VU Research Portal Mastication and oral health in elderly persons with dementia Weijenberg, R.A.F. 2013 document version Publisher's PDF, also known as Version of record Link to publication in VU Research Portal citation for published version (APA) Weijenberg, R. A. F. (2013). Mastication and oral health in elderly persons with dementia: The relationship with cognition and quality of life. General rights Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. • Users may download and print one copy of any publication from the public portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal ? Take down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. E-mail address: [email protected]Download date: 17. Jan. 2021
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VU Research Portal
Mastication and oral health in elderly persons with dementia
Weijenberg, R.A.F.
2013
document versionPublisher's PDF, also known as Version of record
Link to publication in VU Research Portal
citation for published version (APA)Weijenberg, R. A. F. (2013). Mastication and oral health in elderly persons with dementia: The relationship withcognition and quality of life.
General rightsCopyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright ownersand it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.
• Users may download and print one copy of any publication from the public portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal ?
Take down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.
e main aim of this thesis was to study the relationship between mastication,cognition, and quality of life (QoL) in elderly persons with dementia. In a clinicalsetting, an experimental approach (randomized clinical trial; RCT) was used toexamine the e�ect of increased masticatory activity on cognition and QoL. Sup-plemental research was done by reviewing the existing literature. In this generaldiscussion, the outcomes of the RCT will be re�ected upon, including how thisrelates to the literature, and what conclusions can be drawn for the future.
relationship between mastication and cognition
In the literature, there is a body of evidence emerging that there is, in fact, a rela-tionship between mastication and cognition. is literature is discussed in chapter2. e results from the cross-sectional analysis from the baseline data of the RCT, asdiscussed in chapter 6, agree with these �ndings; correlations between global cog-nition and masticatory performance, and between verbal �uency and masticatoryperformance were found. Masticatory performance was assessed with an objectivemixing ability test, which was developed for this purpose, and which is discussedin chapter 5. With this test, the correlation between mastication and cognition wasobjectively studied for the �rst time, in elderly persons with dementia, rather thanthrough self-report, as was done by, e.g., Miura et al. ¹. Furthermore, cognitionwas extensively assessed, instead of only globally screened. e fact that only twocognitive functions showed a correlation means that other cognitive functions – i.e.,(working) memory and attention, visuospatial (working) memory and function,and verbal long-term memory – did not correlate. Others have also found thatmastication in�uences some, but not all, cognitive functions. For example, chewing
138 • chapter 8 – general discussion
a piece of gum might improve sustained attention but not memory ², or chewing apiece of gum improved (working) memory but not attention ³. In healthy elderlypersons, better masticatory function related positively to recall and recognition ofsentences, recall of test session, and prospective memory, but not to face recogni-tion, recall and recognition of actions, attention, and tests for executive function 4.Clearly, there is still more work to be done, to investigate how mastication mightbe related to exactly which cognitive functions.
relationship between quality of life and mastication
Besides cognition, mastication is also related to QoL 5. QoL is a patient-based,nonmedical 6 appraisal of the burden presented to individuals su�ering from de-mentia 7,8. An important part of QoL is being contented 9, having ful�lling en-counters ¹0 and maintenance of dignity ¹¹. QoL can be in�uenced by masticatoryfunction and oral health; for example being able to eat healthy foods without help orthe need for mashing creates enjoyable mealtimes ¹¹ which improves QoL, whereassu�ering from a dry mouth hinders denture use, and thus, speech and social inter-action ¹², which lowers a person’s QoL. Pain of course can play an important role ¹³.Painful conditions such as pain in the skull, jaw, or neck (e.g., TemporomandibularDisorders) are known to lower a person’s QoL ¹4. Assessment of the longitudinaldata suggested that the implementation of the intervention might have negativelyin�uenced QoL, as restless and tense behaviors increased in the intervention group.As discussed in chapter 7, however, the intervention was not implemented success-fully, with oral care being performed more or less haphazardly, and this might haveled to apprehension with the participants.
pain
One interesting �nding of the RCT was that relatively little orofacial pain wasreported. In the cross-sectional analysis, pain during mandibular excursions wasrarely found, as almost 90% of the participants indicated to have ‘no pain’, andthe maximal summed pain score was 4 out of a possible maximal score of 16.However, as mentioned in chapter 1, in elderly persons with (severe) dementia, self-report is most likely unreliable ¹5. Since there are no observation scales speci�callyaimed at assessing orofacial pain, as discussed in chapter 3, presence of pain duringthese mandibular excursions was not measured in another way, besides self-report.Given the voluntary nature of the excursions it was assumed that no major painfulcondition arose during the assessments.
However, since pain tends to be underdiagnosed and undertreated in elderly
pain • 139
persons su�ering from dementia ¹6, it seems likely that there were, in fact, undiag-nosed orofacial painful conditions that in�uenced the mandibular excursions andmasticatory performance. Common oral conditions in elderly persons are, amongstothers: dental caries, (advanced) gingivitis (i.e., in�ammation of the gums; bleedinggums), periodontitis (i.e., in�ammation of the supportive tissue around the teeth),xerostomia (dry mouth), and candidiasis, which can present as: pseudomembranouscandidiasis [in Dutch, spruw]; denture stomatitis; and/or angular cheilitis (�ssures atmouth corners) ¹7. ese conditions are uncomfortable, if not painful. For example,even if it is asymptomatic in most patients, denture stomatitis can be painful ¹8and/or can give a burning sensation in the mouth ¹9. Similarly, pseudomembra-nous candidiasis is often clinically not relevant, but in some patients, it can causediscomfort and changes in taste ¹9; angular cheilitis is most uncomfortable whenone has to open the mouth ¹9, for example during mandibular excursions.
One case in particular was exemplary in how attention for oral health care andpossible presence of pain can improve and impact quality of life (QoL).
One nursing home resident, (let’s call her Ms. Daisy), showed typical behavior. She wasalways in a bad mood, quickly agitated, would never smile or make pleasant conversa-tion, and spent her time sitting alone in her wheelchair, leaning with her arm at thedining table, resting her chin in her hand, covering her mouth a bit. She would lamentand wail, sometimes softly, sometimes she cried out loud. ‘Oh, Ms. Daisy, hush!’ at’swhat the nursing sta� called at her, if she was being too loud or disturbing other residents.On ‘good’ days, she would sit there, alone at the dinner table, quietly whimpering. On‘bad’ days, she would be returned to her room, maybe given some tranquilizing medicine.
When the project started in her nursing home, the resident dental hygienist wasallowed to take the time to visit and inspect every participant’s mouth. Ms. Daisy turnedout the have a serious case of oral candidiasis, and most likely felt discomfort, pain,experienced altered taste. She was perhaps even aware of this, as her general behaviorof avoiding contact and covering her mouth changed immensely when her candidiasiswas treated; she smiled, laughed, even hugged members of the sta�. She no longer feltinhibited to engage in social interactions, had a good mood, and was pleasant to bearound. is re�ected positively on the sta� and other residents, who in turn becamemore pleasant and relaxed.
Clearly, the behavior indicated (orofacial) pain, as described in chapter 3, such ascalling out (vocalization), the sloughed posture (body movements), her behavior(withdrawn; aggressive; sad), holding her face, and resisting oral care. Awareness of(oro-) facial pain would have improved her QoL, and that of those around her, alot sooner.
140 • chapter 8 – general discussion
methodological issues
Randomization, allocation concealment, and blinding
In chapter 4, the proposed method for data collection is described. ere are afew critical comments that can be made. For example, the design was intendedas a longitudinal matched cluster randomized single-blind multicenter design. Inone participating center, due to crossover of nursing sta�, the control group wascontaminated, and the cluster match was lost. is happened early in the project,and therefore it was decided to include the control group in the intervention group.e nursing sta� of the new intervention group was briefed and trained accordingly.Complete randomization and allocation concealment is preferred, to prevent selec-tion bias. However, sometimes a certain ward was thought to be better suited forparticipation in the intervention group than others, for example due to presence ofa stable team of nursing sta� rather than one including many temporary workers.is might have created a selection bias. e study was designed to be single blind,and indeed, the trained examiners were blind for the intervention. It is possiblethat, due to the nature of the dementia, participants were also blind for, or perhapsunaware of, the intervention. However, some data were provided by proxies (such asthe QoL ratings), and these proxies were members of the nursing sta�, who regularlyinteracted with the participant; never for example a family member. ese membersof the nursing sta� were sometimes the same persons that were also performing theintervention. Non-blinded examiners tend to rate more positively, thus creatingascertainment bias ²0. It is possible that inadvertently, bias was introduced; futurestudies should be aware of this limitation and make an e�ort to avoid this.
Missing values
An unexpected �nding was the amount of missing values. It was estimated (chapter3) that there would be about 10% dropout due participant’s relocation and mortality.However, the return rates that could reasonably be expected for the proxy question-naires were not taken into consideration in these calculations.
e initial response rate of the current study is normal to high; in survey studies,return rates on questionnaires are commonly about 60% ²¹ to 70% ²² in communitysamples, and lower (e.g., 42%) ²³ in proxy questionnaires. In the current RCT,proxy-assessed activity of daily living (ADL) baseline scores were obtained for 66.6%(chapter 6; n=76/114). Similarly, 64.4% of the proxies returned completed QoLquestionnaires for baselines assessments (chapter 7; n=67/104). For the longitudinalrepeated assessments, however, results were worse; after 24 weeks, for only 25% ofthe participants, complete case data on QoL were available (chapter 7; n=26/104).
If we view these results in the light of the design, with multiple assessments, wemight understand the response rates better by considering the following. If for a
methodological issues • 141
single survey, the response rate is 65%, then repeating the survey 4 times would leadto an expected response rate of (0.65)4 = 0.18, i.e., a response rate of about 20%,which is in line with the current �ndings of 25% response rates for complete cases.
E�orts to increase response rates were made from the beginning, as personalcontact was established and maintained, the questionnaires were hand-delivered,and follow-up inquiries were made – actions that are known to improve responserates ²¹. e questionnaires were comprehensive, but as length of the questionnairesis not of in�uence on response rates ²¹,²², it is not likely that this was of in�uence onthe results. Generic looking questionnaires were used, which should have been noproblem, because adding a feel of authority to the presentation of the questionnaireby printing logo’s and adding signatures does not improve response rates ²4. As analternative, internet-based surveys might seem appropriate, but they are found tobe less e�ective in generating a response than paper surveys ²5.
It is understandable, but nevertheless most unfortunate, that such low responserates were obtained, and future studies should take these response rates into con-sideration when performing power calculations. Besides missing values due to theresponse rates on the questionnaires, low responses were obtained with the neu-ropsychological tests and the assessment of the masticatory performance.
e response rates for the neuropsychological tests were slightly better comparedto the proxy response rates. Global cognition, for example, was successfully assessedwith the Mini Mental State Examination (MMSE, ²6) in about 80% (chapter 6,n=93/114). Repeated response rates for global cognition were relatively high, 54%(n=56/104). is is probably due to the external trained examiners, who alwaysaimed for 100% response, and only a participant’s (mental or physical) inabilityto participate, rather than a rater’s unwillingness to participate, in�uenced theseresponse rates.
However, less than 50% of the participants were successfully examined with thefull test battery, which was applied to those participants who scored higher than5 of the MMSE (see chapter 3). In fact, a score of MMSE <9, indicating severedementia 9, was obtained for more than half the sample. In Figure 8.1, a frequencydistribution of the MMSE scores is given for the sample from chapter 6, and inFigure 8.2, the same data is presented in a pie chart, clearly illustrating the severityof the dementia in the sample.
e advanced dementia level of the sample was one of the reasons that partici-pants attending daycare, with generally less severe dementia, were actively recruitedin the later stages of the trial. In future trials, it would be worthwhile to activelyinclude, from the beginning, care organizations with residents with less severe de-mentia, such as low-medium care wards (‘verzorgingshuis’) and daycare facilities.A bottom cut-o� score for global cognition at baseline for participation might beconsidered, although global cognition did not appear to in�uence, for example, theability to participate in the mixing ability test, as described in chapter 6, and theoverall participation rates for the neuropsychological tests are not disappointing.
Figure 8.1: Distribution of global cognition of the participants in the cross-sectional study, as-sessed with the Mini Mental State Examination (MMSE). Participants are classi�ed into a Se-vere/Moderate/Mild category (MMSE: 0–9; 10–19 and >20, respectively)9.
Severe Dementia
Moderate Dementia
Mild Dementia
Figure 8.2: Pie chart of participants’ distribution according to Dementia Severity. Note that over halfof the participants su�ered from severe dementia according to Schi�czyk et al., (2010) 9.
methodological issues • 143
Masticatory performance was assessed with a combination of techniques (chap-ter 4). Mandibular excursion assessments were successfully performed in about 40%of the cases (i.e., chapter 6: 42.3% (n=44/104) and chapter 7: 41.2% (n=47/114)).Due to the severity of the dementia, participants often did not understand theverbal instructions at �rst explanation, however, using non-verbal communication,o�ering a demonstration and mimicking the desired motions, successful assessmentwas often still achieved. It was found that maximal mouth opening was easier mod-eled and assessed than protrusion and laterotrusions. Only complete assessmentshave been included in the analyses; it might be worthwhile to reconsider this infuture papers, and only focus on maximal mouth opening, because limited maximalmouth opening alone is considered a clinical sign in studies on temporomandibulardisorders ²7.
e mixing ability test with two-color chewing gum, which was developed forthis thesis, was found to be adequately responsive and reliable (chapter 5), althoughvalidity needs to be further established. e mixing ability test was used to assessthe association between masticatory performance and cognition in a cross-sectionalstudy of the clinical sample (chapter 6) and was taken as a measure of interventionsuccess in chapter 7. e rationale behind this was that if the intervention increasedoral health and thereby masticatory activity, masticatory performance would im-prove as well. Similar assumptions and assessments have been made, for example,when using a timed walk or a “Timed Up and Go” task to investigate the e�ect ofa walking intervention ²8.
A correlation between masticatory performance and cognitive measures wasfound, in a subsample of persons participating in the mixing ability test (chapter 6).About half of the participants did not perform the mixing ability test. ere wereseveral reasons for ‘nonperformance’. First of all, some participants were excludedbased on prede�ned criteria, such as facial paralysis. Others were eligible to par-ticipate, but were withdrawn by an intervening proxy. For example, a member ofthe nursing sta� would indicate that a participant should not perform the mixingability test. is was done without a medical imperative, i.e., there was no physicalor ethical reason that called for exclusion. Instead, the advice was given, for example,out of fear for agitation or exhaustion. Whether or not this fear was based on athorough risk assessment was never debated; the trained examiners were instructedto respect the proxies’ instructions, and thus excluded the participant from thetest. is may have led to a selection bias, which could be re�ected in the higherdependency scores for ADL of the group of ‘nonperformers’. is group comprisedboth the participants that were excluded based on the prede�ned criteria, as wellas those excluded by proxy request. Participants that were more dependent wereperhaps considered too vulnerable, and therefore excluded by a proxy.
144 • chapter 8 – general discussion
implementation of an intervention
Adherence
During the process of implementing the intervention, there was a growing concernabout the actual adherence to the intervention. is was the main reason that an adhoc terminalis analysis was conducted, rather than the planned end-analysis. Severalfactors contributed to the concern with regard to intervention adherence.
Reports for intervention success varied greatly between nurses from the sameward, some mentioning all went ‘great’ whereas others indicated major problems.Attendance to the clinical lessons was low, and after a survey, it was found that,among daily nursing sta�, the awareness of the project and the importance of oralhealth in general was also low. ere were many changes in nursing sta�, dentists,dieticians, and also in management, which did not facilitate embracing and embed-ding of the intervention.
At a few nursing homes, that had a local dental hygienist, plaque checks wereperformed, at baseline and at random intervals later on. ese plaque checks in-dicated no improvement over time. e tick-o� lists, if �lled out, also indicatedlow frequency of oral care (data not shown). On the other hand, when we werepresented with tick o� lists showing 100% successful oral care moments, all �lledout in the same handwriting and ink, it was felt that this was perhaps not re�ectingthe actual situation. Deception by those unwilling or unable to comply is commonin clinical trials, but also impossible to predict, and hard to prevent or prove ²9.
Obstacles for implementation success
e interviews with the daily nursing sta� indicated di�culties such as a lack oftime, and a lack of money, for example to buy oral care supplies or harder foods. Alack of commitment by the managers was also mentioned, leaving the nursing sta�feeling unsupported. ese are common, but serious obstacles for innovation ³0.is lack of managerial commitment was also felt in participating in the clinicallessons.
It was felt that managers did not facilitate or prioritize attendance, as sta� wasexpected to attend the lessons in their own time, without �nancial compensationand with no regard for personal commitment such as caring for (young) familymembers. Only occasionally, adaptations in work schedules were made to facilitateattending clinical lessons. Managers rarely attended the lessons themselves, whichwas most unfortunate as management support and active leadership is related tointervention success ³¹. Sometimes, instead of the daily nursing sta�, replacementsattendees were sent, such as high-school students who were on an orienting intern-ship (‘snu�elstage’). Temporary workforce sta� was excluded from attending theclinical lessons.
implementation of an intervention • 145
Nurses’ ideas about the importance of oral health and their ability in providingoral care can improve after training, although a clinical e�ect of education on oralhygiene is not (yet) evident ³²,³³. is conclusion was recently con�rmed in a reviewstudy ³4. Continuous education and support of sta� on providing oral health care istherefore recommended ³5, especially as nurses are typically only marginally trainedin providing such care, if at all ³²,³6.
In the present study, nursing sta� did not always realize and appreciate thebene�t of good oral health and mastication for general health and QoL. For ex-ample, it was thought that for elderly persons with dementia, having no teeth andeating or being fed pureed foods would be ‘easy and enjoyable’, which did not helpin motivating sta� to provide oral health care. O�ering one clinical lesson was notenough to change this overall negative attitude towards oral care.
Complexity of change
Besides negative attitudes and (perceived) lack of managerial support, the lackof implementing success might be explained by looking at the complexity of theintervention ³7. According to Sterns, Miller and Allen ³7, complex changes are hardto implement. A change is complex when the outcome of the change is uncertain,and the level of agreement between parties is low. On the opposite, a change isnot complex when the outcome is certain and agreement is high. A non-complexchange is for example adding plants to the living room to increase a sense ofhome, or allowing a resident to choose his/her own bedtime, to increase autonomy.ese changes do not involve an elaborate interaction or are the potential sourceof con�ict, the outcome is quite certain, and can thus be implemented easily innursing homes. A complex change, however, is typically only implemented by verycommitted teams and organizations. Providing oral health care is a complex change,as there is uncertainty of the e�ect – will oral health increase, will QoL increase,or perhaps cognition? Having the e�ort being evaluated scienti�cally might haveincreased this uncertainty. ere is much disagreement between the parties; theresident and nursing sta� are likely to have some (initial) con�ict as they attempt toprovide oral care, and despite clinical lessons and supervision of an dental hygien-ist, there were questions regarding (or even resistance towards) certain actions; forexample, about storing dentures overnight, or about brushing teeth when the gumsare bleeding. Having to adapt their approach to each resident individually increasesthe complexity for the nursing sta� even more.
From a literature review on psychosocial intervention, it became clear thatknowing the resident personally is an important factor for intervention success ³8.Interestingly, these authors noted that nursing sta� seem to be preoccupied with therisk of physical harms (e.g., falling) or causing agitation, and are more focused onprevention of oppositional behavior such as outbursts, than they are on promotingautonomy and improving QoL ³8. is is in line with the current observations;
146 • chapter 8 – general discussion
nursing sta� were quite concerned with the physical wellbeing of participants, andwith maintaining a level of serenity in the ward, and could therefore be reluctant tostart providing oral health care, since it caused (initial) resistance behaviors.
clinical relevance
e clinical relevance of these �ndings is profound. It was shown in this thesis,in both literature and the clinical sample, that there is an association betweenmasticatory performance and cognition. is would suggest that maintenance orrehabilitation of oral function is important, especially for those persons most af-fected by cognitive loss and unable to communicate possible pain, such as elderlypersons su�ering from dementia.
At the same time, it was found that successfully implementing an oral healthcare intervention is quite challenging. Comparable results for oral care interven-tions have recently been reported. e implementation of the Dutch ’Oral healthcare Guideline for Older people in Long-term care Institutions’ (OGOLI) ³9 hasbeen studied in another longitudinal design in the Netherlands and Belgium 40,4¹.Unfortunately, after six months, the only positive �nding was that residents whowere completely dependent had less denture plaque. However, all plaque levels werestill higher than expected 40. e results after �ve years were not much di�erent, asthe plaque levels were still high in both intervention group and control group 4¹.Intensive supervision of the implementation seems only marginally bene�cial 4².Similarly, in a residential setting, training the daily nursing sta� led to improve-ments of oral hygiene at 11 month follow up, mostly in denture hygiene, and withalmost half of the residents still having poor oral health 4³. e need for dentaltreatment also remained high despite training in yet another study, even thoughthe sta�’s ability to assess oral health and the residents‘ oral hygiene improved ³³.
Nevertheless, there are also inspiring reports: it was found that an interventionfocused on providing oral health care (i.e., brushing after each meal and weeklycleaning by a dentist or dental hygienist) for nursing homes residents was able todi�erentiate the intervention group from the control group after 6 months and 12months, based on MMSE scores 44. It would be very interesting to further investi-gate the factors that determine the implementation success of an intervention.
e introduction of a designated Oral Health Coordinator (OHC) who re-ceived outside training and ongoing support from a trainer, had a positive e�ect onthe oral health of institutionalized elderly after one year 45. e level of authorityand enthusiasm of the OHC was key in intervention success; more important thaneducation 45. A positive e�ect on oral hygiene was reported after 3 months and evenafter 6 years, of having designated supervising sta� members, alongside picture-based instruction cards, providing materials and practical oral care instructions tonursing sta� in a residential setting 46. Assigning a designated oral care nurse each
conclusions and recommendations • 147
day and equipping this person with a custom-made trolley was found to reduceplaque scores, gingivitis, and periodontal disease 47. Presence of a designated oralcare professional also increases positive attitude towards oral care in nursing homesta� 48.
Committing speci�c members of sta� to performing the oral health care wasfound to be e�ective in improving the oral health of residents su�ering fromdementia 49. In this pilot study, dedicated mouth care aides were allowed spending4 hours per day, for 5 days per week, to providing oral care to all the residents. eyreceived daily training for two weeks, including providing oral care alongside thedentist, followed by expert support for a few hours per week. Training includedtheory and practical information on oral care and also instruction by a psychologiston dealing with behavioral issues they might encounter. ere was a signi�cantimprovement in oral hygiene and thoroughness of care, e.g., �ossing and toothpicking had become part of the routine 49.
e addition of counseling on how to deal with resistant behaviors is promis-ing, indeed. Studies con�rm that resistant 50 and uncooperative 5¹ behavior fromdependent residents (both cognitively healthy and su�ering from dementia) playa major role in oral health. An intervention executed by researchers combiningtactics for reducing resistant behaviors and oral health care best practices provedvery successful 5². In fact, loss of cognition does not have to in�uence oral health,as long as someone is independent for oral health care; however, as one becomesdependent, impaired cognition puts a person at great risk for impaired oral hygiene,most likely due to un-cooperation 5³. Recommendations for reducing care-resistantbehaviors in oral care are available 54, but they are not part of the Dutch guideline ³5nor part of nurses training ³6.
conclusions and recommendations
From all of the above, some suggestions for future research and policy makers canbe made. First, it would still be interesting to investigate the e�ect of increasedmasticatory activity on cognition and QoL in elderly persons with dementia. Asuccessful implementation of an oral health care intervention would be key to this.
Secondly, therefore, it would be worthwhile to further investigate how to imple-ment oral care interventions for elderly persons with dementia. Factors for successwill most likely include continuous education, including individual coaching andproviding the ability to work alongside a dental professional (‘training on the job’),and designating a daily oral care provider, to increase accountability. Training shouldinclude both theory and practical instructions; both in providing oral care and inresponding to resistant and uncooperative behaviors. In order to practically organizethis, our �nal recommendation would be to commit dedicated professionals to thistask, rather than designating a member of the daily nursing sta� to provide oral care
148 • chapter 8 – general discussion
and rotating this responsibility on a daily or weekly basis. is dedicated, designatedoral care nurse, the so-called Denticure, will be trained in both providing oral healthcare for elderly persons and in handling uncooperative behavior. e Denticureprovides all daily oral care, is the liaison between nursing sta� and dental profes-sionals, and since (s)he does not have other nursing tasks, there is no con�ict ofpriorities, or lack of time or skill. Assigning the task of oral care to one or two speci�cpersons rather than the group also creates transparency, direct accountability, andresponsibility. e Denticure can establish good rapport with the residents, and willdevelop a tailored approach for each individual client.
Simply trying to add the task of oral care to the workload and responsibilityof the – already overburdened – daily nursing sta� under the premise of ‘it onlytakes two minutes’ is denying both the value and e�ort of o�ering oral healthcare. As it is of great importance to general health, and, since the nursing homesresidents of the future are expected to o�er challenging dental situations, we wouldstrongly recommend the appointment of a Denticure in every nursing home. Withan estimated possible workload of 4–6 clients per hour 49, one fulltime Denticurecould provide excellent oral health care, once daily, for 40 residents. Specializedtraining for this job must commence as soon as possible, and adequate fundingmust be made available.
references • 149
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