Quick chairside interventions to improve oral hygiene for dependent adults
Dependent adults, such as older adults with dementia and people with disabilities, make up about 10% of the Irish population. There are over 28,000 people registered with intellectual disabilities in Ireland alone. For people with disabilities, oral health can be difficult to achieve and the consequences may impact on them to a greater extent than on others. Oral diseases are often more prevalent and have poorer outcomes. Dental caries, for example, happens at similar rates to the general population, but tends to be treated by extraction among those with disabilities. Globally, periodontal disease can be up to nine times more prevalent among middle-aged adults with a disability, compared to the general population.1-3 Combined, the increased prevalence and unfavourable management of these diseases leads to greater levels of tooth loss and ultimately to oral disability.4 Dental pain can also go undiagnosed and present as challenging, even self-injurious, behaviours, among people with communication impairments. Reparative treatment by the dental team can often necessitate restrictive supports such as anaesthesia, sedation or clinical holding, which do make the treatment of oral disease possible, but also add moral challenges, waiting times and increased complexity of treatment.5 Poor oral health may also have an impact on an individual’s general health.
Barriers to oral health
FIGURE 1: Possible barriers to effective oral hygiene in the home and dental settings for people with disabilities.
There are multiple strands to preventing these poor outcomes for adults with disabilities, including removing plaque and maintaining a healthful diet. Given the central role of plaque in periodontal disease and caries, oral hygiene is the key to oral health for people with disabilities. The key to successful prevention and treatment of periodontal diseases is minimising periodontal inflammation levels lifelong. This can be achieved through effective personal oral hygiene and professional preventive care. However, in practice, this seemingly simple objective is proving elusive. There are many possible barriers to achieving this relating to carers in the home setting, where tooth brushing occurs, and in the dental setting, where risk-based oral hygiene interventions are delivered (Figure 1).
People with disabilities often live dependent lives where their choices and agency are diminished in ways that are unimaginable to most of us, unless, perhaps, we too have cared for vulnerable loved ones. For people who were born with disabilities or developed them young, the receipt of care can come to pave their journey through life, whereas for people who acquire impairments later (like dementia or frailty), a sense of incremental or even sudden dependency can derail hopes and expectations. Regardless of when one becomes vulnerable, dependency changes how day-to-day activities are planned and days are passed.
Oral hygiene might not seem a central focus in the long-term or immediate tasks of dependency and disablement. Surely there are more salient and immediate issues to attend to and resources are, as ever, scarce. There is the daily juggle of waking, cleaning, eating, dressing, toileting and just living, to focus carer energies. These basic human needs must compete with each other for each and every person the carer cares for, and with those of the carer themselves. In the grand juggling act of care, something will inevitably give and, unfortunately, oral hygiene is comparatively optional when prioritising other basic life necessities.
The behaviours of oral hygiene are subject to a dilemma, which leads to people placing short-term personal interests over long-term shared goals, despite the outcome ultimately being worse. So, despite carers wanting to maintain oral health in the long term, brushing is hard to get right and, if done effectively from a periodontic perspective at least, has to be repeated once every two or three days for life.6 This deviation from the usual ‘brush your teeth twice a day’ mantra may seem odd at first, so it is worth a brief comment. Often, standards of care are measured by process rather than outcomes. The focus tends to be on how often carers clean teeth rather than how effectively. We do so adopting standards set for people without disabilities; that is, to brush twice a day and floss regularly. In the context of dependent care, this can be impossible, ineffective and demotivating. This may promote a dilution of resources, which contributes to regular ineffective tooth brushing. In essence, the expectation to meet the mouth care norms set for independent others creates a context where to do otherwise is a deviation from an acceptable standard. If we hold unrealistic expectations for carers, we colour deviations from this standard negatively rather than celebrate carers’ creative solutions. If we fail to convey that we understand a carers’ reality, we have no hope of supporting behaviour change to promote oral health. Often this requires collective action across carers over long periods. It is also bloody, smelly, invasive and, for many, disgusting. It can also elicit behavioural reactions and evoke a sense that the carer is causing pain. While we in the dental profession understand the nirvana that is chemo-mechanical disruption of plaque, for carers the task may seem thankless. There are many natural incentives to diminish the frequency and effectiveness of tooth brushing for dependent adults.
The collective action and short-term versus long-term dilemmas that dependent mouth care brings, and the subtle disincentives that abound, make the poor delivery of oral homecare almost unchangeable. Yet we as a profession must create a future where it is inconceivable that you would not brush teeth. A future where colleagues in care provision expect this of each other. A future where not brushing teeth is seen as neglectful and where limitless biscuit bowls on a table in the middle of the care home is seen as unimaginable.
Oral health professionals are also culpable in this grand failure. We do not incentivise our own professions to see people with disabilities, nor do we properly push prevention. Sure, we pay lip service, but we all know that prevention-led, equitable dental services are little more than pipe dreams gathering dust. No smiles. Gan sláinte.
Innovate for change
We do not need to hark back to the Ottawa Charter to tell us that there are lots of ways to bring change and enable our dependent patients and communities to enhance control over their oral hygiene, diet and oral health. Despite Trojan efforts, there is little hope to be gained from research in this field,7 so we must innovate.
One approach that is recommended by the National Institute of Health and Care Excellence (NICE)8 is mouthcare plans. Mouthcare plans are documented and agreed plans made with the person to meet their oral health goals. They aid planning and communication, which is especially important when there are multiple persons caring for an individual and where there are communication issues. In this article, we offer two examples of how the principles of mouthcare plans can be adopted by dental professionals, through quick chairside interventions that take either one or ten minutes. This is to fit in with the realities of busy practice and hopes to remove some barriers from dental teams in making efforts to improve homecare.
Both of these interventions apply the evidence-based resources that are available on www.brushmyteeth.ie in a structured way. Brushmyteeth.ie is a resource for patients and dental teams that shows people with impairments and their carers how to brush teeth and make mouthcare plans. These resources are designed to change behaviour by applying a number of behaviour change techniques (BCTs).9 Generally speaking, these techniques are activated by modifying a carer’s motivation, capability or opportunity10 to provide or mediate mouthcare, and were designed after scouring the literature to find out what works, for whom, in what circumstances, and why.11
Panels 1 and 2 offer simple instructions in how to apply the techniques, and Panel 3 shows a quick comparison of the two techniques.
Caoimhin Mac Giolla Phadraig
Lecturer, Trinity College Dublin
Dental hygienist, HSE
Trinity College Dublin