Brushing Teeth

In a couple of months Margaret and I will have lived here four years. We go to the dentist every six months. This time the dentist reported that Margaret needed better brushing.

Brushing was a normal part of the morning toiletry events, in the past. She also was up with the rest of the residents. She would then sleep at the breakfast table.

She now goes to bed when tired, or before 10 pm, and gets up when she wakes up or by 10 am. 

Residents have the right of refusal of everything (according to my understanding of Missouri rules). This can be used to justify almost anything not being done in practice. It removes liability for not being done.

The dental office we used has two doors. One is too narrow to pass Margaret’s wheelchair. The other placed her beside the dental chair. Becky put on the TV, down in front of Margaret. She was happy with the “Price is Right”.

Becky sat down on the end of the dental chair with toothbrush in hand after finishing with me (no cavities and healthy gums). She talked with Margaret about brushing her teeth, now, without moving her wheelchair.

The environment for tooth brushing has now been set. We are at the dentist. There are no distractions. There is a toothbrush held where she can easily see it.

“Ready to brush.” (As a command, not as a question.) One finger touches Margaret’s lower lip. The brush lands beside it. Becky keeps on talking. Time passes. The lips open a fraction. The brush turns sideways and enters.

This two-handed approach is part of routine dental practice. One for the tool and one for the mirror. It worked.

It then hit me, “Get a video.”  I did, at about halfway through the brushing. It starts when Becky stopped and then easily started again.  

Brushing Margaret’s teeth was one of the eight items that was discussed at a care plan meeting about a week earlier. 

Federal rules include a provision that if the resident refuses, but doing so puts the resident at risk, and the resident is deemed not competent to understand, then proceed with the action. 

F677 

(Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17) 

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; and 

NOTE: In some cases, residents with dementia may resist the manner in which care is being provided, or attempted, which can be misinterpreted as declination of care. In some cases the resident with dementia does not understand what is happening, or may be fearful of unfamiliar staff, or may be anxious or frustrated due to inability to communicate. Facility staff are responsible to attempt to identify the underlying cause of the “refusal/declination” of care. 

If it is determined that the resident’s inability to perform ADLs occurred after admission due to an unavoidable decline, such as the progression of the resident’s disease process, surveyors must still determine that interventions to assist the resident are identified and implemented immediately. 

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

This seems, to me, to be the case now: bleeding gums when brushing and sent home with toothpaste for bleeding gums.

Once again, behavior in memory care can be controlled by carefully creating the environment in which it is most likely to take place. We cannot take Margaret each day to the dentist.

We can create in memory care the needed environment and train caregivers (two handed approach) to successfully brush Margaret’s teeth. A low stress setting. No outside distractions. A commanding positive approach. A timing that lets Margaret respond as desired. Uniform, regular, execution each day (as possible) by familiar caregivers who have the knack of visiting with her (distracting) as all of this is taking place.

[The more I watch the video, I am thinking we may need to brush Margaret’s teeth when she is watching Family Feud in the activity area. To this day she refuses to have the TV on in our apartment??] 

A few days after the care plan meeting a curious thing was reported. Three assisted living residents had a knock on their doors in the morning:

“Have you brushed your teeth?”

“I need to brush your teeth.”

“I came to brush your teeth.”  “I brush them myself. I have false teeth.”

[11:30am Margaret just left using the assisted walker, after her teeth were brushed using the new toothpaste. I suggested doing this while she was on the toilet. It worked. I did not see how the two caregivers did it.]

My blood pressure: 6:55am 206/99 (woke up and started writing), 7:30am 169/94, and 9:30am 154/73 (after a five minute rest, reading the newspaper, as I finish writing this). Now to get it posted with the video. Write and post in one day; it will be a rare event. 

Writing makes me feel better. I can let things go; but I can always know I can get them back from my posts on the Internet. It may have an effect on my blood pressure too. Doing anything about a stressor seems to reduce it (talking, writing, getting it done).