”.
Falk shares his thoughts on how to shape this joint care concept: “The problem is that caregivers can’t solve this problem on their own, they need help. We just conducted a study showing that the oral health of people living at home is even worse than the oral health of people living in care homes. Usually, you would expect that the informal caregiver is very attentive, that they’re trying very hard because it’s their spouse for example, but apparently, despite them being so motivated they just can’t, they just don’t have the skills to do this. And that’s where dentistry can probably do something early on. For example, when you see an older couple coming, and one of them is likely to experience problems soon, we should seize this moment in time to educate the other spouse about how to deal with it when it happens. A stepwise approach to education, and the same is true for care homes. Even when the formal caregivers are motivated, often the organization of the care homes is insufficient, so you need to talk to quality managers, to the directors, you need to educate the caregivers and the nursing staff regularly. And then stepwise, things are improving overall. Maybe not all people in the care homes will benefit from this immediately, but in the long run, you establish higher quality standards for oral care”.
Larisa continues on the integrative approach with a shocking clinical example: “This was a nursing care resident with Parkinson’s disease, who had a combined mobile/fixed prosthodontic appliance. And nobody removed the mobile prosthesis for over two years. The nurse that was taking care of him didn’t attend to his needs, she didn’t understand what a combined prosthesis was and didn’t know how to remove it. And I kept thinking, who was the dentist that thought a combined prosthesis – which was hard to remove – was a good dental rehabilitation solution for a person with Parkinson’s”. An initiative from Canada inspired her: “In this project (The Brushing up on Mouth Care Project by McNally et al.) they changed the entire system, involving administrators, managers, nurses, a dental hygienist, an assistant, and an oral health champion who took initiative. And it showed just how important it is to have this very integrative approach when it comes to the improvement of oral care”.
Falk agrees: “There is not one solution. It’s one of those things where you need to be adaptive, and every character is different, so you have to look and adapt to their needs”.
Supporting caregivers as oral health professionals
It is safe to say there are many barriers for caregivers when it comes to providing oral care. But oral care professionals can support them in many ways. Larisa starts: “We need to start by setting goals, but those goals have to be very realistic. We have general recommendations about oral care, coming from preventative and paediatric dentistry for example, but it’s very questionable whether these goals can also be applied to the oral care that is provided by caregivers in this specific population”. And this realization initially went against her beliefs and training as a periodontist: “But I don’t think this is a loser approach, I think adapting oral care for this specific population is something that can make it feasible and sustainable. If we try to enforce general recommendations that are meant for the general population, such as brushing twice per day for two minutes, or interdental care, I’m not sure that we are going to reach any goal at all”. She then continues with a list of tips and tricks that can help caregivers on a daily basis:
- Try to make an individualized checklist of oral care steps for each patient, even if it’s just four simple things that they need to do, so you don’t forget anything.
- Have a toolkit ready, so that everything you use for dental care is in one spot.
- For care-resistant patients, always perform oral care procedures at the same time and in the same area, to soothe them and take away some of the resistance.
- If the person can perform oral care himself or herself to some extent, try a technique that she calls “chaining”, which means that the individual starts performing oral hygiene procedures by himself or herself, which is then followed by the caregiver doing some additional steps to ensure proper oral hygiene. You can think of finishing the tooth brushing or performing interdental cleaning.
- Adjust any sort of dental hygiene aids to make them easier to use. For example, put a little towel around the handle of a toothbrush, secured with an elastic, to make it bigger so they can have an easier grip. You can use other materials as well, such as a bicycle tire or adhesive tape.
- Electric toothbrushes can support individuals with special needs.
- Make oral care a routine for individuals with dementia for example who exhibit care-resistant behaviour, so that they know what to expect
- Standing in front of a person to perform oral care procedures might induce care-resistant behaviour, since you can be perceived as a threat by that person. So instead, stand behind this person and hand them a mirror.
- Try “bridging”, which means that you put the toothbrush in the hand of your patient, and you start brushing their teeth. That engages their senses and gives them a feeling of what you’re doing, because they’re holding the toothbrush themselves.
She then wraps it up with an important message about persons with full dentures: “Caregivers generally don’t know that dentures need to be removed, so they are just kept in the mouth. This can contribute to candidiasis, which can then further contribute to pain, discomfort, itchiness, inability to eat, and that has a huge potential to cause problems further down the way. Caregivers need to be taught what is in the mouth of the individuals they’re taking care of, and how to deal with these specific circumstances. And as Falk said, we’re witnessing a completely different oral status of an 80-year-old, compared to 40, 50 or 60 years ago”.
Falk can only second that: “You just need to be very pragmatic in these situations and can’t expect everything you would expect in a practice setting”. He then adds a few things to the list mentioned by Larisa: “Consider using a highly fluorinated toothpaste, which is not something that is done very often. I use a 5000 ppm toothpaste for all of my very old patients, as it has been proven for example to prevent root caries quite effectively. Mouthwashes are also interesting because they’re easy to apply. These chemical products can support the mechanical part of oral hygiene”. He continues by mentioning the importance of communication: “Our main task is going out there and to talk to the people. That’s already 50% of our success, talking to the people, talking to the nurses, the quality managers, the care home directors. All in order to establish an environment where there can be better oral health and better oral hygiene. It can make a big difference if the nursing staff somehow has a little bit more time for oral health, if they see that oral health is a priority in their care home, if they can ask questions to the dental staff. We see from a number of studies that caregivers in care homes are very insecure. Allowing them to talk to a dental professional every three to six months makes a big difference in their confidence, their abilities of how to deal with the oral health of these elderly people and these complex situations. For example, showing them once how to remove a denture can make a huge difference for that individual. It may take us 15 seconds, but it can make a big change for the caregiver and the one who is given care to”.
Make sure to catch all episodes of the SUNSTAR Conversations PRO series by subscribing to our YouTube Channel. The next sessions are focused on 2 special webinars to tackle the interrelationships between oral health and general health, in conjunction with the Sunstar World Perio Research Awards.