J Dent Educ. 69(9): 1015-1017 2005
© 2005 American Dental Education Association
The Oral Health Status of Nursing Home Residents: What Do We Need to Know?
Albert H. Guay, D.M.D.
Oral health care for elder residents of nursing homes often presents a challenge,1–4 particularly to those individuals who must rely on caregivers for their daily oral health maintenance. These caregivers assume the daily responsibility for good oral hygiene practices that were once the responsibility of the patient. Because of this shift in responsibility, monitoring of the oral health status of elder residents becomes very important.
Approximately 5 percent of Americans over the age of sixty-five, now about 1.75 million people, are residents of long-term care facilities where they have problems receiving adequate dental care. There are relatively scant data on the utilization of dental services by residents, but what are available indicate low utilization. A high prevalence of oral disease and the need for dental treatment are also evident.1
It is essential that adequate and reliable information about the oral health status of residents in long-term care facilities be available to patients, their families, oral health care providers, caregivers, facility managers, federal/state nursing facilities surveyors, and managers of assistance programs. This information can be invaluable in designing, monitoring, and improving oral health care practices so that the oral health of residents of long-term care facilities can be optimized.
This article will discuss information-gathering and reporting on the oral health status of residents in long-term care facilities. Some suggestions will be offered to enhance the quality of the information gathered with the view of making that information more valuable in serving the oral health needs of this vulnerable elderly population.
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The Omnibus Budget Reconciliation Act of 1987
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The Omnibus Budget Reconciliation Act of 1987 (OBRA) and subsequent federal regulations established requirements for nursing facilities related to dental services and the periodic evaluation of the health, including the oral health, of residents in those facilities. In summary, nursing care facilities that receive Medicare or Medicaid funds, besides providing for dental care, must periodically assess the health, including the oral health, of their residents using the prescribed Minimum Data Set (MDS). The appropriate treatment needs of residents must be met either by staff dentists or by dentists under contract with the facility to provide those services. There are indications that in some areas these requirements are not being met or are only partially being met.5
The American Dental Association (ADA) and Special Care Dentistry (SCD) believe that the dental content of the MDS proves to be an incomplete appraisal of the oral health of individuals when used by nursing facility staff, as required by the Centers for Medicare and Medicaid Services (CMS). A revised version of the oral health data required in the MDS is important.
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The Minimum Data Set (MDS)
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The MDS is a resident assessment questionnaire used to assess the health of each nursing facility resident. Dental personnel do not complete the questionnaire. The current requirements for oral health data are listed in OBRA in MDS 2.0 (Section L) Oral Status and Disease Prevention. They are:
- Debris (soft, easily removed substances) present in the mouth prior to going to bed at night,
- Has dentures or removable bridge,
- Some/all natural teeth lost—does not have or does not use dentures (or partial plates),
- Broken, loose, or carious teeth,
- Inflamed gums (gingiva); swollen or bleeding gums; oral abscesses; ulcers or rashes, and
- Daily cleaning of teeth/dentures or daily mouth care by resident or staff.
The ADA and SCD have suggested revisions to the MDS. They are:
- Resident has chewing problems or mouth/facial pain or discomfort,
- Resident has abnormal mouth tissue (ulcers, masses, oral lesions) (look under denture or partial denture if one is worn),
- Resident has a problem with a denture or partial denture (chipped, broken, loose, uncleanable, or missing),
- Resident has natural teeth or tooth fragments; if no, skip remaining items,
- Resident has an obvious cavity(s) or broken tooth (teeth),
- Resident has a loose natural tooth (teeth), and
- Resident has inflamed or bleeding gums.
With these recommended changes in the MDS, a better and more useful picture of the complete oral health status of residents in nursing facilities can be obtained. Adequate and accurate oral health status information is essential for understanding the nature and extent of oral health problems existing in the resident population of these facilities. Without this understanding, it will be difficult to develop effective tactics and programs to effectively address these problems. This information will also be useful in identifying potential problems in the residential community and designing steps that might be taken to prevent them or reduce their severity. When potential problems are identified by MDS data, a nursing facility survey review may be indicated. The more relevant data that will be gathered through an improved MDS questionnaire will facilitate these efforts.
Finally, with the baseline data that a more effective MDS can generate on the oral health status of nursing facility residents, quantitative data can be obtained on the effectiveness of any program aimed at improving the oral health status of residents. Evaluation of the MDS can also aid in developing training programs for facility staff so they may become more effective front-line providers of daily good oral health practices for those under their care.
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An Oral Health Quality Indicator
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Well-designed and meaningful quality indicators can be effective tools to use in quickly identifying areas of concern, so that more in-depth studies can be done in those areas where problems are more likely to exist. They can add efficiency to a monitoring system because they direct resources and attention to potential problems and away from areas where problems are least likely to exist. Generally, indicators are easy to construct and to identify from data, measure factors critical to the outcome desired, and have adequate specificity and sensitivity to be relevant.
It is not practical—so will most likely not be done—to do a complete review of even a random sample of patients’ records to determine the oral health status of a resident population. Use of an appropriate indicator can provide a sign to surveyors that a more in-depth study may be warranted. One example of an oral health quality indicator might be the number of instances of residents reporting oral or facial pain per one hundred residents. A number above an established threshold may indicate that a problem exists and should be investigated further.
An oral health quality indicator, or small number of indicators, would be valuable in the surveillance of the oral health of nursing facility residents. Using data generated within the MDS, an indicator(s) could identify a facility that should have a complete state survey of their dental capabilities and practices.
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Diagnostic Codes
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Vulnerable elders who are residents of nursing facilities commonly have a medical history and health status that is complex.6 Comorbidities are common, and these individuals often take a number of medications on a daily basis. Their general health often has a significant bearing on their dental health and the dental care they require. In addition, their dental health can have an important effect on their general health.
It is important that all of the health care providers who attend to these patients are aware of their health history and current health status. Codification of this information in the patient’s health record is an effective way of allowing practitioners to review this information in a timely manner.
The SNOMED diagnostic coding system has been designated as a standard system for recording diagnoses in patients’ electronic health records. The SNOMED system has the ADA-developed SNODENT dental diagnostic system embedded in it. The SNODENT system goes beyond the identification of a primary diagnosis. Its hierarchical structure allows for the codification of the severity of the disease, comorbidities, patient characteristics, and other factors that have a bearing on the treatment provided and the outcome of that treatment.
Use of these systems could enhance the ability of practitioners to record individual patient diagnoses and perhaps enhance, in aggregate, MDS facility data for resident patients and to quickly be able to obtain an understanding of the health status of the patients they treat. Appropriate treatment planning and a meaningful appraisal of the outcome of treatment provided can be significantly enhanced through the use of a comprehensive diagnostic coding system. Implementation of the SNODENT system should be explored.
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How Can We Get the Information We Need?
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First of all, there must be a universal understanding of the importance of oral health for residents of long-term nursing facilities and its relationship to the overall health of individuals. In order to evaluate the oral health status of residents, meaningful data must be gathered through the Resident Assessment Questionnaire and the facility assessment process. These data must be made available to those who have need of it. One or more Oral Health Quality Indicators should be developed that would be useful in identifying potential oral health problems worthy of further study or a state survey review. Finally, the designated diagnostic coding system should be employed and linked to the MDS to simplify the means by which all practitioners who must understand the health of their patients can do so.
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How Will This New Information Help?
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The first step in solving any problem is understanding it. These enhanced data will show what problems exist, to what extent they are present in the residential population, and to what degree. This information will provide the foundation for effective interventions and the evaluation of the success of any interventions initiated. For example, if survey data indicate that a number of residents have inflamed or bleeding gums, inadequate daily oral hygiene may be a significant problem with a great number of residents. The facility may implement an initiative with caregivers to attack the identified oral hygiene deficiencies. Periodic reassessments will give an indication of how the initiative is working and any effect on the oral health status of residents. Program modifications may be in order if it is not showing positive effects.
Besides the direct effect on resident care, problems identified and quantified through survey data may be useful in garnering support from policymakers for resources to improve the oral health of residents.
The potential uses for clear, relevant data on the oral health status of long-term care facilities residents are unlimited. When resources are scarce, only good information can assist in the most efficient allocation of available resources for the benefit of all.
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Footnotes
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Dr. Guay is the American Dental Association’s Chief Policy Advisor. Direct correspondence and requests for reprints to him at American Dental Association, 211 East Chicago Ave., Chicago, IL 60611-2678; 312-440-2844 phone; 312-440-7488 fax; guaya{at}ada.org. The views expressed in this article are not necessarily those of the American Dental Association or its subsidiaries.
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REFERENCES
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- Oral health in America: a report of the surgeon general. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
- Strayer M. Oral health care for the homebound and institutionalized elderly. J Cal Dent Assoc 1999;27(9):703–8.
- Ellis AG. Geriatric dentistry in long-term-care facilities: current status and future implications. Spec Care Dent 1999;19(3):139–42.
- Etinger RL, Mulligan R. The future of dental care for the elderly population. J Cal Dent Assoc 1999;27(9):687–92.
- Sinykin SG. A crisis in the community. Northwest Dent 2000;Nov–Dec:15–8.
- Lamster I. Oral health care services for older adults: a looming crisis. Am J Public Health 2001;94(5):699–701.
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