Oral Care Aides in Nursing Homes
A Master’s Paper submitted to the faculty of the University of North Carolina at Chapel Hill
in partial fulfillment of the requirements for the degree of Master of Public Health in
the Public Health Leadership Program
Aimee McHale, JD, MSPH
Sheryl Zimmerman, PhD
The epidemic of poor oral hygiene among nursing home (NH) residents has been well
researched and documented for several decades. A high proportion of NH residents do not
receive daily mouth care, which leads to tooth loss, increased dental plaque, and periodontal
disease. Poor oral hygiene has been found to have an impact on systemic diseases as well, such
as malnutrition, heart disease, diabetes complications, and pneumonia. The majority of residents
rely on NH staff to provide daily mouth care due to high levels of cognitive and functional
impairment. NH staff are often unable to provide the necessary care due to lack of training, time
demands, not understanding its importance, and encountering residents who resist care. Nursing
assistants are responsible for bathing, dressing, and grooming; these demands often lead nursing
assistants to put mouth care as a last priority. Several evidence-based solutions have been tested
to overcome these issues such as mobile dental units, dental nurses, licensed dental hygienists,
and staff education, but arguably, the most feasible and promising is the dedicated oral care aide
An oral care aide is a trained nursing assistant whose primary role in the NH is to provide
daily mouth care all residents who require assistance. The oral care aide model removes the
barriers that nursing assistants often report with having to provide daily mouth care to residents
with dementia in addition to providing other activities of daily living care. This paper
recommends the employment of one oral care aide per 100-bed NH. The cost of the oral care
aide should be reimbursed by Medicaid and Medicare largely because the cost savings from
reduced pneumonia cases and hospitalizations will defray a significant portion of cost of
employing the oral care aide. The need for this investment is high. The aging population in the
to previous generations, the current aging population will be more likely to retain their natural
teeth when they enter a NH, which ironically will present more challenges because natural teeth
Currently, there are over 1.3 million older adults in the United States (U.S.) who live in
nursing homes (NH) (Harris-Kojetin et al., 2019). The number of Americans over the age of 65
is projected to increase from 47.8 million in 2015 to over 87.9 million in 2050, which will
comprise 22% of the population by 2050 (Harris-Kojetin et al., 2019). The population of
Americans over 85 years of age is expected to triple during the same time and will represent 5%
of the U.S. population by 2050 (Vespa, Medina, &Armstrong, 2020). This demographic shift
toward an older population will lead to an increase in the number of older adults who require NH
care. Estimates indicate that among Americans over age 65, 52% will require some long-term
care in their lifetime (Favreault & Day, 2015). The most common reasons for moving into NHs
include safety concerns (e.g., wandering behaviors in dementia); health maintenance needs (e.g.,
receiving medications and other nursing treatments); and assistance with activities of daily living
(ADL) such as bathing, dressing, and grooming (Fong et al., 2015; Gaugler et al., 2007; Gaugler
et al., 2009; Toot et al., 2017)
.One of the most often overlooked ADLs is daily oral hygiene.
Nursing homes are federally regulated; the Omnibus Budget Reconciliation Act of 1987
(OBRA) mandates that NHs that receive Medicare or Medicaid funds, in addition to providing
for dental care, must periodically assess the oral health of their residents (Guay, 2005). The
instrument used to assess oral health is the Minimum Data Set (MDS). The MDS is required to
be completed on admission and annually for all NH residents receiving Medicaid or Medicare
funds, which represents most residents in NHs. The MDS includes a short section about oral
health and dental status. The following items are included on the form: broken or loosely fitting
unable to examine; or none of the above. The adequacy of this instrument to assess oral health
has been criticized and could play a role in the ongoing poor condition of teeth and gums of
many NH residents (Guay, 2005; Zimmerman et al., 2017).
Importantly, NHs can be cited for poor oral hygiene by state surveyors. NH surveys are
conducted to ensure that NHs’ performance and practices are in compliance with federal
requirements. These surveys are conducted annually and are not announced in advance to the
NHs (CMS, 2020a).
Tooth loss in older adults can occur due to chronic conditions or due to the medications
used to treat those conditions that may lead to dry mouth and dental caries (Griffin, Jones,
Brunson, Griffin, & Bailey, 2012; Tan, Lexomboon, Sandborgh-Englund, Haasum, & Johnell,
2018; Lexomboon et al., 2018). Another leading cause of tooth loss is poor oral hygiene
(Hujoel, Hujoel, & Kotsakis, 2018). The majority of NH residents require assistance with daily
oral hygiene due to cognitive and functional impairment (Zenthofer et al., 2017; Chen, Clark, &
Naorungroj, 2013; Nordenram & Ljunggren, 2002), In NH settings, between 50% and 75% of
residents have dementia (Harris-Kojetin, et al., 2019). Due to high levels of cognitive and
functional impairment in NHs, roughly 85% of residents report difficulty brushing their teeth
(Gulati, 2017; Sloane et al., 2007) and 94% of denture wearers are unable to clean their teeth
without assistance (Stein & Harry, 2009). Given the high prevalence of physical and cognitive
impairments, NH residents often rely on staff assistance for their oral care (Zenthofer et al.,
2017; Chen, et al., 2013; Nordenram & Ljunggren, 2002). This dependence leads to poor oral
hygiene with reports finding that 41% of NH residents have plaque on their teeth, 20% have at
least marginal gingival bleeding, and 77% have periodontal disease (Zellmer, Gahnberg, &
In NH settings, responsibilities for residents’ daily mouth care is typically assigned to
nursing assistants. Although nursing assistants are responsible for this care, they often fail to
provide the necessary care due to lack of training, time constraints, not understanding its
importance, and encountering residents who resist care (Chalmers et al., 1996; Coleman, 2002;
Dharamsi et al., 2009; Jablonksi et al., 2009; Stein & Harry, 2009). Resistance to care is common
among residents with cognitive impairments such as dementia. Studies have found that 90% of
nursing assistants encounter care-resistant behavior during mouth care and fewer than 20% feel
prepared to manage challenging behaviors (Frenkel, 1999, Coleman & Watson, 2006). NH staff
are responsible for bathing, dressing, and grooming for residents and may be assigned as many
as 10-12 residents per day. The high volume of residents assigned to their care and insufficient
preparation to provide care to those who resist it, can cause NH staff to be reluctant or unable to
provide daily oral care (Louis, 2013; Hoben et al., 2017, Pino, Moser, & Nathe, 2013;
Zimmerman et al., 2017).
This confluence of factors frequently leads nursing assistants to prioritize other care,
often putting mouth care at the bottom of the list (Louis, 2013). In one NH with a policy
requiring tooth brushing twice a day, oral care assistance was provided for only 16% of residents
and no nursing assistant brushed residents’ teeth for two minutes, flossed the teeth, or wore clean
gloves (Coleman & Watson, 2006). A more recent study videotaped residents receiving mouth
care from a staff member in a NH. The average time spent brushing teeth was approximately one
minute, and in over two-thirds of observations tooth brushing only occurred on the facial tooth
structures (Yoon, Ickert, Wilson, Mihailidis, & Rochon, 2020). NH administrators have similar
issues with prioritizing oral care, with 25% of administrators reporting that oral care can be
Jasinevicius, Sawyer, & Masden, 2005). These time demands are likely why studies have shown
that oral hygiene is better in NHs with higher levels of staffing and lower rates of staff turnover
(Pino et al., 2003).
In addition to receiving poor daily mouth care, NH residents often do not receive
adequate professional dental care. Unfortunately, Medicare does not cover routine dental
services and most NH residents are unable to pay for the services themselves (Chalmers, Carter,
& Spencer, 2003). Reports suggest that between 33-70% of residents have not seen a dentist in
five or more years (Stein & Harry, 2009). There are some mobile clinics in the U.S. that provide
care to NH residents, but their availability is limited. Studies have shown that dentists often
prefer to provide dental services in a fully-equipped dental office, which adds the additional
difficulty of transporting residents (Chalmers et al., 2001). Further, dentists report having
inadequate training and little interest in NH dentistry, with 60% reporting inadequate training
and more than half stating they were not interested in providing care to NH residents (Chalmers
et al., 2001). Access to dental hygiene services is also limited, with only 46% of facilities report
having access to a dental hygienist (Chalmers et al., 2001).
Oral Hygiene and Systemic Disease
Poor oral hygiene has been found to have an impact on systemic diseases, such as
malnutrition, heart disease, diabetes, and pneumonia (Jablonski et al., 2009, Holm-Pederson,
Schultz-Larsen, Christiansen, & Avlund,2008). Malnutrition is one of the most widely known
effects of poor oral care due to tooth loss which leads to a decreased intake of nutrient-rich foods
(Nowjack-Raymer & Sheiman, 2007). Tooth loss is associated with painful, difficult mastication,
often making older adults unable to chew hard foods such as fruits and vegetables (Walls &
myocardial infarction compared to those without periodontal disease (Slavkin,1999).
Periodontal disease is also associated with a 19% increased risk of coronary artery disease,
which increases to a 44% increased risk among persons aged 65 years or older (Janket, Baird,
Chuaung, & Jones, 2003). Dental pathogens are hypothesized to contribute to heart disease
either directly by entering the blood stream and attaching to plaque, or indirectly by increasing
the levels of circulative inflammatory mediators in the blood (Slavkin, 1999). Periodontal disease
is common in individuals with type 1 and type 2 diabetes mellitus, and is regarded as one of the
leading complications of the disease (Holtfreter et al., 2009; Kidambi & Patel, 2008) which in
turn contributes to insulin resistance and increased difficulty maintaining glycemic control
(Soell, Hassan, Miliauskaite, Haikel, & Selimovic,2007; Taylor & Borgnakke, 2008).
One of the most studied systemic diseases related to mouth care is pneumonia.
Pneumonia is the second most common infection in NHs (Liapikou et al., 2014; Oh, Weintraub,
& Dhanani, 2004). Morbidity and mortality rates due to aspiration pneumonia are high, with an
estimated 200,000 cases annually, resulting in 15,000 deaths. Hospitalization for pneumonia is
common and those hospitalized can have mortality rates ranging from 13 to 41% (Stamm &
Stankewicz, 2020). Dental decay, poor oral hygiene, and dependence on assistance for oral
hygiene have all been documented as risk factors for developing aspiration pneumonia
(Scannapieco & Myolette, 1996, Raghavendran, Mylotte, & Scannapieco, 2007, Terpenning et
al., 2001, Abe, Ishihara, Adachi, & Okuda, 2006; Langmore 1998, Langmore, Skarupski, Park,
& Fries, 2002; Pace & McCullough, 2010). Poor oral health leads to the colonization of
respiratory pathogens in the oral cavity. These pathogens accumulate in dental plaque and are
then released into the saliva and aspirated into the respiratory tract (Scannapieco & Myolette,
health care can reduce the risk of pneumonia in long-term care settings (Liu et al., 2018; Sjögren,
Wardh, Zimmerman, Almstahl, & Wilkstrom, 2016). These findings must be considered with
caution and further trials need to be conducted to draw more reliable conclusions.
Evidence-based solutions to improving mouth care
Several approaches have been developed and evaluated in NHs to improve oral hygiene.
This section summarizes some of the initiatives that been effective in increasing staff knowledge,
improving staff attitudes, reducing resistance to care, and improving resident oral hygiene.
Mobile Dental Unit
Janssens et al. (2018) reviewed the impact of a mobile dental unit on the oral health of
381 residents from 21 NHs in Belgium. The purpose of the mobile dental unit was to support the
NH staff and to provide preventative and curative oral healthcare to residents who could not
access regular dental care. This study found that the percentage of NH residents who required
oral treatment was reduced from 65.9% to 31.3%, meaning there was a significantly lower
prevalence of caries, need for fillings, and need for extractions between baseline and follow-up
(Janssens et al., 2018). The authors concluded that the introduction of the mobile dental unit
helped stabilize residents’ oral health and reduced the need for treatment (Janssens et al., 2018).
Nurses and nursing assistants (N=546) completed questionnaires about the program to assess
their knowledge and attitudes about oral health at baseline and at the completion of the study
(Janssens, Vanobbergen, Lambert, Schols, & De Visschere, 2017). The results from the
respondents showed a significant increase in staff knowledge and improved attitudes about oral
Barbe et al. (2019) studied the effect of using a dental nurse for regular tooth brushing on
the oral health of NH residents. Residents were assigned to two conditions: the intervention arm
received brushing by a dental nurse every two weeks for three months (N=50) and the control
arm received standard care by the NH staff (N=25). Both arms also received training that
included oral hygiene recommendations for daily practice in NHs. The authors found significant
improvement in plaque and gingival scores in the intervention arm. Among control group
residents, the number of teeth decreased and the number of dental caries increased. The authors
concluded that having regular professional brushing by a dental nurse every two weeks can help
reduce caries and preserve natural teeth (Barbe et al., 2019).
Licensed Dental Hygienist
Amerine et al. studied the impact of a dental hygiene champion on the oral health in three
NHs in Arkansas (2013). The dental hygiene champion was a licensed dental hygienist who
provided on-site support for NH staff. The NHs were randomized into three arms. In the first
intervention arm, nursing assistants received oral hygiene training and an oral health protocol
guidebook that illustrated effective oral health care. In the second intervention arm, nursing
assistants received the same training followed by hands-on support by the dental hygiene
champion for eight weeks. Nursing assistants in the control group did not receive education or
hands-on support. Results from the study showed that presence of the dental hygiene champion
was more successful than education and the oral health guidebook alone, suggesting that the
presence of the dental hygiene champion might improve the oral hygiene of NH residents and
Volk et al. pilot-tested a coaching model using dental hygienists to increase the quality of
daily mouth care provided to residents in 22 New York State NHs. NH staff received oral care
training and the dental hygienist coaches were responsible for on-site visits, performing spot
checks on oral care, answering staff questions, educating staff, and retraining staff. The coaches
also provided ongoing contact with the NH staff by telephone. To determine the effectiveness of
the program, dental plaque, gingiva, and denture plaque scores were obtained at baseline, six
months, and 12 months. Overall, all scores improved from baseline, showing improvement in
oral hygiene (Volk, Spock, Sloane, & Zimmerman, 2020).
Low-cost Cleaning Devices
Schwindling et al. studied the long-term effectiveness of oral health education of nursing
assistants in 14 NHs (2018). A total of 269 residents were assigned to two conditions: the
intervention group received oral health education and ultrasonic cleaning devices for dentures
and partials, and the control group continued standard care in the NH. The authors found
statistically significant improvements in dental plaque and denture plaque scores in the treatment
group compared to the control group (Schwindling, Krisam, Hassel, Rammelsberg, & Zenthofer,
2018). Oral care knowledge among nursing assistants improved and the overall oral health
among the NH residents improved. The authors concluded that education and the use of
ultrasonic devices can be an effective low-cost solution to improve oral hygiene (Schwindling et
Jablonski et al. tested the efficacy of a non-pharmacological, relationship-based
intervention on NH residents with dementia who resisted mouth care (2018). The intervention
establishing rapport by approaching the resident at eye level; providing mouth care in front of a
sink and in front of a mirror; avoiding elderspeak; distraction; starting the mouth care task and
having the resident finish it; and hand-over-hand, where the caregiver walks the resident through
the task. The study enrolled 101 residents (intervention = 55, control = 46) from nine U.S. NHs.
The authors found that residents in the intervention group were twice as likely to allow mouth
care and allowed mouth care to be carried out for a longer duration. The study found only small
improvements in oral hygiene and it was not statistically significant between the two groups.
The authors concluded that management of refusal behaviors might be a more realistic approach
than reducing or eliminating refusals to mouth care (Jablonski 2018).
Staff Educational Interventions
A recent systematic review of the use of oral health educational interventions alone for
NH staff and residents did not find any meaningful effects on improving the oral hygiene of
residents (Albrecht, Kupfer, Reissmann, Mühlhauser, Köpke, & 2016). This study adds to the
literature that educational interventions alone are not enough to produce sustainable changes in
oral hygiene practices. Training should include some type of hand-on training or ongoing
coaching for the NH staff.
Dedicated Oral Care Aide Model
The most feasible and therefore promising model for improving oral hygiene in NHs
appears to be the use of a dedicated oral care aide, especially to care for persons with dementia;
the dedicated model seems to be successful because it removes the barriers that nursing assistants
often report with having to provide time-consuming daily mouth care to residents with dementia
while providing other ADL care. The oral care aide is a nursing assistant who is trained by a
residents. This aide is often assigned to residents who are resistant to care or who require
extensive assistance with oral care. This model provides the benefits of an aide whose sole
responsibility is to meet oral care needs of the residents and remove the burden from staff who
are often overwhelmed and do not have the time to provide mouth care to residents who may
Researchers from Sweden studied the long-term effects of an oral health aide on resident
oral health (Wardh & Wikstrom, 2014). Three oral care aides were selected to provide care in
one NH in Sweden and were trained by dental hygienist and dentists. The results from the study
found that the oral care aides raised NH staff awareness on the importance of oral care and
increased the number of residents who received regular oral care (Wardh & Wikstrom 2014).
Pronych et al. pilot-tested an intervention using oral health coordinators in three NHs in
New Hampshire (2010). The researchers selected three NHs of varying sizes and created an oral
health coordinator position at each site. The oral health coordinator was an existing staff
member who worked with the research dental team and ensured that mouth care was provided
daily. In addition to the creation of the oral health coordinator role, the nursing assistants at each
NH received training in mouth care. Training consisted of a one-hour lecture style presentation,
pre/post-test to measure basic oral health knowledge, and a job shadowing component for
hands-on training. The authors measured the efficacy of their approach by using the debris index
simplified to score plaque levels. Plaque levels were assessed at baseline, two months, six
months, and 12-month intervals. The results of the study showed improvements in oral hygiene
in all three NHs (Pronych, Brown, Horsch, & Mercer, 2010). This study shows the importance of
who can also encourage other staff members to provide care when necessary (Pronych et al.,
Another study utilized dedicated oral care aides to provide oral hygiene care for residents
of a Veterans Affair Medical Center (VAMC) nursing home (Bassim, Gibson, Ward, Paphides,
& DeNuccie, 2008) where oral care aides were assigned to two of the four NH wards. For
residents who could perform their own care, oral care aides were responsible for setting up,
encouraging and monitoring self-care. For residents who were unable to perform their own care,
oral care aides provided comprehensive oral care. Oral hygiene care included tooth brushing,
mouthwash, and denture care (Bassim et al., 2008). The findings from the study showed a
decrease in plaque and dental debris scores among residents in the wards with an oral care aide.
The authors also found that that odds of dying from pneumonia in the wards without an oral care
aide was three times higher than the group that receive regular oral care from oral care aides
(Bassim et al., 2008). The authors advocated for the use of oral care aides in long-term care
Sloane et al. conducted a study to develop a person-centered evidence-based mouth care
program in NHs using oral care aides (2013). The study was completed in three North Carolina
NHs over an eight-week intervention period. Two oral care aides were selected at each NH and
were expected to spend 4 hours per day, 5 days a week providing mouth care (Sloane et al.,
2013). The oral care aides were trained by a dental hygienist and geriatric psychologist, on
topics including oral pathology, dementia care, and individualized care planning with skills
training. The authors found that plaque, gingival, and denture plaque scores improved in as little
as eight weeks. However, the study found that the time required for oral care increased from 3.5
follow-up to evaluate their self-efficacy to provide mouth care. The oral care aides reported an
improvement in being able to give advice about mouth care, being able to provide mouth care
without force, and getting residents to cooperate (Zimmerman et al., 2014).
Researchers further explored their oral care aide model by conducting a 2-year trial in 14
NHs to determine whether the mouth care practices improved oral hygiene and denture outcomes
(Weintraub et al., 2018). The study used a similar model to the previous study and had one oral
care aide per intervention NH (N=7). The oral care aide received training and support from a
dental hygienist. NH staff were also trained in recommended mouth care practices and were
encouraged to provide daily oral care. The control NHs (N=7) did not receive training and
standard mouth care continued in those homes. The authors found a sustained reduction in
plaque, gingival, and denture plaque scores over the 24-month period (Weintraub et al., 2018).
The results from the two-year trial were analyzed to determine if there was a reduction in
the incidence of pneumonia (Zimmerman et al., 2020). NH resident charts were abstracted
quarterly over the two-year period and pneumonia was considered present based on the diagnosis
of pneumonia recorded in the nurse or medical provider notes. Findings from the study included
a statistically significant reduction in pneumonia rates during the first year of the study
(Zimmerman et al., 2020). However, in the second year the rate of pneumonia was
non-significantly higher in the intervention homes. The authors suggested that that the lack of
significant results in the second year may be associated with sustainability, and that improving
mouth care in the U.S. NHs may require the presence of dedicated oral care aides (Zimmerman,
et al., 2020).
Requirements for policy change around the oral care aide model in NHs
Annually, there are an estimated 200,000 cases of aspiration pneumonia in NH residents
and around 30% of those residents are hospitalized for pneumonia (Norman & Yoshikawa,
2006). The median cost for treating aspiration pneumonia among those aged 65 and older in
2012 was $30,280 (Wu, Chen, Wang, & Pinelis, 2017). A recent study using oral care aides
found a reduction in the pneumonia cases during the first year of the program (Zimmerman et al.,
2020). This reduction in pneumonia could have cost savings for Medicare and Medicaid that
could potentially offset the cost of a dedicated oral care aide.
To examine this point, Stearns et al. (2020) completed an economic evaluation of the
cost-effectiveness of the oral care aide model in the intervention NHs. For the economic
evaluation, an incremental cost-effectiveness ratio was estimated to determine the costs per
pneumonia case avoided by the oral care aide model compared to controls during the first year
only. Costs included estimates of oral care (including training and related wages and benefits)
and hospitalization for pneumonia. Estimates with stratification by treatment status and
clustering by NH, which can be generalized beyond the study sample, show a 58.3% likelihood
that the oral care aide model was cost-saving and a 38.4% likelihood of being cost-effective
(median cost per pneumonia case avoided $1,581).
The cost estimates from Stearns et al. (2020) are similar to other estimates from previous
researchers (Terpenning & Shay, 2002; Yoneyama, et al., 2002). Yoneyama et al. (2002)
estimated that if each NH hired a nurse aide to do nothing but oral hygiene, pneumonia rates
would only need to decrease by 10% to result in a net benefit savings.
Thus, it seems that providing mouth care to NH residents using a dedicated oral care aide
model may be cost saving, as well as improve resident quality of life due to decreased
effect policy change may related to the source of the funds (the payer) for the care aide and to
whom the savings accrue.
Medicare and Medicaid coverage for oral care aides
Chalmers and Ettinger (2008) called for the presence of dental champions in NHs to
increase timely dental treatment and improve oral hygiene care. While this model is likely to
improve care and outcomes, there are simply not enough dentists and dental hygienists available
and/or interested in working in NHs to meet the need. Therefore, the model of the dedicated oral
care aide provides the most promise and feasibility for improving oral hygiene in NH residents,
and is hereby recommended to be a required position in U.S. NHs.
In terms of the related staffing requirements, Sloane et al. (2013) found that proper mouth
care took staff on average 6.7 minutes per resident to complete. The authors suggested that if
everyone in a 100-bed NH required care, but had been receiving none, the 6.7 minutes to
complete care would require an additional 11 staff hours per day. In order for this coverage to be
feasible for most NHs, the cost of the oral care aide would need to be covered by Medicaid and
Reimbursement for oral care aides under Medicare and Medicaid could quite readily be
modeled after the social service designee requirements for NHs. The Nursing Home Reform Act
of 1987 required that all Medicare and/or Medicaid certified NHs meet the medically-related
social services needs of their residents (Code of Federal Regulations, 2012). The law requires
that NHs with more than 120 beds employee a full-time social worker. However, the law does
not require a degree in social work to be qualified (Code of Federal Regulations, 2012). NHs
residents, but they are not required to have a full-time social worker and can have other
arrangements to meet those needs.
To derive evidence as to the training of social service personnel in U.S. NHs, a
self-administered survey was collected from social services directors from a nationally representative
sample of NHs. A total of 1071 social services directors responded to the survey and the results
showed that 50% had a degree in social work (Bern-Klug & Kramer, 2013). Consequently, there
is regulatory precedent that reimbursable care can be provided by those without professional
NHs should be required to have oral care aide-to-resident ratios sufficient to achieve
important healthcare outcomes – most notably, a reduction in pneumonia rates. The policy will
build off the research from Sloane et al. (2013), which estimated that if each mouth care
encounter takes an average of 6.7 minutes per resident to complete, a NH with fewer than 80
beds would be required to have one oral care aide, and NHs with more than 80 beds would have
two oral care aides. Note that that the 6.7 minutes includes time to sanitize supplies and prepare
for the next resident.
Calculation: 480 minutes per day / 6.7 minutes per resident = 71.64 residents per day Given that that not all residents will require care or require care taking an entire 6.7
minutes, one aide per 80 residents is a lower aide:resident ratio than is necessary. While 85% of
residents require some assistance with daily mouth care (Gulati, 2017; Sloane et al., 2007), the
percentage of residents who resist care and require the entire amount of time for care will be
lower. Therefore, the policy recommendation that makes the most sense for the Centers for
Medicare & Medicaid Services (CMS) to enact at the federal level is for each NH is to have at
“full-time equivalent”) can be increased or decreased proportionally based on the number of beds in
each NH. This recommendation is based on the recent study published by Zimmerman et al.
(2020) that used one oral care aide per NH, the average size of which was 105 beds. The authors
were able to find that the presence of oral care aides led to a reduction in pneumonia rates over a
12-month period (Zimmerman et al., 2020) and sustained reduction in plaque, gingival, and
denture plaque scores over the 24-month period (Weintraub et al., 2018); hence, one aide per 100
bed NH (which is roughly the average size of a U.S. NH) is advisable (CMS, 2020b).
Training Oral Care Aides
The oral care aides need to be trained by a dental hygienist or similar professional who
has been trained to deal with resistive behaviors among residents with dementia. This person
should also provide support to allow the aide to feel empowered to provide daily mouth care to
residents who may be resistant to care. Alternatively, NHs could use similar programs that are
widely available on the market such as Mouth Care Without a Battle (Sloane et al., 2013).
Mouth Care Without a Battle is an evidence-based approach to person-centered daily mouth care for persons with cognitive and physical impairment. It is a training-based DVD for NH staff on
best practices in oral hygiene and how to overcome resistance to care among older adults with
Another beneficial approach would be for community colleges to adjust their curricula to
include mouth care in the certified nursing assistant training. The requirements for nursing
assistants vary by state, but programs typically take about 4 to 12 weeks to complete and the
average time spent on mouth care is 30 minutes (NCDHHS, 2020). The time spent on this
education is valuable because it has been found that nursing assistants have a persistent belief
assistants with less than a high school education are more likely than their more educated
counterparts to believe that poor oral hygiene does not affect overall health (Pyle, Nelson, &
Sawyer, 1999). Believing that oral hygiene is unimportant, and that lack of oral care is relatively
benign may highlight an important reason that oral care is often neglected.
The policy of requiring an oral care aide in every U.S. NH provides the most promise for
improving the oral health of older adults. Data from NH oral hygiene assessments among NH
residents has revealed poor oral hygiene since the 1960s (Lotzkar, 1977). In one study,
two-thirds of examined NH residents were determined to be in need of dental treatment (Lotzkar,
1977). More recent oral assessments among NH residents have found substantial oral debris and
untreated tooth decay (Louis, 2013). The health consequences of poor oral hygiene are
well-described and should not continue to be neglected. The need for NH reform and federal
regulation in this area cannot be overstated.
Quality of care in U.S. NHs has been a concern for decades. In 1986, the Institute of
Medicine (IOM) published a set of recommendations for reforming NHs to improve the quality
of care (IOM, 1986). These recommendations were accepted by Congress and enacted through
the Nursing Home Reform Act as part of OBRA of 1987. A few examples of quality
improvement recommendations in the IOM report included provisions relating to physical
restraints, antipsychotic use, and catheter use. When the Reform Act was first passed in 1987,
physical restraints were widely accepted as an option to manage the behavior of residents who
wandered or were agitated (CMS, 2008). However, the use of physical restraints was not
The effects of the law were dramatic, and daily use of physical restraints decreased from 21.1%
in 1991 to 5.0% in 2007 (CMS, 2008).
The use of antipsychotic medications to address behavior and mood disorders among
older adults in NHs has similarly been a longstanding national concern. Antipsychotics have
“black box warnings” issued by the federal Food and Drug Administration due to their risk of
life-threatening adverse events (FDA, 2008). However, a significant percentage of NH residents
are still prescribed these medications. In response to these concerns, CMS partnered with the
National Partnership to Improve Dementia Care in Nursing Homes to decrease the national
prevalence of antipsychotic use among NH residents. This partnership allowed them to decrease
the national prevalence by 38.9 % to 14.6 percent in 2018 (Verma, 2019).
Concerns about indwelling catheter use in NHs have been raised since before the reform
act was passed and the overall prevalence was estimated to be as high as 10% among residents
(Gurwitz et al., 2016). Indwelling catheters have been used in NH residents because they can
alleviate the care of incontinent residents. However, there are related troubling consequences
such as urinary tract infections and bacteremia, as well as the fact that catheters can restrict
ADLs (Gurwitz et al., 2016). In 2002, CMS began a national quality initiative in NHs that
receive payments from Medicare, to limit the use of indwelling urinary catheters to instances that
are medically justified (Gurwitz et al., 2016). The effects of this initiative have also been
dramatic -- in 2019, the national percentage of NH residents who had an indwelling catheter
inserted and left in their bladder was 1.9 percent (CMS, 2020).
The NH staff behaviors and practices outlined above were not easy to change. However,
with the right federal policy in place, the oral care aide model can be just as successful as these
pneumonia, hospitalizations, mortality, and other systemic diseases. The time for policy change
is now. The U.S. aging population is increasing and will need long-term care services.
Compared to previous generations, the current aging population will be more likely to retain
their natural teeth when they enter a NH. This situation will present even more challenges than
today, as natural teeth are more likely to build up plaque which could lead to increased systemic
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