Page 7
Lack of Nursing Staff in Traditional Dental Offices
The nursing staff could provide several essential services for frail elderly nursing home residents seeking care in a traditional dental office. However, for a variety of reasons, including financial, residents who receive dental care outside the facility are accompanied by nurses’ aides rather than nurses. As a result, several vital nursing functions are lost to the dental team. For example, sedation and patient monitoring which facilitate care of the cognitively impaired resident cannot be provided by a nurse’s aide. The nursing staff plays other critical roles when dental care is provided within the nursing home. The nursing staff has intimate knowledge of the functional capabilities of each nursing home resident and can help assess the ability of residents to provide self-care including oral hygiene. The staff can provide information about the resident’s ability to tolerate appointments at certain times of day and on the need for medications when breathing problems or angina occur. If severely handicapped or incontinent residents need to urinate during a dental procedure, the nursing staff can help the resident as needed. Incontinence is one of the most common problems of nursing home residents and the homebound.
Lack of Properly Trained Oral Health Providers
Dental disease continues to be widespread and unchecked among functionally dependent older adults. One reason for this is that few dentists have received the level of training needed to make them comfortable in providing oral health care services outside the traditional office situation.8 Dr. Teran Gall, Director of Special Projects for the California Dental Association and a recognized expert in geriatric dentistry, makes the following observation: Dental education is limited largely to working on well patients. Most dental school interactions are not with compromised patients and there are very few opportunities for students to work with patients in nursing homes or do mobile dentistry and visit homebound individuals. Dental school training does not afford students the same opportunities as medical school opportunities to work with physically and medically compromised patients. As a result, many dentists may be uncomfortable working with patients who have special needs.
Ettinger, Watkins, and Cowen reviewed the status of geriatric dental education and found that the number of dental schools reporting the existence of didactic geriatric content has risen to 100 percent but that great curricular variation exists. Often a course in geriatrics is taught as an elective, so only a portion of the dental student body receives it. Variability exists in faculty training as well. The most recent survey reports that 12 percent of schools still have no required course and 17 percent have no specific geriatric course. Clinical preparation in geriatric dentistry lags behind. Ettinger, Watkins, and Cowen state: Regardless of repeated epidemiological evidence of the increasing dental need and demand of the older patient, over 25 percent of schools still report no geriatric clinical component. In addition, years after the Omnibus Reconciliation Act mandating a dentist of record in each nursing home facility, 45 percent of dental schools do not offer students any opportunity to experience working in a nursing home environment. Dr. Michael Strayer, a Professor of Geriatric Dentistry and Gerontology at Ohio State University College of Dentistry, is involved in one of the few programs in the country that offer students experience in treating geriatric patients. Dr. Strayer acknowledges that treating older patients presents diagnostic challenges:46 “One of the things I try to stress to students is that as patients get older, the signs and symptoms are not the same as they are in younger adults. For example, when older patients have pneumonia, they don’t necessarily present with a fever or cough. They often just have a general, vague feeling of not being well. The same thing can apply to periodontal disease or even dental abscesses in natural teeth. They may have dental problems but don’t have the symptoms you would find in a younger population. So it becomes problematic for practitioners.”
Physicians, nurses, and nurses aides have regular contact with homebound and nursing home residents. But training to recognize oral problems, oral lesions, or oral sequelae of chronic systemic conditions and the medications to treat these conditions is limited.47 The following exemplifies how the limited training and lack of medical integration with oral health care contributes to unmet need. Federal legislation enacted into law in 1992 (Omnibus Budget Reconciliation Act or OBRA 1987) was an ambitious effort to improve the standards of nursing home care in all areas, including oral health and dentistry. Any nursing home accepting Medicare or Medicaid reimbursement is required to complete a Minimum Data Set (MDS) assessment upon resident admission and at least yearly thereafter.48 Two sections of the MDS deal specifically with oral conditions. A nurse typically completes the oral/dental status section; a dietician completes the oral/nutritional status section.