Summer Dolezel

Rachel Hopson
Kimmie Poe
Jennifer Shoemaker

Development of Oral Health Program

Needs Assessment
A. General Data:
1. High Hope Care Center, located at 475 High Hope Road Sulphur, LA 7066,
is a retirement community for patients aging in range from 49-99. They
are dedicated to meeting the physical, emotional and social needs of their
residents in an environment that feels like home.

2. Description of services offered

This skilled nursing facility provides the services needed to enhance the
quality of the residents lives as well as care for their special needs with
dignity and compassion. Some of the amenities provided are basic cable
television, beauty parlor and barbershop, and transportation services to
and from medical appointments. They also provide nursing services such
as medical management, wound care, IV therapy, respiratory care,
diabetic management, prosthetics, and rehabilitation. They offer quarterly
dental services for all residents or as needed. They have a dietary and
special nutritional needs management counselor and offer support
services such as showering, dressing assistance, walking, eating, and
other life activities. They also have social and recreational activities such
as movies and games. Religious services are also available to all
residents. (1)

3. Description of the target group

Our client population is the nursing staff and certified aides to the nurses.
The total amount being. Our target population is the male residents
aging in range from 46-99 with some remaining natural teeth. There is a
total of 25 male residents in our target group. The most prevalent
ethnicity in our target population is Caucasian. Only 3 out of 25 residents
brush their teeth twice a day. The other 22 residents are incapable of
independently brushing and need assistance from the staff. Out of 25
residents, only 1 is capable of flossing; however, he chooses not to. This
means that none of our residents floss. Among our residents there are 8 in
which they have some kind of removable appliance and only 6 clean their
appliances daily. The other 2 residents clean their appliance once a week.
The majority of our target population takes medication that can have
negative effects on their oral cavity.
4. Description of Staff Population

The executive director is overseeing our agency. There is an array of

nurses on site. The staff nurses are RN, LPN, and CNA. The RNs are in
charge of assessing and implementing the residents care and treatment
while working with the LPNs. RNs help develop the final outcome of the
facilitys residents. All the nursing home employees are required to be
licensed in Louisiana. Each RN has a minimum requirement of 2-6 years of
education while LPNs typically have 1 year of education. Each CNA is
required to undergo nurse assistant training within 4 months of
employment. CNAs work under licensed nurses and typically help in
maintaining the well-being and health of the residents. They help the
residents in tasks such as eating, grooming, bathing, hygiene, and using
the bathroom. There is also a qualified Dietician on site. The Dietician is
federally qualified by the American Dietetic Associations Commission
(ADAC) on Dietetic Registration. The other training is in education and
implementing dietary planning and needs. The Dietician oversees food
service at the facility. This entails meal planning and a complete, overall
balanced diet for each resident. There are other staff on site such as 2
secretaries, 4 maintenance workers, and an IT tech. However, this staff
does not play a direct role in daily activities among residents. Their main
agenda is to maintain the function and appearance of the nursing home.
(5)

5. Other important data

High Hope Care Center residents, as a whole, have a predominantly low

overall dental health knowledge. High Hope Care Centers water supply
comes from the city of Sulphur. It is a community water supply system
that flows at optimal fluoride concentration of 0.7ppm. (8) The residents
oral health education is what one would classify as old school and their
views and values are fixed. For example, many were taught to use hard
toothbrushes, floss only when something is caught in their teeth, and
preventative dentistry was unheard of. Until their values of oral health can
be identified, their habits on oral health will remain the same.

6. Information related to dental health

No transportation is needed because all treatment is provided at the

facility. As for preventative measures a Dentist and Hygienist go to the
facility 4 times a year to care for the residents. The LPNs assist the
residents with brushing, flossing, and removable appliance maintenance.
There has not been an Oral Health Program presented to this facility.

7. Constraints and alternative strategies

 1. Constraint: The staff and residents may not seem interested in the
lesson or not deem it valuable based on their own preconceived
knowledge of oral health care.
Alternatives: Explain to the staff and the residents the importance of
maintaining good oral hygiene by using visual aids and typodonts.
2. Constraint: The staff may not want to participate due to time
constraint
Alternative: Alert the staff on the planned time needed and have
presentation organized with most important data first.

Goal:

To create and implement an oral health program that will train the nurses
and nursing aides in increasing residents overall oral health.

Objectives:

To increase the awareness of the nurses of dental health and the

needs of the residents by DATE
To decrease the plaque level of the residents by .5 by end of the
program
To reduce gingival bleeding index by 5% by end of program
To educate the staff on the importance of proper brushing, flossing
and prosthesis maintenance.
To demonstrate proper brushing/flossing on a typodont.
To provide each resident with written instructions on each lesson
taught.
To evaluate the plaque and bleeding indices. (2)

Rationale:

In todays world, people are not only living longer but are also keeping their
natural teeth longer. Preventative oral health care is a relatively new topic.
Overall, the prevalence of both partial and total tooth loss in seniors have
decreased from the early 1970s according to the latest survey of the National
Health and Nutrition Examination Survey (1999-2004). Despite this
improvement, significant disparities remain in some population groups. Men
statistically retain their natural teeth longer than women, and people over the
age of 65 have an average of 18.9 remaining teeth. (3) Root caries is a major
cause of tooth loss in older adults, and the loss of these teeth is the most
significant negative impact on their quality of life. Nearly half of all adults age
75 and older have had or experienced root decay. You can see the roots of
your teeth when your gums have shrunk from gum disease, brushing too hard
or incorrectly, and also some age-related gum changes. This exposed root
surface is much more common in older adults and this is when you
experience root caries. This part of the exposed tooth does not have the
protective enamel so they are more prone to cavities. This can then spread
to the inside where the nerve of the tooth lies and cause a toothache or
infection. Older adults are more likely to be taking medications that can
cause dry mouth and since saliva is our natural protector, when there is
less saliva there is a greater chance of getting cavities. Another reason
elderly patients have trouble taking care of their mouth could be due to
medical problems such as loss of eyesight, dexterity issues like arthritis or
stroke. This increases their risk of not realizing there may be food debris or
plaque stuck on tooth surfaces adding to their cavity risk. (6)
A study was conducted by the International Journal of Dentistry (IJD) in 2011
regarding elderly at greater risk for developing root caries. They discovered
that root caries is one of the most significant problems in elderly today. The
elderly is at risk for root caries due to dentures/partials, lack of dexterity, a
shift from complex to simple sugars, and poor oral hygiene. (6)
A common problem among denture and partial wearing individuals is denture
stomatitis, also known as oral thrush. This is when the normal flora in the
mouth is altered and a yeast or fungal infection is able to thrive on the
mucous membranes of the oral cavity. Diabetics, individuals taking steroids,
or antibiotics are at an increased risk for developing thrush. If untreated the
condition can cause soreness in the mouth and may lead to poorly fitting
dentures in the future. The treatment for this condition is good oral hygiene,
keeping your dentures as clean as possible, and medication if necessary. (7)

1. Session 1 (week 1)
a. Executive Administrator and Head Nurse
i. Presentation of oral health program
ii. Discuss target population and needs of patients
iii. Give head nurse the letter of confirmation of oral health
program
iv. Discuss importance of good oral hygiene and preventative
regimen for patients
v. Administer Oral Health Survey
2. Session 2 (week 2)
a. Nurses and Nurse aides
i. Present the overall oral health program for the patients
ii. Use pamphlets given to us Oral B to discuss periodontal
disease
iii. Test the level of education with a pre-test for the nurses and
nurses aides
iv. Discuss the importance of good oral hygiene and the
importance of daily plaque removal
v. Discuss the importance of properly cleaning removable
devices
vi. Ask if there are any concerns/questions

This session will require an hour and will only need the nurses and
nurses aides.

8. Session 3 (week 3)
a. Nurses and Nurse Aides
i. Pre-test about proper brushing technique and preventative
methods
ii. Discuss the pretest using a PowerPoint presentation
iii. Demonstrate proper brushing and flossing techniques on
typodont
iv. Evaluate the nurse and nurses aides on their ability to
properly brush and floss on a typodont
v. Disclose them
vi. Evaluate the nurse and nurses aides on their ability to
properly brush and floss on their own teeth
This session will require an hour and a half and will need the
nurses and nurses aides.
9. Session 4 (week 4)
a. Nurses and Nurse Aides
i. Review topics from prior session
ii. Discuss periodontal disease and importance of prevention or
halting pamphlet.
iii. Demonstrate how to properly clean prosthesis
iv. Demonstrate how/when to use Polydent cleaner

This session will take an hour and a half and will need the nurses and
nurses aides.
10.Session 5 (week 5)
 a. Nurse, nurse aides, and residents
i. Review previous topics (brushing/flossing frequency,
periodontal disease, Polydent tablets, removable prosthesis
care)
ii. Post-test on the review topics for the nurses and nurses
aides
iii. Observe nurse and nurses aides brush and floss the
residents
iv. Observe the nurses and nurses aides on proper prosthetic
cleaning
v. Leave survey for administrators, managers, nurses, and
nurses aides to reflect on the oral health program and need
for improvement

This session will require a 1-2 hours and will need nurses,
nurses aides, and 1 resident per nurse.

Budget:
Toothbrushes- donated by Colgate Pharmaceuticals
Toothpaste- donated by Colgate Pharmaceuticals
Denture brushes- donated by LIT
Polydent- donated by LIT
Disclosing tablets- donated by LIT
Ziploc bags- $3.00
Brochures- Free
Gloves-Free
Mask-Free
Protective Eyewear-Free
Tongue Depressors-donated by LIT
Gauze- donated by LIT
Floss- donated by LIT
Mouthwash- $5.00
Cups- donated by LIT
Total: $8.00
Time Table:
1st visit: Tuesday February, 7th 2017 at 2:30 pm
2nd visit: Tuesday March, 28th 2017 at 2:00 pm
3rd visit: Tuesday April 4th 2017 at 2:00 pm
4th visit: Tuesday April 11th 2017 at 2:00 pm
5th visit: Tuesday April 18th 2017 at 2:00 pm

Evaluation:

Formative Evaluation:
1. Meet with all the non-residents once a week to ensure that all needs are met
during the OH program
2. Survey on basic oral health status given to residents by nursing staff
3. Pre-test on basic dental knowledge prior to any lesson or activity
4. Assess the needs of the population by observation
5. At the end of each session, a verbal Q and A will be given to assure
competency

Summative Evaluation:
1. We will provide the non-residents with a dental resource list that will provide
dental treatment.
2. The Executive Administrator will contact the local dentist to assess the rate of
utilization for restorative services for the residents.
3. Residents will be provided with a post-test to assess their learned oral health
knowledge.
4. We will provide the Executive Administrator with a questionnaire that will
allow her to assess the success of the Oral Health Program. This will also
allow her to offer any suggestions or changes that she deems helpful to the
overall success of the program.

Appendix
Oral health survey, program evaluation, pretest, posttest
Oral Health Pre-test
1. What is plaque?
A. Sugary food
B. Sticky white film on your teeth
C. Staining on your teeth

2. What causes plaque?

A. Sugary foods or carbohydrates
B. Smoking
C. Medications

3. What causes cavities?

A. Frequent consumption of sugary foods
B. Protein
C. Eating less sugar

4. How can you prevent cavities?

A. Brushing/flossing regularly
B. Drinking sugary beverages through a straw
C. Drink more milk

5. Why is fluoride important?

A. It's not important
B. Restores teeth and makes them strong
C. Prevents bone loss
Summary: 2nd visit
Tuesday March 28, 2017 2:00 PM

On March 28, 2017 we implemented our project. We arrived at the site around 1:50
PM and discussed amongst each other before entering the establishment our
lesson. We assigned each student their part in order to maintain a flow once we
were with the nurses and aids. You must be buzzed in the front door to enter the
site. Once we were inside High Hope Care Center, we were met by the Executive
Director, Mary Rainwater. She introduced herself, as this was the first time we had
met in person. She was unable to be at the site on our initial assessment visit. We
explained to her our intentions and goals for our program. We told her we were
going to begin our Oral Health Program and target the nurse population that works
directly with the 24 male residents on site. We explained to her that a big part of
our profession was promoting education and access to care. She agreed that the
nurses and residents would benefit from our information and said she would like to
sit in with us as well. We were directed to their sun room in the center of the site
where there were 2 couches and 2 chairs with a large table in the center. We were
met there by 5 CNAs (CNA1 Head Nurse, CNA2, Kelly, Taylor, and Alex), one of
which was the head CNA of the hall. The hall is the wing on the site that the
male population resides on. We began with an introduction of each of us. We said
our names and that we were students form the LIT Dental Hygiene Program in
Beaumont, Texas. We told the CNAs that we were implementing an oral health
program at their facility to help aid in the training of the population assisting with
the male residents to increase their overall oral health. We will increase the
awareness of the need for good dental health of the residents. We explained that
this session is an introduction to promote oral health and create a mutual
understanding amongst our staff population. We told them that by increasing their
awareness of dental health and educating them on the importance of brushing and
flossing, we will decrease their plaque level.

Initially, the staff of CNAs seemed very timid and even annoyed at our being there.
We began this lesson with the pre-test created. We passed the test out and
explained that we wanted a baseline of where each nurse was with their own oral
health knowledge. They each sat on the couches and chairs around the table. Jenny
and Kimmie sat in between two of the CNAs, Summer sat next to the other CNA and
Rachel stood. Overall the CNAs did well on the pre-test. The questions they missed
were the question on what causes plaque. &&&&&&&&& put that smoking causes
plaque. &&&&&&&&&&&&&&&& put that . We discussed each of the questions
from the test and went over each of the correct answers along with addressing the
incorrect answers. We did this all without pointing out which CNA had missed one.
Our objective here was not to make the CNAs embarrassed about their lack of oral
health, but to increase their oral health knowledge. After we finished our discussion
with the pretest, we asked if there were any questions. Alex stated that they were
only able to brush the residents teeth once a day. This was a perfect opportunity to
explain plaque. Rachel used the flip-book to discuss what plaque was, how it
forms and how important it is to remove it. We told them that if they were only
going to brush the residents teeth one time per day, then the night nurses should
be the ones to do this. Kelly looked very puzzled and said Well what about stinky
breath in the morning? Why brush them at night? They are just going to bed. So,
we began our use of the pamphlets to discuss periodontal disease. First, Jenny used
our Oral B pamphlet to discuss the basic components of the periodontium. She
discussed the umbrella of periodontal disease and how it begins with gingivitis.
The CNAs seemed extremely interested at this point. After going over the process
and how destructive but preventable the disease is, we began our discussion on
brushing. Kimmie used the typodont to show each CNA proper brushing techniques.
Kimmie explained that small circular motions were good and to maintain light
pressure. She also said to make sure that they are brushing the residents tongues.
Taylor (CNA) said Why are we brushing their tongue??! Summer explained that it
harbors plaque and bacteria just the same as their teeth and causes bad breath.
Kimmie went over the 45-degree angulation needed to have the sweeping action
along the gums to aid in removal of the plaque that is down below the gums.
Kimmie passed around the two typodonts and we worked with each CNA to ensure
they were understanding the proper technique. CNA1 said its hard to get the
residents to spit the toothpaste out and she sometimes just skips brushing because
of it. Rachel explained that in those cases, using warm water and the toothbrush is
just as good. Jenny explained that since there is some mechanical brushing, it
doesnt matter if they used toothpaste. Jenny explained that the toothpaste does
however have fluoride in it, but if the residents are not capable of spitting the
toothpaste out, then to not use it. Rachel asked if they CNAs knew what fluoride
was and each CNA said yes. Rachel explained that in a few minutes she was going
to go over Fluoride. Summer then asked if they were flossing the residents? The
answer was no, by all the CNAs. They said that it was near impossible to floss them
without being bit or the residents choking. We explained that there are many floss
aides on the market, and showed them several pictures of some. They all stated
that they were unaware of the aids and that would help them floss the residents.
Summer told the CNAs to hold their hand out flat in front of them. She said to close
their fingers together tight. Then she said now imagine we poured honey all over
your hand. Summer asked them if they thought they would be able to wipe it all off
with a wipe. Most of them said yes. However, Summer then told them to open their
fingers. Each CNA then smiled. Summer explained to them that flossing is what gets
off all the plaque and debris in between their teeth. She told them that 40% of the
bacteria remains on the residents teeth if they arent being flossed. Rachel then
went through each item in the flip book including plaque, brushing, flossing,
gingivitis, periodontitis and fluoride. We than asked the CNAs how often they are
cleaning the residents removable devices. CNA1 and CNA2 said they asked the
residents to take them out and put them in their holders with water in them but
some do and some dont. Jenny explained that it is extremely important to not only
be removing the residents removable devices but manually cleaning them. We
briefly discussed denture stomatitis and candidiasis but realized with were
beginning to lose the interest of the CNAs. We thanked each CNA for their time and
they were dismissed. We then shook Mary Rainwaters hand, thanked her for her
time as well, and we left.

We were at our site for just over an hour. We had 6 overall participants. Strengths of
the program were that pamphlet, the flip-book, typodont and Summers visual on
flossing. The pamphlet was a great aid to our program because it not only has
pictures, but goes through the anatomical structures of the periodontium. This
helped our target population understand the effects of not properly removing
plaque and its destructive nature. All of the CNAs said they were unaware of the
irreversible bone loss that occurs below the gumline. Being able to show them
pictures of the change in structures from gingivitis to periodontitis was very
valuable. The flip book was extremely beneficial to our discussing the importance of
flossing, brushing, and plaque. Rachel was able to go into more detail about
Fluoride using the flip-book. The pictures for each category got a good bit of
discussion started amongst our target population. The typodont was a vital tool for
Kimmie teaching the CNAs proper brushing techniques as well as showing them the
anatomical structure of the mouth. Summers visual on flossing using her hand and
imaginary honey being poured over it was great! We could see immediately the
realization on each of the CNAs faces.

A weakness of our program we experienced was that the sun room we were in
was noisy. It is a common area for residents and staff to congregate so that was an
issue. We would recommend using a more intimate setting or smaller room so there
are not as many distractions. A smaller, more quiet room would be a more ideal
setting. We did request a sink for our next visit so perhaps we will be in a different
room.

Our outcomes of our objectives were succeeded. We educated the target population
on what plaque is, where it comes from, and how important it is to remove it. We
succeeded in showing them proper brushing techniques and the importance of
flossing. We discussed the need for the residents appliances to be removed each
night and the importance of proper cleaning to avoid bacterial and/or fungal growth.
We were able to make the learning aspect of this program fun by making small
jokes about how fun it is to brush other peoples teeth and how difficult it was for
each of us to learn on each other. Overall, this visit was a success!

Summary 3rd visit: april 4, 2017

Lesson plan for visit 3:
4/4/17
 1. Meet with the following CNAs: member1, member 2, Alex, Taylor, Kelly.
2. Go over previous session: what plaque is, proper tooth brushing, flossing, and
periodontitis.
3. Have the CNAs brush their teeth in the restroom.
4. CNAs will come back and we will let them chew on a disclosing tablet.
5. They will spit in the cup.
6. We will give them a mirror for them to look at what they missed while
brushing.
7. Then we will take a plaque score on each CNA.
8. After we evaluate each score, we will let them brush off the remaining
disclosing solution.
9. After they properly brush the pink solution off, we will end the session with a
brief discussion about what we will teach on next visit, which will include:
importance of halting periodontal disease, how to properly clean prosthesis,
and how to use polident cleaner.

Summary of visit 3:
4/4/17

Today, when we went to High Hope Center, we met with the following CNAs
as the previous visit: member 1, member 2, Kelly, Taylor, and Alex. To start the visit
off, we went over the previous gathering, which included: what plaque is, proper
tooth brushing, flossing, and periodontitis. We asked if anyone could tell us what
plaque is. Kelly told us that it is a sticky substance that makes your teeth feel fuzzy.
Then we asked how long one is supposed to brush his or her teeth. Taylor said one
should brush his or her teeth for two minutes, morning and night. Then, Jenny
asked why is it important to floss? Alex stated that its important to get food out of
your gums. No one could tell us what periodontitis is. We re-instated that it is bone
loss and its irreversible and our job is to halt the progression of the disease. After
our recap of last weeks lesson, we proceeded to todays lesson. We had each CNA
go to the restroom and brush their teeth. They came back and we gave them each
a disclosing tablet. A barrier we faced today was some were skeptical of the
disclosing tablet; another barrier was the lighting made it hard to see in our CNAs
mouths. A few thought it would taste bad; however, each one went to the bathroom
and disclosed and spit in the sink. When each CNA came back, we let them look in
their mouth with a mirror. We pointed out the spots they missed when brushing
their teeth. Then we took a plaque score on each CNA. Member 1 had a plaque
score of 1.3%, which is considered good. Member 2 had a plaque score of .66%,
which is considered good. Alex had a plaque score of 1.83%. Taylor had a plaque
score of 2.16%, and that is considered fair; and Kelly had a plaque score of .83%,
which is considered good. After we evaluated each of their plaque scores, we had
them go to the restroom and remove the excess staining. The CNAs were amazed
at what proper versus improper tooth brushing can do. To end the session, we told
them what we are going to talk about next week, which is, the importance of halting
periodontal disease and how to properly clean prosthesis and use polident clean
 Reference
1. "Skilled Nursing." Charleston Healthcare Group. N.p., 27 Oct. 2015. Web.
14 Feb. 2017.

2. Nathe, Christine N. "Dental Public Health and Research." 9780134255460 |

Dental Public Health and ... | Knetbooks. N.p., n.d. Web. 14 Feb. 2017.

3. National Institutes of Health. U.S. Department of Health and Human

Services, n.d. Web. 14 Feb. 2017.

4. "Root Decay." Wisdom Tooth Project. N.p., n.d. Web. 28 Feb. 2017.

5. Presented by Paul & Perkins PA. Nursing Home Abuse Guide. N.p., n.d.
Web. 27 Mar. 2017.

6. Hindawi. Elderly at Greater Risk for Root Caries: A Look at the

Multifactorial Risks with Emphasis on Genetics Susceptibility.
International Jounral of Dentistry. Hindawi Publishing Corporation, 06 July
2011. Web. 27 Mar. 2017.

7. Mouth Conditions > Denture Stomatitis (Thrush). We are the Oral Health
Foundation. N.p., n.d. Web. 27 Mar. 2017.

8. City of Sulphur, Louisiana Homepage. Water Treatment / City of Sulphur,

Louisiana. N.p., .d.Web. 27 Mar.2017.