As the population ages, the number of people requiring long-term care facilities (LTCFs) rises proportionally. More than half of the people turning 65 today will need long-term care during their life journey. Many of them will need assistance with activities of daily living (ADLs) due to cognitive and/or physical impairment. Most will need help with oral hygiene.1
Oral health impacts quality of life
Oral conditions adversely impact the quality of life of seniors residing in all types of facilities, from assisted living and private group homes to memory care and skilled nursing residences. Studies reveal a large number of nursing home residents have difficulty chewing and eating, jeopardizing their nutritional status and depriving them of one of their few remaining pleasures.1 Losing the enjoyment of food due to preventable or treatable oral issues is nothing less than tragic.
Many geriatric residents are dealing with missing or broken teeth, ill-fitting dentures, bleeding gums, coated tongues, dry mouth and lips, toothaches, sensitivity, and burning sensations in the mouth. While some oral issues are due to chronic health conditions and the side effects of some medications, most are the result of a lack of professional oral-health care.1,2
Oral hygiene poses significant challenges for both patients and caregivers in LTCFs. Senior residents often have difficulty keeping up with daily oral hygiene. They may have lost the dexterity and/or coordination to brush and floss their own teeth, or they forget their oral hygiene due to cognitive decline. Facility caregivers and certified nursing assistants (CNAs) working as part of a hospice team may not be adequately trained to work with the oral hygiene needs of dementia patients or those with Alzheimer’s, amyotrophic lateral sclerosis (ALS), or Parkinson’s disease. Additionally, many facilities are understaffed, and oral hygiene may not be given priority when people need feeding, toileting, wound care, and medication supervision. Caregivers and CNAs may be expected to provide daily oral care but are not held accountable for fulfilling those duties, leaving vulnerable, elderly patients susceptible to oral issues that can threaten their systemic health.3
Related reading:
- House calls for the homebound: A compelling practice model
- Using teledentistry to improve access to care for seniors
- Mobile dentistry: Do well while doing good
Beyond the physical limitations and pain, oral conditions also affect seniors emotionally. Many shy away from social interactions due to mouth dryness and pain, broken or missing teeth, or halitosis. As a result, some cannot or will not smile or laugh, further isolating themselves and setting the stage for loneliness and depression.1 Oral care is a basic human need impacting physical, mental, and social well-being. Seniors require and deserve adequate oral care—a need being addressed by the emerging field of mobile dentistry.
Mobile dentistry on the rise
Treating LTCF patients in a dental office can be problematic. Many residents are nonambulatory, and wheelchairs don’t fit well in the treatment area. It is not easy, or always possible, to transfer the patient from their wheelchair to the dental chair. Elderly patients who have lost the ability to bear weight on their legs require large Hoyer lifts to transfer them. Visits to a dental office might require the assistance of a trained aide, adding cost and complexity to the situation. Patients with Alzheimer’s might act out, shout, or cause a public disturbance if they perceive they are being rushed or coerced into treatment. Many of these obstacles are mitigated when patients are treated by trained professionals in comfortable, familiar surroundings, as is the case with mobile dentistry.
Like physical health, the oral health of seniors tends to decline over time if not properly attended to. Dentists and hygienists can provide care to reduce oral bacteria that can result in local and systemic infections, chronic diseases, and needless pain and suffering. Through regular dental visits, dental professionals improve the quality of life for seniors who may not otherwise receive treatment.
Mobile dentistry is a viable practice option with a few caveats. There is no quick in-and-out when working with nursing home patients. Geriatric patients don’t move or think quickly due to physical and cognitive deficits. They need to be talked to respectfully, reassured, and made to feel at ease. They may need to be gently coaxed to open their mouths, or encouraged to share a story about their grandchildren to help establish rapport. Nursing home and long-term care patients are subject to good and bad days, and mobile dentistry professionals are at the mercy of these fluctuations. Certainly patience, compassion, and flexibility are required for success in this setting. On the other hand, working closely with the nursing home or assisted care facility, dental professionals can readily see and treat a number of patients in one stop without the frustrations of in-office appointment cancellations and no-shows.
Hygienists require a dentist’s supervision
Mobile dentistry is immeasurably rewarding, but it is a field wrought with unique challenges, the foremost being gaining access to nursing home or assisted care facilities. Where dental hygienists are concerned, some states don’t allow hygiene services unless a dentist is present or a dentist has performed an exam first. Currently, 35 states allow dental hygienists to initiate treatment after using an accepted protocol to assess patient need. Some states provide hygienists with permits to render care under the sponsorship of a dentist but without the dentist there to supervise them. Obtaining a permit may require working a preset number of hours under a dentist’s direct supervision.3 As such, when pursuing mobile dentistry, it is invaluable for hygienists to establish a working relationship with a local dentist.
Knowledge of one’s state laws is a must. In the state of Florida, for instance, once the dentist has performed the exam, the hygienist can go in and clean the patient’s teeth over the next 18 months before another exam is required. Mobile hygienists are beginning to advocate for standardized laws allowing direct access to LTCFs so they can best serve a growing population in dire need of their services. While education and awareness pave the way for positive change, it will take passionate, energetic, and committed hygienists to make it happen. In the meantime, it helps to know how to get one’s foot in the door.
Like any new business, mobile dentistry requires establishing credibility and legitimacy. The first step to gaining access to patients in an LTCF is setting up a limited liability company (LLC). Neither difficult nor expensive, an LLC provides the legal protection within which the mobile dental professional may work. Such protection might already exist at the dental office(s) where the hygienist normally practices; a mobile practice needs to be set up as a legal business as well. With an LLC in place, any debts, claims, liens, or lawsuits against the business are limited to the assets of the business, thereby protecting the owner’s personal assets. Note that this excludes criminal acts or acts of negligence perpetrated by the business owner.4
While working at a dental office, the hygienist may be one of many employees. In states allowing dental hygienists to establish their own practice, an employer identification number (EIN) must be established for tax purposes. This federal tax ID number also helps prevent identity theft and simplifies setting up a business bank account.5
Once the legal and financial bases are covered, the next step is getting the word out to seniors and senior care facilities. This means coming up with a business plan and marketing strategy, and could include doing presentations at senior care facilities and associations serving seniors, printing business cards, writing introductory letters, creating educational videos, and even going door-to-door. It may take several attempts, but persevere. Eventually, doors will open.
Another concern of mobile dentistry is getting paid for services. If the state allows it, Medicaid can be billed, but reimbursement does not ensure full compensation. With permission from the facility, it is advisable to call the family directly to discuss treatment options regarding their loved one. The fee to clean their teeth on-site often ranges from $80–$125 per visit, and visits can be scheduled monthly or every three months. The family can pay by check, credit card, or by one of the banking apps popular with small businesses such as Stripe, Venmo, or Zelle. These apps enable the hygienist to send professional invoices for services rendered. Once an agreement is reached, it is important to have the responsible family member sign it as the senior patient may no longer be responsible for his or her finances. Now you’re ready to see patients at last!
Unforeseen challenges
One unanticipated obstacle is the narrow window of time one gets when interacting with this unique population. Appointments have to be made either early in the morning after their breakfast or right after lunch. Many residents require a nap in the afternoon, and more active residents may have activities scheduled. Experience shows there is no competing with bingo!
Mobile dentistry presents physical challenges that are not immediately apparent; staying fit is essential. Autoclaves and mobile suction machines are heavy pieces of equipment. They need to be loaded into a vehicle, unloaded, set up, disinfected, broken down, and reloaded. Additionally, twisting and prolonged bending are required when working on patients in wheelchairs or propped up in beds. This places undue stress and strain on the back, neck, shoulders, and wrists.6 One must carefully consider their own musculoskeletal health when purchasing everything from suction units to treatment instruments. Attention to ergonomics and self-care are key to longevity in this field.
Seniors have special oral-care needs, and mobile dental professionals must decide which oral-care products to use and recommend for the senior patient. Unlike working in a dental office where home oral-care products may be selected for a general patient population, mobile dentistry provides the opportunity to select supplies specifically designed for seniors. While there are many good products to choose from, Closys Silver toothpaste and mouthwash are explicitly designed for the oral-care needs of adults 55 and older. They are gentle, soothing, and well tolerated by geriatric patients even when mouth sores and burning sensations are present.
Many patients in LTCFs have heavily coated tongues. While xerostomia is a common cause, this condition can also result from having medications crushed up and added to patients’ foods for ease of administration. Eventually, a food/medication residue builds up on the dorsal surface of the tongue, dampening taste sensation and the enjoyment of food. A coated tongue can also be a source of oral malodor and may lead to aspiration pneumonia.7 Closys mouthwash safely loosens the residue so it lifts off and is easily scraped away, leaving the patient’s mouth refreshed. Many seniors also have adult caries and periodontal disease. Closys Silver toothpaste remineralizes the teeth and strengthens the enamel while inhibiting plaque regrowth and biofilm buildup.8 Likewise, Closys can be used as a preprocedural rinse to clean dentures, partials, and mouth guards. It is always beneficial to reduce the patient’s pathogenic load and inflammatory burden; a clean tongue and oral cavity do just that.
Mobile dentistry professionals may find it hard to keep the lines, or tubing, of portable units impeccably clean. These units involve low- and high-volume suction, so cleanliness is of the utmost importance. Closys makes a waterline cleaner that is easily transportable, so best practices for preventing infection can always be maintained.
The worst, or perhaps saddest, aspect of mobile dentistry is the little, if any, follow-up care occurring in between professional visits. Dentists and hygienists may go in and do a thorough, comprehensive job, leaving the patient with sparkling clean teeth and a refreshed oral cavity, only to return to find the patient has not had their teeth brushed in a month. In one nursing home, a resident’s daughter noticed a terrible odor coming from her mother’s mouth. Her mom, who was in memory care, was also complaining of mouth pain. The daughter had no idea her mother had a partial that had not been removed since she entered the facility 10 years earlier. Covered in black mold, it took 20 minutes to remove, taking one of her canines along with it. Mobile dentistry professionals encounter appalling situations; hopefully they inspire actions that result in adequate oral care for all seniors living in LTCFs.
Are you up to the task?
Taking care of elderly patients is not for everyone. Those who have the patience, demeanor, and calling must research their state’s laws, develop a business plan and marketing strategy, cultivate a working relationship with a dentist in the community (for hygienists), obtain the necessary equipment, and order supplies and products that will best serve them and the needs of their geriatric patients.
Presently, oral care in LTCFs often falls in the same category as nail and hair care. Due to its far-reaching effects on health and well-being, oral care needs to be made as important as wound care and medication management. This will entail legislative change and the determination of hard-working, committed dental professionals. Could mobile dentistry be your calling? What a wonderful way to enjoy a quality career while improving the quality of life for seniors in need.
Editor's note: This article appeared in the December 2021 print edition ofDental Economics.References
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7. Abe S, Ishihara K, Adachi M, Okuda K. Tongue-coating as risk indicator for aspiration pneumonia in edentate elderly. Arch Gerontol Geriatr. 2008;47(2):267-275. doi:10.1016/j.archger.2007.08.005
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