A R T IC L E S
The Montana Advisory Dentist Program A. Jack T errill, DDS John Elliott, DDS, MPH
Patients in long-term-care facilities are receiving better dental care as the role of the advisory dentist has been defined. Dental health for patients has been assessed, individual oral hygiene regimens have been designed, and in-service training programs have been established in each of the facilities.
eople of this country are living longer than people formerly did. Great numbers of our elderly citi zens- spend the last years of their lives as residents of nursing homes. The staffs of these homes and the dental profession have neglected the oral health of this segment of our population. Many practicing den tists have been asked to serve as ad visory dentists to nursing homes. Federal law requires that a dentist be affiliated with the nursing home for it to qualify as a long-term-care facil ity under Medicare and Medicaid programs. What role should the den tist assume? What should the staff of the nursing home do to assure that their residents maintain good oral health? The Montana Advisory Den tist Program was developed to assist the dental profession and nursing home staffs in solving these serious problems. The Montana Advisory Dentist Program was designed as a joint ef fort of the Division of Hospital and 402 ■I ADA, Vol. 98, M arch 1979
Medical Facilities, the Bureau of Dental Health of the Montana State Department of Health and Environ mental Sciences, and the Montana Dental Association. Funding was provided by the US Public Health Service, Health, Education, and Wel fare, Region VIII, and the Montana Department of Social and Rehabilita tive Services. Goals and objectives
The overall goal of the program was to improve the dental health of pa tients in long-term-care facilities by assuring their access to dental care and good oral hygiene. The objec tives of the program are: —to find an advisory dentist for each long-term-care facility in Mon tana; —to develop the role of the advi sory dentist and to develop guidelines for performing this ser vice;
—to provide each patient in a long-term-care facility with access to dental care; —to provide in-service training in oral hygiene for appropriate staff of long-term-care facilities; —to develop continuous oral hygiene programs for each patient in long-term-care facilities; and —to assure that the dental pro gram in each long-term-care facility is permanent. To comply with the regulations governing Title X IX Medicaid pro grams, long-term-care facilities must obtain the services of an advisory dentist who assists patients in ob taining regular and emergency den tal care and must provide an annual in-service training program on oral hygiene for staff members. In answer to these requirements, the Bureau of Dental Health and the Council on Dental Health of the Montana Den tal Association developed the “Guidelines for the role of an ad visory dentist to long-term-care facilities.” The guidelines for an ad visory dentist are summarized: □ Arrange with the facility to conduct screening examination of all patients, including screening for oral cancer, assessment of dental care needs, determination of the pa tient’s capability to undergo dental treatment, and the prescription of oral hygiene regimens for each pa tient. The advisory dentist should assist the facility in making the ar rangements for dental treatment,
A R T IC L E S
with priority on referral to the pa tients’ own dentists. □ Determine, in conjunction with the facility, a time interval (at least every six months] for follow-up vis its to evaluate whether treatment needs have been met, to screen new residents of the facility, and to de termine if oral hygiene prescriptions are being followed. □ Be available for emergency treatment or arrange for another den tist to be available. □ Provide in-service training in oral hygiene for staff members. As an example, the advisory dentist could train dental auxiliaries who, in turn, could teach the oral hygiene procedures to the facility’s staff. As patients with natural teeth are, by far, in the minority in long-termcare facilities, training in oral hy giene for patients with partial or complete dentures or edentulous pa tients is equally if not more impor tant than training in the routine hygiene techniques of brushing and flossing. A manual1 was designed to serve as a reference for planning in-service training programs for long-term-care facilities and to have in the facilities for use as a resource to guide the staff in oral hygiene care for pa tients. At least one copy of this man ual (approved by the Council of Den tal Health, Montana Dental Associa tion) was distributed to each longterm-care facility and each advisory dentist by the Bureau of Dental Health. The Bureau of Dental Health used a great deal of information gathered from forms and oral hygiene manu als for similar programs in Wyom ing, Colorado, and Idaho to develop personal screening forms, screening data forms, and the manual on oral hygiene. The Division of Hospital and Medical Facilities helped de sign a model agreement between the advisory dentist and the long-termcare facility. The sources of the program de pended on the cooperation of administrators of the nursing homes. At the beginning of the program, persons in the Bureau of Dental Health and administrators of the
nursing homes were unknown to one another. The Division of Hospi tal and Medical Facilities made the introductory contact and maintained liaison throughout the-program. In the program design, the advi sory dentist was paid an hourly con sultant fee for accomplishing the specified services. It was decided that the advisory dentist should sign an agreement with the long-termcare facility to eliminate the chance of his being an advisory dentist in name only. The services to be ac complished by the advisory dentist included screening of all patients in the facility who had given consent to
participate in the program; comple tion of a personal screening form for each patient and writing an oral hygiene prescription on the back of the form, if needed (the form was at tached to the patient’s health record after the required data were re corded); gathering and summariz ing data from all personal screen ing forms for the Bureau of Dental Health, State Department of Health and Environmental Sciences; design of an oral hygiene in-service training program for the facility’s staff on the basis of needs observed during the screening (describing this program on the screening data form and im-
ORAL HEALTH SCREENING
Med1ca 1di_
Wîng_
Tor Elderly and Chronically 111
Med icare__
Room_ Bed
Private _Age_
Oate __Phys!cian_
Personal Dentist_ Nursing Home_____
CLINICAL Yes
No
I.
Patient is edentulous
2.
Dentures or partial dentures A. Has never had dentures___ B. Has full upper___ lower___ C. Has partial upper___ lower___ D. Dentures worn yes___ no____ If no: 1. Do not f i t___ 2. Unable physically or mentally to wear dentures___ 3. Refuses to wear___
3.
Condition of natural teeth and supporting structures A. B. C.
4.
Condition of dentures or partial dentures Upper Lower A. Satisfactory _____ _____ B. Remake _____ _____ C. Re line _____ _____ D. Repair _____ _____ E. Adjust _____ _____ F. Clean _____ _____
D. E.
Satisfactory______ Need restorations_ Need extractions
Need prophylaxis (cleaning)_ Need periodontal care_______
Condition of oral tissues A. Gum tissues 1. Satisfactory slight 2. Periodontitis: -------B. Palate, tongue, cheeks, lips
1.
Normal________________
2.
Lesions present (give locatlon_
5.
Patient is capable of carrying out own oral hygiene:
Yes____ No_
I.
General physical condition: Needs wheelchair or crutches_ Ambu latory___
2.
Specific physical condition J s on regular medications Yes___ No___ A. Currently belog treated for lllness_ B. Needs special diet_____ C. Coronary or arterial disease_____ D. Should not undergo dental procedures involving stress or anesthetics^ E. Can be referred for any needed dental care_____ F. Drug allergies Physician's Name________________
Health History Non-ambu Iatory_
Patient complaints:______________ ______________________________________________________
REFER FOR CARE------YES_
Examining Dentist_
Terri11-Elliott : M O N TAN A ADVISORY DENTIST PROGRAM ■ 403
A R T IC L E S
plementing the program in the facil ity before billing the state for ser vices); referral of patients needing dental care to dentists of the pa tients’ choice and notifying the staff of his availability for emergency care (Illustration). On completion of the program as designed, each long-term-care facil ity and its administrator would have a record of the dental health status and dental care needs of each pa tient, a summary data form on file showing all dental health needs of patients, an in-service oral hygiene program designed specifically for the facility by the advisory dentist, an oral hygiene prescription for staff to follow for specified patients, a dentist to provide emergency care and assist in referring patients to a dentist of their choice, and assur ance of availability to dental care for patients. The State Department of Health and Environmental Sciences would benefit from the screening of all pa tients in long-term-care facilities by having on file the names of all advi sory dentists and the assurance that they are functioning; obtaining data to show the dental health status, lo cation, age, and accessibility to den tal care of all patients in long-termcare facilities; and receiving assur ance that in-service oral hygiene programs were being implemented in long-term-care facilities.
Initial screening effort The effectiveness of the program plan and the forms for the screening were evaluated at one facility before a training program for advisory den tists was started. The Cascade County Convalescent Home in Great Falls, the largest nursing home in the state, with an average patient oc cupancy of 230, was selected for the evaluation. The only other public health dentist in the state, Dr. Ken neth Christenot, was named as its advisory dentist and “ screened” this facility with the assistance of one of us (J.T.). We wanted to be sure that the de veloped screening form was appli cable to the oral health of the geriat 404 ■ JADA, Vol. 98, March 1979
ric patients who occupy these facilities and to determine the number of patients that could be screened each hour while making it a meaningful experience for the pa tient. After the screening team spent three days examining acrylic and vulcanite dentures and edentulous patients— more of whom were older than 100 than were younger than 40 years—the team’s approach to the original problems changed. The overall goal remained the improve ment of the dental health of the geriatric patients confined to the nursing homes in the state. The ob jective of the screening portion of the program needs to be assessment of the dental care and oral hygiene needs of the patients and, on the basis of those needs, designing a realistic in-service training program that fits the individual institution. It became obvious that the objective of the program for the geriatric patient is to keep him comfortable, with a clean and healthy mouth, and not bother him with dental care he will not use or does not need. For example, a 76-year-old wom an, who once choked on her den tures and has not worn them for more than a year, chokes every time they are inserted. She chews institu tion food without teeth; there is no apparent damage to her health. Under these circumstances, it is doubtful if the appliances (in this case, dentures) will ever be used. Each advisory dentist should refer to the “Guidelines” before screening persons in a facility. Screening is performed to discover those in need of referral for care. The screener need not record the number of resto rations or extractions needed, but only that at least one is needed. A diagnosis should not be made at the screening. The oral hygiene pre scription for the patient should be described in full, and that only if needed. In this nursing home, few oral hygiene prescriptions were needed as a clean, healthy mouth was the rule rather than the exception. The facility had had an oral hygiene pro gram in progress for several years
under an in-service training di rector. In other facilities, the oppo site could be true. The final evalua tion of the total screening program should indicate what type of inservice program should be designed to improve the existing conditions. Lack of organization at times made the patients unavailable to the team for examination. It was possi ble for the team to screen ten to 12 patients an hour and have time to chat with the patient to increase the image value of the program, but lunch hours and employee coffee breaks often disrupted the routine. The nursing home directors, with advance planning, can make it pos sible for the screening process to move quickly and with little disrup tion. The equipment needed to screen patients is minimal; a dozen mouth mirrors, a dozen explorers, a good light source (a flashlight if nothing else is available), a cold sterilizer and solution for instruments, several cloth towels, hand tools for adjust ing dentures, and screening and evaluation forms.
Training of advisory dentists Training the advisory dentists to implement and complete the pro gram in the facilities was the most difficult problem. The 79 longterm-care facilities involved were scattered across the state of Mon tana. Most communities had only one facility as far as 150 miles away from the next; only a few com munities had as many as three facilities. The billing forms, agreements, and contracts required by the state and federal regulations, in addition to the screening forms, had to be explained on a face-to-face basis to the advisory dentists. The largest group that was assembled for training was 25 dentists, and some of the training had to be accom plished on an individual basis. It became evident that the general dental practitioner is not equipped to merely screen patients. He is trained to diagnose and mentally form treatment plans as he is looking
A R T IC L E S
at the patient’s mouth. In screening, he must record conditions, not diag nose and count each abnormality.
Results In spite of the tremendous amount of time and effort needed in training, designing, and implementing of the program, advisory dentists in 77 of the 79 (97%) long-term-care facil ities in Montana completed the program during an eight-month period. In one facility, the assigned advisory dentist refused to cooperate with the program, whereas in the other, the administrator refused to appoint an advisory dentist. In all, 78% (3,780 of the 4,817 possibly eli gible patients) were screened by an advisory dentist. Most of the pa tients who were not screened either refused or were unable to complete the consent forms. By age, the greatest percentage of patients (41.5%) in long-term-care facilities were 80 to 89 years old; more than 81% were older than 70, and more than 90% were older than 60 years (Table). These are truly geriatric patients and, predictably, most of them (72%) were edentulous. Of the edentulous patients, 81% wore dentures, 19% had no dentures, and many did not want dentures and would not wear them if they had them. Construction of new dentures was recommended for about half of the edentulous pa tients. Dentures for 12% of the pa tients needed repair mostly for brok en or chipped teeth caused by dropping of the dentures during cleaning. The advisory dentist gave instructions for cleaning dentures over a bowl of water with a towel over the porcelain to prevent break age if the dentures were dropped. Twenty percent needed no more than routine cleaning of their den tures. For this purpose, advisory dentists recommended purchase of ultrasonic cleaners for the larger facilities. Of the group of patients with natu ral teeth, 74% needed prophylaxis or periodontal treatment, or both. About half of this group needed res torations (41%) or extractions (47%).
Table ■ Ages of patients screened. Age_______ __
No.
Younger than 40 40 to 49 50 to 59 60 to 69 70 to 79 80 to 89 90 to 99 100 or older
96 74 159 365 793 1,512 633 17
If the program had been limited to screening for oral cancer, it would have been worthwhile. The advisory dentists reported 206 soft tissue le sions ranging from ulcers from den ture pressure to basal cell car cinoma. At the time the reports were submitted to the Bureau of Dental Health, biopsy specimens of three lesions had been examined and were diagnosed as cancerous; two of the patients had been treated and treat ment had been arranged for the third. Biopsies of an additional four lesions were performed with no re port yet available, and biopsies of seven lesions were being done. Pap smears had been completed on three lesions, and these were diagnosed as benign. Eighty-three percent of the pa tients in long-term-care facilities in Montana are ambulatory or could use special transport devices (wheel chairs or walkers) to get to a dental office for care. The balance, 17% were either bedridden or nonambu latory to a point that services would have to be brought to them. Twenty-six percent (960) of the pa tients were referred to their dentists for care. Almost half (46%) of the patients were handicapped and could not perform their own oral hygiene pro cedures. It is this group of patients who especially benefit from welldesigned, in-service training pro grams that teach the staff members how to care for oral hygiene needs. During the training sessions, the advisory dentists were requested to screen the patients first and then de sign an in-service training program for the staff that would fit the needs of the patients in that facility. The best training session on brushing and flossing is useless to a facility with 98 edentulous patients and three patients with natural teeth
Percent :
2.6 2.0 4.4 10.0 21.7 41.5 17.3 0.5
who may already practice good oral hygiene. In the report on the design of the in-service programs to the Bureau of Dental Health, the advi sory dentists included their ac tivities that seemed to be helpful to the staff of the facilities. These in cluded giving instructions on the use of several hygiene aids, on brushing and flossing of the teeth, on care and cleaning of dentures, on care of the tissues of patients with dentures and of edentulous patients, and on care of patients taking Dilan tin and similar drugs; training staff to recognize oral pathologic condi tions; lecturing on nutrition and nu tritional supplements and on symptoms of oral disease (decay, periodontitis, denture sores, and soft tissue lesions); and giving instruc tions on when to call the consulting dentist. The American Dental Asso ciation film, “The Senior Smile,” which incorporates a little of all the preceding, was shown in all facilities.
Recommendations In reviewing the screening data forms, the Bureau of Dental Health found several recommendations made by advisory dentists that should be considered by the longterm-care facilities. First, the pur chase of ultrasonic cleaners to clean dentures would be of special value in the larger facilities. Second, iden tification of all dentures with the first and last name of the patient is necessary if several dentures are placed in the ultrasonic cleaners. This can be accomplished with transparent cold-curing acrylic or one of the paint-on acrylic products on the market. Third, minimal den tal equipment, such as mirror and explorers, a good light, and an elec tric hand tool with burs, arbor disks,
Terri U-EUiott : M O N TAN A ADVISORY DENTIST PROGRAM ■ 405
A R T IC L E S
and so forth, for adjustments of den tures and other minor services should be available at the larger facilities. The dentist can set up a similar kit to take to smaller facilities on call. Summary
The geriatric patients in the longterm-care facilities in Montana have benefited from the Advisory Dentist Program. The dental health status of the majority of those who gave per mission to be screened has been as sessed, and they have been referred to a dentist for necessary care. The advisory dentist is no longer just a name on an inspection form, but in all but two facilities in Mon tana, has had a functional role at least once. The administrators of the facilities think the program is so worthwhile that the agreements with the advisory dentists are being renewed.
406 ■ JADA, Vol. 98, March 1979
The in-service training programs specifically designed for each facil ity have been effective and should be continued at least once a year. Clean mouths are now the rule, not the ex ception. Consideration for the happiness and comfort of the geriatric patient should be given before dental treat ment is recommended. A patient who refuses to wear the dentures he has probably will not wear a new set. Certainly, pain should be eliminated as quickly as possible. Dental care for the geriatric patient should have as its objective a clean, happy, com fortable mouth for the patient. The Advisory Dentist Program has pointed out one change and one ad dition needed in the Montana Dental Practice Act. The law should be changed so that a dental hygienist can provide dental hygiene services to the patients in the long-term-care
facilities without the direct supervi sion of the dentist (on premise). After screening, the dentist should be able to prescribe the oral hygiene care the patient needs and the dental hygienist should complete the care as prescribed. A requirement that all dentures be identified permanently with the patient’s first and last names at the time of processing should be added to the current law. Dr. Terrill is chief, Bureau of Dental Health, Montana State Department of Health and En vironmental Sciences, Helena, 59601. Dr. El liott is regional dental consultant for Region VIII of the US Public Health Service, Denver, Colo. Address requests for reprints to Dr. Ter rill.
1.
Oral hygiene manual for long-term-care
facilities. State of Montana, Department of Health and Environmental Sciences, Division of Hospital and Medical Facilities and Bureau of Dental Health, 1976.
The Montana Advisory Dentist Program A. Jack T errill, DDS John Elliott, DDS, MPH
Patients in long-term-care facilities are receiving better dental care as the role of the advisory dentist has been defined. Dental health for patients has been assessed, individual oral hygiene regimens have been designed, and in-service training programs have been established in each of the facilities.
eople of this country are living longer than people formerly did. Great numbers of our elderly citi zens- spend the last years of their lives as residents of nursing homes. The staffs of these homes and the dental profession have neglected the oral health of this segment of our population. Many practicing den tists have been asked to serve as ad visory dentists to nursing homes. Federal law requires that a dentist be affiliated with the nursing home for it to qualify as a long-term-care facil ity under Medicare and Medicaid programs. What role should the den tist assume? What should the staff of the nursing home do to assure that their residents maintain good oral health? The Montana Advisory Den tist Program was developed to assist the dental profession and nursing home staffs in solving these serious problems. The Montana Advisory Dentist Program was designed as a joint ef fort of the Division of Hospital and 402 ■I ADA, Vol. 98, M arch 1979
Medical Facilities, the Bureau of Dental Health of the Montana State Department of Health and Environ mental Sciences, and the Montana Dental Association. Funding was provided by the US Public Health Service, Health, Education, and Wel fare, Region VIII, and the Montana Department of Social and Rehabilita tive Services. Goals and objectives
The overall goal of the program was to improve the dental health of pa tients in long-term-care facilities by assuring their access to dental care and good oral hygiene. The objec tives of the program are: —to find an advisory dentist for each long-term-care facility in Mon tana; —to develop the role of the advi sory dentist and to develop guidelines for performing this ser vice;
—to provide each patient in a long-term-care facility with access to dental care; —to provide in-service training in oral hygiene for appropriate staff of long-term-care facilities; —to develop continuous oral hygiene programs for each patient in long-term-care facilities; and —to assure that the dental pro gram in each long-term-care facility is permanent. To comply with the regulations governing Title X IX Medicaid pro grams, long-term-care facilities must obtain the services of an advisory dentist who assists patients in ob taining regular and emergency den tal care and must provide an annual in-service training program on oral hygiene for staff members. In answer to these requirements, the Bureau of Dental Health and the Council on Dental Health of the Montana Den tal Association developed the “Guidelines for the role of an ad visory dentist to long-term-care facilities.” The guidelines for an ad visory dentist are summarized: □ Arrange with the facility to conduct screening examination of all patients, including screening for oral cancer, assessment of dental care needs, determination of the pa tient’s capability to undergo dental treatment, and the prescription of oral hygiene regimens for each pa tient. The advisory dentist should assist the facility in making the ar rangements for dental treatment,
A R T IC L E S
with priority on referral to the pa tients’ own dentists. □ Determine, in conjunction with the facility, a time interval (at least every six months] for follow-up vis its to evaluate whether treatment needs have been met, to screen new residents of the facility, and to de termine if oral hygiene prescriptions are being followed. □ Be available for emergency treatment or arrange for another den tist to be available. □ Provide in-service training in oral hygiene for staff members. As an example, the advisory dentist could train dental auxiliaries who, in turn, could teach the oral hygiene procedures to the facility’s staff. As patients with natural teeth are, by far, in the minority in long-termcare facilities, training in oral hy giene for patients with partial or complete dentures or edentulous pa tients is equally if not more impor tant than training in the routine hygiene techniques of brushing and flossing. A manual1 was designed to serve as a reference for planning in-service training programs for long-term-care facilities and to have in the facilities for use as a resource to guide the staff in oral hygiene care for pa tients. At least one copy of this man ual (approved by the Council of Den tal Health, Montana Dental Associa tion) was distributed to each longterm-care facility and each advisory dentist by the Bureau of Dental Health. The Bureau of Dental Health used a great deal of information gathered from forms and oral hygiene manu als for similar programs in Wyom ing, Colorado, and Idaho to develop personal screening forms, screening data forms, and the manual on oral hygiene. The Division of Hospital and Medical Facilities helped de sign a model agreement between the advisory dentist and the long-termcare facility. The sources of the program de pended on the cooperation of administrators of the nursing homes. At the beginning of the program, persons in the Bureau of Dental Health and administrators of the
nursing homes were unknown to one another. The Division of Hospi tal and Medical Facilities made the introductory contact and maintained liaison throughout the-program. In the program design, the advi sory dentist was paid an hourly con sultant fee for accomplishing the specified services. It was decided that the advisory dentist should sign an agreement with the long-termcare facility to eliminate the chance of his being an advisory dentist in name only. The services to be ac complished by the advisory dentist included screening of all patients in the facility who had given consent to
participate in the program; comple tion of a personal screening form for each patient and writing an oral hygiene prescription on the back of the form, if needed (the form was at tached to the patient’s health record after the required data were re corded); gathering and summariz ing data from all personal screen ing forms for the Bureau of Dental Health, State Department of Health and Environmental Sciences; design of an oral hygiene in-service training program for the facility’s staff on the basis of needs observed during the screening (describing this program on the screening data form and im-
ORAL HEALTH SCREENING
Med1ca 1di_
Wîng_
Tor Elderly and Chronically 111
Med icare__
Room_ Bed
Private _Age_
Oate __Phys!cian_
Personal Dentist_ Nursing Home_____
CLINICAL Yes
No
I.
Patient is edentulous
2.
Dentures or partial dentures A. Has never had dentures___ B. Has full upper___ lower___ C. Has partial upper___ lower___ D. Dentures worn yes___ no____ If no: 1. Do not f i t___ 2. Unable physically or mentally to wear dentures___ 3. Refuses to wear___
3.
Condition of natural teeth and supporting structures A. B. C.
4.
Condition of dentures or partial dentures Upper Lower A. Satisfactory _____ _____ B. Remake _____ _____ C. Re line _____ _____ D. Repair _____ _____ E. Adjust _____ _____ F. Clean _____ _____
D. E.
Satisfactory______ Need restorations_ Need extractions
Need prophylaxis (cleaning)_ Need periodontal care_______
Condition of oral tissues A. Gum tissues 1. Satisfactory slight 2. Periodontitis: -------B. Palate, tongue, cheeks, lips
1.
Normal________________
2.
Lesions present (give locatlon_
5.
Patient is capable of carrying out own oral hygiene:
Yes____ No_
I.
General physical condition: Needs wheelchair or crutches_ Ambu latory___
2.
Specific physical condition J s on regular medications Yes___ No___ A. Currently belog treated for lllness_ B. Needs special diet_____ C. Coronary or arterial disease_____ D. Should not undergo dental procedures involving stress or anesthetics^ E. Can be referred for any needed dental care_____ F. Drug allergies Physician's Name________________
Health History Non-ambu Iatory_
Patient complaints:______________ ______________________________________________________
REFER FOR CARE------YES_
Examining Dentist_
Terri11-Elliott : M O N TAN A ADVISORY DENTIST PROGRAM ■ 403
A R T IC L E S
plementing the program in the facil ity before billing the state for ser vices); referral of patients needing dental care to dentists of the pa tients’ choice and notifying the staff of his availability for emergency care (Illustration). On completion of the program as designed, each long-term-care facil ity and its administrator would have a record of the dental health status and dental care needs of each pa tient, a summary data form on file showing all dental health needs of patients, an in-service oral hygiene program designed specifically for the facility by the advisory dentist, an oral hygiene prescription for staff to follow for specified patients, a dentist to provide emergency care and assist in referring patients to a dentist of their choice, and assur ance of availability to dental care for patients. The State Department of Health and Environmental Sciences would benefit from the screening of all pa tients in long-term-care facilities by having on file the names of all advi sory dentists and the assurance that they are functioning; obtaining data to show the dental health status, lo cation, age, and accessibility to den tal care of all patients in long-termcare facilities; and receiving assur ance that in-service oral hygiene programs were being implemented in long-term-care facilities.
Initial screening effort The effectiveness of the program plan and the forms for the screening were evaluated at one facility before a training program for advisory den tists was started. The Cascade County Convalescent Home in Great Falls, the largest nursing home in the state, with an average patient oc cupancy of 230, was selected for the evaluation. The only other public health dentist in the state, Dr. Ken neth Christenot, was named as its advisory dentist and “ screened” this facility with the assistance of one of us (J.T.). We wanted to be sure that the de veloped screening form was appli cable to the oral health of the geriat 404 ■ JADA, Vol. 98, March 1979
ric patients who occupy these facilities and to determine the number of patients that could be screened each hour while making it a meaningful experience for the pa tient. After the screening team spent three days examining acrylic and vulcanite dentures and edentulous patients— more of whom were older than 100 than were younger than 40 years—the team’s approach to the original problems changed. The overall goal remained the improve ment of the dental health of the geriatric patients confined to the nursing homes in the state. The ob jective of the screening portion of the program needs to be assessment of the dental care and oral hygiene needs of the patients and, on the basis of those needs, designing a realistic in-service training program that fits the individual institution. It became obvious that the objective of the program for the geriatric patient is to keep him comfortable, with a clean and healthy mouth, and not bother him with dental care he will not use or does not need. For example, a 76-year-old wom an, who once choked on her den tures and has not worn them for more than a year, chokes every time they are inserted. She chews institu tion food without teeth; there is no apparent damage to her health. Under these circumstances, it is doubtful if the appliances (in this case, dentures) will ever be used. Each advisory dentist should refer to the “Guidelines” before screening persons in a facility. Screening is performed to discover those in need of referral for care. The screener need not record the number of resto rations or extractions needed, but only that at least one is needed. A diagnosis should not be made at the screening. The oral hygiene pre scription for the patient should be described in full, and that only if needed. In this nursing home, few oral hygiene prescriptions were needed as a clean, healthy mouth was the rule rather than the exception. The facility had had an oral hygiene pro gram in progress for several years
under an in-service training di rector. In other facilities, the oppo site could be true. The final evalua tion of the total screening program should indicate what type of inservice program should be designed to improve the existing conditions. Lack of organization at times made the patients unavailable to the team for examination. It was possi ble for the team to screen ten to 12 patients an hour and have time to chat with the patient to increase the image value of the program, but lunch hours and employee coffee breaks often disrupted the routine. The nursing home directors, with advance planning, can make it pos sible for the screening process to move quickly and with little disrup tion. The equipment needed to screen patients is minimal; a dozen mouth mirrors, a dozen explorers, a good light source (a flashlight if nothing else is available), a cold sterilizer and solution for instruments, several cloth towels, hand tools for adjust ing dentures, and screening and evaluation forms.
Training of advisory dentists Training the advisory dentists to implement and complete the pro gram in the facilities was the most difficult problem. The 79 longterm-care facilities involved were scattered across the state of Mon tana. Most communities had only one facility as far as 150 miles away from the next; only a few com munities had as many as three facilities. The billing forms, agreements, and contracts required by the state and federal regulations, in addition to the screening forms, had to be explained on a face-to-face basis to the advisory dentists. The largest group that was assembled for training was 25 dentists, and some of the training had to be accom plished on an individual basis. It became evident that the general dental practitioner is not equipped to merely screen patients. He is trained to diagnose and mentally form treatment plans as he is looking
A R T IC L E S
at the patient’s mouth. In screening, he must record conditions, not diag nose and count each abnormality.
Results In spite of the tremendous amount of time and effort needed in training, designing, and implementing of the program, advisory dentists in 77 of the 79 (97%) long-term-care facil ities in Montana completed the program during an eight-month period. In one facility, the assigned advisory dentist refused to cooperate with the program, whereas in the other, the administrator refused to appoint an advisory dentist. In all, 78% (3,780 of the 4,817 possibly eli gible patients) were screened by an advisory dentist. Most of the pa tients who were not screened either refused or were unable to complete the consent forms. By age, the greatest percentage of patients (41.5%) in long-term-care facilities were 80 to 89 years old; more than 81% were older than 70, and more than 90% were older than 60 years (Table). These are truly geriatric patients and, predictably, most of them (72%) were edentulous. Of the edentulous patients, 81% wore dentures, 19% had no dentures, and many did not want dentures and would not wear them if they had them. Construction of new dentures was recommended for about half of the edentulous pa tients. Dentures for 12% of the pa tients needed repair mostly for brok en or chipped teeth caused by dropping of the dentures during cleaning. The advisory dentist gave instructions for cleaning dentures over a bowl of water with a towel over the porcelain to prevent break age if the dentures were dropped. Twenty percent needed no more than routine cleaning of their den tures. For this purpose, advisory dentists recommended purchase of ultrasonic cleaners for the larger facilities. Of the group of patients with natu ral teeth, 74% needed prophylaxis or periodontal treatment, or both. About half of this group needed res torations (41%) or extractions (47%).
Table ■ Ages of patients screened. Age_______ __
No.
Younger than 40 40 to 49 50 to 59 60 to 69 70 to 79 80 to 89 90 to 99 100 or older
96 74 159 365 793 1,512 633 17
If the program had been limited to screening for oral cancer, it would have been worthwhile. The advisory dentists reported 206 soft tissue le sions ranging from ulcers from den ture pressure to basal cell car cinoma. At the time the reports were submitted to the Bureau of Dental Health, biopsy specimens of three lesions had been examined and were diagnosed as cancerous; two of the patients had been treated and treat ment had been arranged for the third. Biopsies of an additional four lesions were performed with no re port yet available, and biopsies of seven lesions were being done. Pap smears had been completed on three lesions, and these were diagnosed as benign. Eighty-three percent of the pa tients in long-term-care facilities in Montana are ambulatory or could use special transport devices (wheel chairs or walkers) to get to a dental office for care. The balance, 17% were either bedridden or nonambu latory to a point that services would have to be brought to them. Twenty-six percent (960) of the pa tients were referred to their dentists for care. Almost half (46%) of the patients were handicapped and could not perform their own oral hygiene pro cedures. It is this group of patients who especially benefit from welldesigned, in-service training pro grams that teach the staff members how to care for oral hygiene needs. During the training sessions, the advisory dentists were requested to screen the patients first and then de sign an in-service training program for the staff that would fit the needs of the patients in that facility. The best training session on brushing and flossing is useless to a facility with 98 edentulous patients and three patients with natural teeth
Percent :
2.6 2.0 4.4 10.0 21.7 41.5 17.3 0.5
who may already practice good oral hygiene. In the report on the design of the in-service programs to the Bureau of Dental Health, the advi sory dentists included their ac tivities that seemed to be helpful to the staff of the facilities. These in cluded giving instructions on the use of several hygiene aids, on brushing and flossing of the teeth, on care and cleaning of dentures, on care of the tissues of patients with dentures and of edentulous patients, and on care of patients taking Dilan tin and similar drugs; training staff to recognize oral pathologic condi tions; lecturing on nutrition and nu tritional supplements and on symptoms of oral disease (decay, periodontitis, denture sores, and soft tissue lesions); and giving instruc tions on when to call the consulting dentist. The American Dental Asso ciation film, “The Senior Smile,” which incorporates a little of all the preceding, was shown in all facilities.
Recommendations In reviewing the screening data forms, the Bureau of Dental Health found several recommendations made by advisory dentists that should be considered by the longterm-care facilities. First, the pur chase of ultrasonic cleaners to clean dentures would be of special value in the larger facilities. Second, iden tification of all dentures with the first and last name of the patient is necessary if several dentures are placed in the ultrasonic cleaners. This can be accomplished with transparent cold-curing acrylic or one of the paint-on acrylic products on the market. Third, minimal den tal equipment, such as mirror and explorers, a good light, and an elec tric hand tool with burs, arbor disks,
Terri U-EUiott : M O N TAN A ADVISORY DENTIST PROGRAM ■ 405
A R T IC L E S
and so forth, for adjustments of den tures and other minor services should be available at the larger facilities. The dentist can set up a similar kit to take to smaller facilities on call. Summary
The geriatric patients in the longterm-care facilities in Montana have benefited from the Advisory Dentist Program. The dental health status of the majority of those who gave per mission to be screened has been as sessed, and they have been referred to a dentist for necessary care. The advisory dentist is no longer just a name on an inspection form, but in all but two facilities in Mon tana, has had a functional role at least once. The administrators of the facilities think the program is so worthwhile that the agreements with the advisory dentists are being renewed.
406 ■ JADA, Vol. 98, March 1979
The in-service training programs specifically designed for each facil ity have been effective and should be continued at least once a year. Clean mouths are now the rule, not the ex ception. Consideration for the happiness and comfort of the geriatric patient should be given before dental treat ment is recommended. A patient who refuses to wear the dentures he has probably will not wear a new set. Certainly, pain should be eliminated as quickly as possible. Dental care for the geriatric patient should have as its objective a clean, happy, com fortable mouth for the patient. The Advisory Dentist Program has pointed out one change and one ad dition needed in the Montana Dental Practice Act. The law should be changed so that a dental hygienist can provide dental hygiene services to the patients in the long-term-care
facilities without the direct supervi sion of the dentist (on premise). After screening, the dentist should be able to prescribe the oral hygiene care the patient needs and the dental hygienist should complete the care as prescribed. A requirement that all dentures be identified permanently with the patient’s first and last names at the time of processing should be added to the current law. Dr. Terrill is chief, Bureau of Dental Health, Montana State Department of Health and En vironmental Sciences, Helena, 59601. Dr. El liott is regional dental consultant for Region VIII of the US Public Health Service, Denver, Colo. Address requests for reprints to Dr. Ter rill.
1.
Oral hygiene manual for long-term-care
facilities. State of Montana, Department of Health and Environmental Sciences, Division of Hospital and Medical Facilities and Bureau of Dental Health, 1976.
