Katherine Ford visited her father, Dean Piercy, a World War II veteran with dementia, at a nursing home in Roanoke, Va., for months before she noticed the dust on his electric toothbrush. His teeth, she found, had not been recently brushed, so she began doing it herself after their lunches together.
But after he complained of a severe, unrelenting headache, she said, she badgered the staff to make an appointment with his dentist. The dentist found that a tooth had broken in two, and he showed Ford the part that had lodged in the roof of her father's mouth. "I was livid," said Ford, 57, a court reporter.
"I'm there every day, pointing out he's in pain — and he had dental insurance. So there's no reason this wasn't addressed."
In nursing homes across the country, residents like Piercy suffer from cavities, gum disease and cracked teeth, in part because their mouths are not kept clean. While residents now require more dental care than in the past, nursing home employees are rarely prepared to provide it.
Aides are swamped with other tasks, and when elderly charges must be helped to the toilet, fed or repositioned in bed, brushing teeth often falls to the bottom of the to-do list.
Even when care is available, few staff members are trained to cope with the rising numbers of residents with dementia who resist routine dental hygiene.
"I always say you can measure quality in a nursing home by looking in people's mouths, because it's one of the last things to be taken care of," said Dr. Judith A. Jones, head of the department of general dentistry at Boston University.
"Aides change someone's Depends, change a catheter or turn somebody every few hours, but teeth often don't get brushed twice a day."
The neglect can lead to terrible pain for the residents. Worse, new studies suggest that this problem might be contributing to another: pneumonia, a leading killer of the institutionalized elderly.
"The lack of daily oral care in nursing facilities is "an epidemic that's almost universally overlooked," said Dr. Sarah J. Dirks, a dentist who treats nursing home residents in San Antonio.
There are no current national assessments of oral health in nursing homes, but since 2011, at least seven states have evaluated residents using a survey developed by the Association of State and Territorial Dental Directors.
One was Kansas, where dental hygienists examined 540 elderly residents in 20 long-term care facilities. Nearly 30 per cent of the residents had "substantial oral debris on at least two-thirds of their teeth," according to a report issued by the Kansas Bureau of Oral Health. More than a third had untreated decay.
The screeners saw plenty of fillings and crowns but concluded that "regular dental care has become a thing of the past" for many of the elderly residents.
In Wisconsin, nearly 1,100 residents from 24 homes were examined. About 31 per cent had teeth broken to the gums, with visible roots; 35 per cent had substantial oral debris from meals past.
The problem has been graphically documented in state and federal inspections of nursing homes. In Texas, inspectors noted one resident with memory problems in too much pain to eat, her lower gums red, swollen and packed with food debris.
A 2006 study of five facilities in upstate New York found only 16 per cent of residents received any oral care at all. Among those who did, average tooth brushing time was 16 seconds. Supplies like toothbrushes were scarce, the report said.
At the Raleigh Court Health and Rehabilitation Center in Roanoke, where Piercy was a resident, the administrator, Mark Tubbs, said in a prepared statement that he could not discuss Piercy's case because of federal privacy laws, nor corroborate Ford's account.
"All patients receive medically necessary, high-quality care, including oral care and hygiene," Tubbs said."Just as nursing home workers are expected to help residents bathe, or reposition them to avoid bed sores, they are supposed to brush the teeth of residents who can't do it themselves. So important is this task that it was federally mandated in the Omnibus Budget Reconciliation Act of 1987, which set new standards for nursing homes.
"They should be getting their care, but a lot of people don't," acknowledged Dr. David Gifford, the senior vice president of quality at the American Health Care Association, a trade group representing two-thirds of nursing homes nationwide.
Some residents decline help, he noted, and nursing home employees can do little about it.
"It's a very personal thing to have someone else brush your teeth," Gifford said.
"A lot of residents don't want it, don't like it and will ask not to have it."
Many arrive at nursing homes with poor teeth, he added, after long periods without seeing a dentist.
Certainly, oral care can be a vexing challenge for nursing homes. Elderly Americans are likelier than ever to retain their natural teeth. Edentulism — total tooth loss — in seniors declined between 1988 and 2004, according to data from the National Health and Nutrition Examination Surveys.
"Before, they came in with dentures," said Barbara J. Smith, the manager of geriatric and special-needs populations at the American Dental Association.
"Now it's a whole different ballgame." Dentures are easier for nursing home staff to clean.
Nearly two-thirds of those who stay in a facility long-term have dementia, and many resist oral care, clenching their mouth shut or even trying to hit aides. The National Institutes of Health is financing research to address such resistance among nursing home residents with dementia.
Many prescription drugs — including some antidepressants, medications for high blood pressure, and anti-seizure medications — can reduce saliva and dry out the mouth. Without daily oral care, elderly people taking such drugs are especially prone to "a relatively rapid deterioration," said Dr. Ira Lamster, a dentist and a professor of health policy at the Mailman School of Public Health at Columbia University in New York.
-New York Times Service.
