Saskatchewan Seniors Oral Health and Long Term Care Strategy

Saskatchewan Seniors’ Oral Health
and Long Term Care Strategy
Better Oral Health in Long Term Care: Best
Practice Standards for Saskatchewan
Saskatchewan Oral Health Coalition October 24, 2016

A clean, healthy, pain-free mouth contributes
greatly to:
• chewing and being able to enjoy a variety of
nutritious foods
• clear speech and communication
• sleeping well
• overall health
• general comfort and a higher quality of life
• a more attractive personal appearance, positive
self-esteem and satisfying social interactions
Our Goal: Health and Wellness
Better Oral Health in Long Term Care

Status of Oral Health among older adults in
Long Term Care (LTC) homes in Saskatchewan

Approximately 72% of residents in long term homes
reported that routine oral hygiene is their greatest single
need. (findings from University of Saskatchewan - College of Dentistry pilot study)

• LTC residents often suffer from some form of dementia,
and most have physical and medical challenges too.
• These fragile elderly are at an especially high risk for a
number of serious conditions because they:
• Often forget to brush their teeth or are unable to do it
without help
• May resist or refuse assistance
• May have problems recognizing and reporting pain and
discomfort in the mouth
Resident Challenges

So if these are the facts…
• Increasing population and associated high
prevalence of chronic diseases
• Population of older adults will experience
“doubling phenomena”
• Population over age 65 will double by 2030
• Older adults are retaining more teeth
• Retention of natural teeth puts them at risk for
dental and oral diseases such as caries and
periodontal diseases

Better Health and Wellness
• If the mouth is being cared for like the rest of the body,
diseases manifesting in the mouth like diabetes and cancer
can be spotted sooner.
• If there is regular daily care and prevention, there will be
less oral disease and less systemic disease – heart disease,
diabetes, stroke, aspiration pneumonia.
= Less health care dollars being spent,
while achieving
a better quality of life for our people

Proportion of Seniors:
• In 2015, 14.6% of the residents of Saskatchewan were
seniors. (Statistics Canada, 2015)
• By 2036, 23.3% of Saskatchewan residents are expected to
be seniors. (Statistics Canada, 2010)
16.10%
18.40%
18.60%
18.90%
19%
17.60%
16%
14.80%
14.60%
11.60%
17.50%
10.90%
6.80%
3.70%
0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% 16.00% 18.00% 20.00%
Canada
Newfounland and Labrador
Prince Edward Isaland
Novo Scotia
New Bruswick
Quebec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
Nunavut
Proportion of Population ≥ 65 years old

Aging Population and Long Term Care
Homes:
• In 2011, the percentage of Canadians seniors living in
Special Care Homes increased with age. ( Census 2011)
0
5
10
15
20
25
30
35
40
65 to 69 years 70 to 74 years 75 to 79 years 80 to 84 years 85 years and over
PercentageofCanadiansLivingin
SpecialCareHomes
Age Group
Men Women Total
*Special care homes refers to nursing homes, chronic care or long-term care hospitals and residences for senior citizens

Aging Population and Long Term Care
Homes:
• In 2014, there were 111 Residential Care Homes in
Saskatchewan with 9,024 residents. The average age was
79 years. 55.7% of the residents were ≥ 85. (Continuing Care Reporting
System 2014-2015)
• In 2014, 49.7% of residents of Residential Care in
Saskatchewan had dementia (6.1% Alzheimer's disease,
dementia other than Alzheimer's disease 46%) (Continuing Care
Reporting System 2014-2015)

Aging Population and Oral Health
Problems:
•Dental Caries
•Edentulism (tooth loss)
•Oral Candidiasis
•Oral Pre-cancerous/cancerous Lesions
•Periodontal Disease
• Xerostomia (dry mouth)

Dental Caries
Coronal Caries:
• Canadians 60–79 years had the highest average DMFT
(15.7) (Canadian Health Measures Survey 2007-2009)
• In 39 Long Term Care (LTC) hospitals in Vancouver area,
on average, 50.4% had coronal caries; and the average
DMFT was 26.6 (Wyatt CC, 2002)

Dental Caries
Root Caries:
• 11% of Canadians 60–79 had untreated root caries (Canadian Health
Measures Survey 2007-2009)
• In Vancouver, the proportion of LTC hospital residents
with root caries was 68.8% (Wyatt CC, 2002)

Edentulism and Denture Stomatitis:
• Canadians 60–79 years had the highest rate of
edentulism (22%) (Canadian Health Measures Survey 2007-2009)
• In Nova Scotia, among LTC residents, 41% were
edentulous; 41% had some mucosal abnormality. Most
of the dentures in lower jaw were non-retentive (59%)
and almost half were unstable (49%) (Matthews DC, et al 2012)

Oral Pre-cancerous/cancerous Lesions
• In Canada, more deaths occur from oral cancer than
from melanoma or cervical cancer. (Canadian Cancer Statistics 2015 ).
• The five-year survival rate for oral cancer is much lower
(68% and 61% in female and male respectively) than the
most common cancers, that is breast cancer and prostate
cancer (Canadian Cancer Statistics 2015 ).

Periodontal Disease
(gingivitis and periodontitis)
• In Nova Scotia, among LTC dentate residents, 67% had
Loss of Attachment (LOA) of ≥ 4 mm at one or more site
(Matthews DC, et al 2012)

Xerostomia (Dry Mouth)
• In a survey in LTC residents of Nova Scotia, the most
common (36%) problem was xerostomia (Matthews DC, et al 2012)
Photo courtesy Peri-Products UK

Importance of Prevention/Detection
of Oral Problems in the Elderly
• Daily removal of plaque is an important factor for the
maintenance of dental, gingival and periodontal health
( Arora V et al 2014)
• Brushing twice a day is the least expensive and most
effective physical method to remove and control dental
plaque (South Australian Dental Service 2009)

• A recent two year follow-up study showed, using fluoride
toothpaste in elderly people slowed down the rates of
progression of both coronal and root caries (Wyatt CC et al, 2014).

• Antibacterial agents such cetylpyridinium chloride
(Perivex) provides protection against dental plaque and
gingivitis. Perivex is non-fluoridated, alcohol free
antibacterial mouth cleaning gel and is highly
recommended for the residents at risk of choking. (Silva MF et al
2009)
• Brushing with mild soap and water is an effective way to
clean dentures (South Australian Dental Service 2009)

Impacts of Poor Oral Health
• Major health, social, psychological consequences
• Economic impacts
• The total cost of poor oral health in older Australians
is estimated to be more than $750 million per year
(Social Development Committee Parliament of South
Australia, 2010)
• Employment of an “oral care specialist” such as a
dental assistant, could result in net cost saving of
more than $300 million annually (Stein PS, 2009)

Limited Access to Dental Services
• It is difficult for LTC residents to access oral care
because dental services are mostly limited to
emergency care within Canadian LTC homes.
(Wyatt CC, 2009).
• Many LTC homes lack space for a dental unit.
• Not all private dental clinics are wheelchair
accessible, or do not meet the demands of
providing oral care to patients with dementia.
(Yao Cs et al 2014)

Daily oral care and basic professional
dental services can:
•Enhance the overall health and quality of life (Dyck D et al, 2012)
•Improve the success of treatment (BC Dental Association, 2011 )
•Reduce dental plaque (Dyck D et al, 2012 )
•Reduce the need for emergency care (BC Dental Association, 2011 )
•Reduce the need for invasive/complex treatment (BC Dental
Association, 2011 )
•Reduce the overall cost of care (Wyatt CC et al 1997, BC Dental Association,
2011 )
•Reduce the progression of oral disease (BC Dental Association, 2011 )

Programs/Services in Canadian Provinces
• British Columbia: The Geriatric Dentistry Program (2002):
The program now offers services to the residents of several
intermediate and extended care hospitals. Oral examinations
and basic oral care are provided at the bedside using mobile
dental equipment, while complex treatment is provided at
University of British Columbia dental clinic, or at clinic within
the hospital.

• Ontario: Halton, Ontario Oral Health Outreach Program
Oral health assessments for individuals entering a LTC home,
or clients living in the community who may require oral
health services is completed. At the time of the oral health
assessment, financial assistance is offered to qualifying
individuals to cover the cost of dental treatment. In addition,
the program maintains a data base of oral health
professionals willing to provide services to clients in their
offices or other settings.

• Alberta: Alberta Health Services – Calgary Zone

Saskatchewan Projects
Background:
During 2007-2008, pilot projects began in Saskatoon and
Regina to provide clinical oral health services to the residents
at LTC homes
• Regina: Santa Maria Senior Citizens Home
• Full dental operatory
• Dr. Maureen Lefebvre
• Saskatoon: St. Ann’s Home and Saskatoon Convalescent
Home
• Portable dental equipment
• Dr. Raj Bhargava

Regina Pilot:
• The College of Dentistry (U of S) partnered with Santa
Maria Senior Citizens Home to provide support for:
o administration
o human resources (dental assistant)
o oral health status/data
o treatment needs

• College of Dentistry, (U of S) partnered with St. Ann’s
Nursing Home/Saskatoon Convalescent Home
• Residents and their families were surveyed on basic oral
health information.
• Saskatoon Health Region – Population and Public Health,
Dental Health Educators provided education to long term
care staff at two long term care homes.
Saskatoon Pilot:

Survey Results:
A 2007 Saskatoon Health Region survey of staff, residents, and
residents’ families showed that:
• 35% of residents were experiencing problems with their
teeth/gums;
• 69% of residents only accessed oral care when there were
problems (mobility was the main reason);
• 64% of residents perform their own daily care; and
• the main reasons LTC staff do not provide daily care to
residents is uncooperative residents, and not enough
time.

Regina and Saskatoon Data:
• Average age 86 (n = 200)
• Male 29%; Female 71%
• Residents requiring dental care: 67%
• Residents with decay: 55% with decay
• Residents with nerve involvement pain and/or infection):
15%

• Residents with own teeth: 50%
• Residents with no teeth: 50%
• Residents with faulty dentures: 46%
• Dentures with no identification: 71.5%
• Average treatment cost* per resident: $137.00
*Included oral hygiene services, treatment (fillings and extractions) and denture
repair

• Staff understanding of oral health issues
increased significantly between pre and
post surveys.
• Staff indicated most challenging aspects of
providing mouth care were:
• uncooperative residents
• not enough time
• not enough/any appropriate supplies

Better Oral Health in Long Term Care:
Best Practice Standards for
Saskatchewan
Since 2011, the Saskatchewan Oral Health Professions
(SOHP) and Saskatchewan Oral Health Coalition have
been collaborating to develop a model for oral health
care in LTC:
• conducted best practice literature review
• developed policies and procedures
• continued data collection
• informed and include other health regions and
providers.

Background:
• In 2011, the Saskatchewan Oral Health Professions
(SOHP) and Saskatchewan Oral Health Coalition (SOHC)
endorsed the use and adaptation of the Australian Better
Oral Health in Residential Care
• Better Oral Health in Long Term Care: Best Practice
Standards for Saskatchewan program was focus tested
in Saskatoon Health Region at Parkridge Centre, in two of
their neighborhoods, in early 2014.

• Better Oral Health in Long Term Care: Best Practice
Standards for Saskatchewan is a train-the-trainer
model teaching the best practices to provide daily
oral care.

• The Parkridge Centre pilot was used as the
model for full implementation in other LTC
homes in Saskatoon Health Region.
• Saskatoon Health Region Population and Public
Health Dental Health Educators provided pre-
assessments, facilitator training, and monitored
implementation.

Portfolios: Educators’, Professional, Staff)
Educators’ Portfolio Professional Portfolio Staff Portfolio

Best Practice Standards for Saskatchewan
Posters and Pamphlets

Oral Health Assessment Tool (OHAT)

Oral Health Care Plan (OHCP)

The oral care costs are included in the $20.25/month charged
to each resident for personal care items. (Pilot program at Parkridge Centre in Saskatoon )
Residents with Natural
Dentition Not Requiring
Assistance:
•Fluoridated toothpaste
($0.72)
•Toothbrushes GUM ($0.52)
•End-Tuft toothbrushes GUM
($0.50)
Residents Needing Assistance or
Having Swallowing or Expectorating
Difficulties:
• Perivex ($1.67)
• Toothbrushes GUM ($0.52)
• End-Tuft toothbrushes GUM ($0.50)
Residents that are edentulous:
•Perivex ($1.67)
•Toothbrushes GUM ($0.52)
•Polident Tablet ($0.11)
Basic Oral Hygiene Supplies

Long Term Care Smiles:
The Journey of Implementing
an Oral Health Program at
Parkridge Centre, Saskatoon

2011 – Yearly treatments

November 2012
Why
re-invent the
wheel?

• The oral health kit is
based on the model used
@ Deer Lodge Centre in
Winnipeg.
Equipment
• Meetings with Material Management to bring products into
our Stores inventory.

MAY 2014

Clinical Nurse Educators used a mannequin with teeth and
tongue to educate the staff and champions of each
Neighborhood/Unit.

Practice
on each
other

Work Standards Developed
(Parkridge Centre Staff Development and Saskatoon
Health Region Dental Educators)
1. Oral Care Routine Assessment:
• Basic assessment process
2. Proper Oral Health in LTC:
• Basic oral care for natural teeth
• Basic oral care for the Edentulous resident
• Oral care for a resident with dysphagia

Presently at Parkridge Centre:
• Oral care has now been implemented on all
neighborhoods (units), staff are practicing oral care
techniques.
• Products have been assigned SKU numbers and can be
ordered through our Saskatoon Health Region
Materials Management (Stores) by the neighborhood
clerks.
• A Dental Assistant visits the neighborhoods weekly to
educate staff, assist with new resident assessments,
conduct 6 month re-assessments and staff referrals to
deal with challenges for oral care of residents. This is
paid by the Saskatoon Health Region.

Daily Oral Care Supply Costs:
• Included are: toothbrushes, toothpaste, Perivex non-
foaming antibacterial gel, denture cups, Polident, and
mouthwash.
• The costs are included in the $20.25 charged monthly to
each resident for personal care items at Parkridge
Centre.
Cost per resident Before implementation After implementation
Standard Toothbrush,
toothpaste, denture cups,
Polident, mouthwash
Toothbrushes (2 types)
toothpaste, Polident,
Perivex, denture cups,
mouthwash
Per resident/month $1.78 $2.83

Update: 2016
• Oct 2015 saw the transition from the pilot project as the
Saskatoon Health Region OHP hired a dental assistant
into the LTC OH Coordinator position.
• LTC OHC has audited/refreshed staff at Parkridge and
implemented Better Oral Health in Long Term Care: Best
Practice Standards for Saskatchewan at Sherbrooke and
Sunnyside
• More LTC homes in Saskatoon Health Region interested
• Saskatoon Health Region LTC Advisory Committee has
the reviewed Better Oral Health in LTC strategy and is
supportive.

LTC - Oral Health Coordinator Role:
•Train staff to provide daily care
•Provide health education and
promotion
•Communicate/liaise with family
•Coordinate/liaise with LTC staff
to expedite effective care
•Coordinate consent/medical
history process as required

LTC Oral Health
Coordinator
Oral Health
Assessment
Tool Kit

Thankful Residents
This particular resident was
having her partial dentures
cleaned every day, but not
her natural teeth!
Notice the big smile after the
care aide has completed her
oral care!
This particular care aide
requested that I visit and
help her become more
comfortable doing oral care
for this resident, who was
new to her area of care.

Love this Smile
This Residents’ body has
stiffened up and he can
no longer care for his
own mouth on his own.
A care aide assists him by
guiding his hand with the
hand over technique, but
some days he can’t grip
his toothbrush at all.
They then provide full
assistance.

Smiles all Around
This resident is happy
he is able to see the
dentist in his own
home, and also that I
have been able visit him
to help him brush and
floss his own teeth
more effectively.
He told me “no one had
ever explained to him
why he should brush his
teeth”.

Before assistance After assistance

Resident that has benefited with the
use of an electric tooth brush
Before brushing After brushing

I have been asked by residents and their
families:
“Why do LTC homes have spaces allotted
for beauty salons
and physical therapy rooms in the planning
of the building development,
but no Dental Clinics ?”

The SOHP and SOHC have developed and
endorsed the following recommendations
for consideration and action by the
Saskatchewan Ministry of Health:

Recommendation #1:
The Saskatchewan Government, Ministry of Health,
endorse the Saskatchewan Seniors’ Oral Health and
Long Term Care Strategy developed by SOHP
collaboratively with SOHC and Seniors Health and
Continuing Care in the Saskatoon Health Region.

Recommendation #2:
An OHC, who is a registered and licensed oral health
professional (minimum of one) , should be employed in each
health region to facilitate the delivery of initial oral
assessments, dental examinations and treatment, daily oral
hygiene for residents and oral health education. The OHC will
work collaboratively with the LTC, multi-disciplinary team to
improve the oral and overall health of residents.

Recommendation #3:
Upon entry into a LTC home, an initial oral assessment must be
completed by a registered and licensed oral health professional, through
the general and medical consent provided by the LTC home.
i. Oral assessments should be routinely performed every 6 months
thereafter, by an oral health professional or a health care
professional trained in oral health assessments.
ii. Non-oral health professionals performing oral health assessments or
care will receive appropriate training developed by the
Saskatchewan Oral Health Professions.
iii. Training will be provided by oral health professionals.

Recommendation #4:
Initial oral assessments will include:
i. Personal client record*, including consent for dental examination
ii. Review of medical and dental history
iii. Complete examination of the oral cavity, which includes:
• Assessment of hard and soft tissues
• Assessment of oral hygiene care
• Oral cancer screening
• Denture assessment
*Note: Implementation of a Saskatchewan electronic health record should include an oral health record.

Recommendation #5:
Oral Health Care Policies and Procedures for LTC and Personal Care
Homes* are standardized and implemented based on best practice for
optimal oral and overall health for residents in LTC in Saskatchewan.
Policies should ensure that every LTC resident has the right and access to
the following oral health care services:
i. An individualized oral health care plan
ii. Basic oral hygiene supplies
iii. Daily oral hygiene
iv. Access to professional oral health services
v. Oral health record included within the health record
vi. Dental recommendations/orders are followed
*Note: As per Section 23 of the current Personal Care Home Regulation (1996), each resident receive a dental
examination, as necessary.

Recommendation #6:
Treatment needs based on the dental examination, may be provided by
dentists, denturists, dental hygienists, dental therapists and/or dental
assistants. Residents may access dental services through their personal
oral health professional or through dental services as available through
the LTC home. Dental examinations require:
i. Consent for dental examination
ii. Treatment plan and progress notes
iii. Estimate and consent for financial responsibility
iv. Consent for treatment

Recommendation #7:
The Saskatchewan Seniors’ Oral Health and Long
Term Care Strategy is incorporated into post-
secondary educational health training programs,
orientation, and continuing professional
development (i.e. for care aides, nurses, physicians,
etc.).

Recommendation #8:
The standard for new LTC homes includes provision for
a treatment room suitable for a variety of health
professionals including access to portable dental
equipment to facilitate dental treatment.
Kitchen/
Dental Clinic!

Recommendation #9:
Surveillance, evaluation and continuous quality
improvement be performed on an ongoing basis to
demonstrate improved health and oral health status
outcomes.

Recommendation #10:
The Saskatchewan government establish a safety net
program to increase access to oral health services for low
income seniors (similar to Ministry of Health
Supplementary Health/Family Health Benefits or Alberta’s
Dental Assistance for Seniors Program through which low
income seniors are eligible for up to $5000 every 5 years for
those aged 65 and older).

Our Provincial Vision for
• Consistent integration of oral health into policy and
practice of LTC homes
• A provincial framework for oral health assessment, oral
health care planning and oral care treatment for residents
• A multidisciplinary team approach to improve the oral
health of the residents

• Improved quality of life for residents who suffer from poor
oral health and nutritional deficiencies
• Regular assessments and oral health treatments
• Residents receiving oral health treatment in the LTC homes
rather than having to face the challenges involved with
travelling offsite for care

• Decreased occurrence of systemic conditions in the
residents
• Decreased health care spending

How can you support
and/or move Better Oral
Health in Long Term Care
forward in your
workplace?

https://youtu.be/OjISugM0Tv8

Thank you!

Saskatchewan Seniors Oral Health and Long Term Care Strategy

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