Dental Tribune USA

Dental hygiene for dependent adults

By Shirley Gutkowski, RDH, BSDH, FACE
October 23, 2009

I think it’s safe to say that, in general, the oral care of dependent adults is bad. Perhaps the word horrible is more accurate, or abysmal, shameful, poor, dreadful, terrible or awful and possibly even awe full! The teeth, broken, malaligned and stained, are covered with a thick coating of biofilm, once called plaque. Caregivers think this is normal. They don’t make the connection between nice teeth and their dependent charges.

There are a multitude of reasons for this disconnect. The people who study these types of things find a couple of interesting insights. For one, as the dental IQ of the caregiver increases, the oral health of their charges increases. They also find that a dental health care professional on-site increases oral care incidence for the resident. The third finding shows that oral care in-service meetings (regardless of the duration) increase oral care over a short term but the benefits fade away quickly.

It’s time to shift our thinking. The quickest easiest thing to do is remove all teeth. No teeth, no biofilm, no dental problems. Many a care provider has uttered this wish. They don’t know what we know about the decrease in the quality of life these dependents undergo once their teeth are removed. The caregivers have a gut feeling that teeth are a locus of infection, and removing them will surely help their charges. They’re right.

Oral health care providers must answer this question: How can dental professionals decrease the complications of teeth in the dependent adult population without adding stress to caregivers? The answer is to shift the thinking down a notch from mechanical means of biofilm disruption to biofilm disruption, period. It is possible to do one without the other.

Recent research has given us a list of ways to address biofilm without the use of caustic chemicals. Many of the tools we’ve been trying to use to address oral biofilm aren’t really penetrating. If they do, they penetrate a short distance into the film and never affect the dormant or persister microbes deep inside. Most typical rinses, pastes and creams, affect the free floating, planktonic bacteria – no problem. The biofilm reestablishes itself quickly after the danger is past.

There are many microbes that contribute to film part of the biofilm. For the most part they use sucrose and convert it, not only to acids, but to the polyscharride covering as well. This covering makes it easy for the biofilm to adhere to the tooth, and protects the microbes from attack. If the microbes are not sheltered by the polyscharride, they are easy to kill.

Science has found four ways to interfere with the adhesion process of oral pathogens. They are lactoferrin, cranberry, licorice root extract, and xylitol. Including any of these into the diet of those dependent adults will decrease the microbes ability to adhere to the hard or soft tissue. Let’s see how swapping these ingredients in a normal routine will work.

For Breakfast:

  • Provide only cranberry juice in place of the traditional rotation of juices (orange, apple and cranberry)
  • Hot or cold cereal sweetened with xylitol

For Lunch:

  • Apple sauce to help swallow the daily noon round of medication sweetened with xylitol.

For Snack:

  • Finish with xylitol gum or mint

For Dinner:

  • Finish with xylitol candy or mint

For Evening Snack:

  • Licorice root sucker

Daily oral care routine:

  • Xylitol toothpaste
  • Xylitol mouthwash
  • Xylitol dry mouth spray

Lactoferrin is not a viable product for this type of use as yet. Currently it is being used in chronic wound care mixed with xylitol.

The biofilm associated with dental disease is very sensitive to pH changes. Using products to change the pH will also shift the biofilm to a more homeostatic one. The shift can be accelerated by using bicarbonate rinse, which is poorly tolerated. Mixing xylitol into drinking water is a way to increase oral pH and help hydrate the dependent adult. Recaldent and NovaMin in pastes have a great track record of increasing oral pH for hours after application. Arginine compound pastes shares that benefit as well. Even if these pastes are put onto the finger of the resident for them to apply themselves pH shift will occur stopping biofilm growth on a dime.

We know that xylitol has residual effects for years after use. It’s prudent for all clinicians to advise all patients approaching declining age to start using xylitol products as a preventive. Use of these products, with an eye towards biofilm reduction, as opposed to brush and floss education may be the answer everyone has been waiting for.

Online courses

Earn your C.E. credits online through the three-part series: Simple Advanced Treatment Modalities for the Dependent Patient.

Angie Stone and Shirley Gutkowski pool their expertise to offer a three-part series of live and interactive webinars. The series starts with “Who is Taking Care of the Dependent Patient Every Day?” on Thursday, 5 November at 7 PM (EST). Attendees will learn what a typical day is like in the life of a nursing assistant, what education they have been provided and what their position is regarding oral care.

Each module is offered live and interactive, as well as recorded and archived, and offer ADA CERP credits. You can find Angie and Shirley’s online series under >> Online Courses.


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