Mobile Treatment of Geriatric Patients by Dr. Rich Bailey

This Townie made his “dream job” come true, and explains not just why but how

by Dr. Rich Bailey

The first time I screened patients in a nursing home, I felt like I’d stepped into a fourth-world country: I saw angry tissue, food impaction and caries everywhere I looked (Figs. 1–3, p.?68–69). Who was responsible? How did it get this bad? How do we fix it?
Not knowing where to start, I took some continuing education courses on geriatric dentistry and noticed a few things immediately:

1. The dental industry has done a lot of research on why seniors are so vulnerable, but no one has created a reliable system to prevent these problems. (More on this later.)
2. It also seems that equipment designers didn’t have senior citizens in mind when they designed most mobile equipment. For example, most seniors hate the cold, so what’s going to happen when you bring a patient in her 90s out into a parking lot in February to get into your dental RV? Transferring her out of her wheelchair inside your vehicle is a whole other problem.
3. Most importantly, very little training exists on how to create an efficient workflow in a mobile setting—it’s a very different animal. And if dentists can’t see how they can earn a living at something, they’re not likely to do it.

I wanted to help these precious seniors, because I get a real kick out of them: They’re authentic and quirky—past the stage of trying to sell you or impress you. I knew I would enjoy serving them if I could overcome these challenges.

Chairside treatment— in different chairs
I started experimenting with equipment first. I quickly discovered that a great way to irritate a senior citizen is to have him sit in a mobile dental chair. (One patient told me, “I feel like I’m sitting on a two-by-four!”) And once you’ve upset him, you can forget about dentistry.
Next, I tried a machine that tips seniors back in their wheelchairs—which was great for them, but terrible for me. The machine had a wide base, so it kept me stooping and cranking my neck. For another period, I brought in a conventional dental chair on a pallet jack. It worked, but it felt like football practice moving the equipment.
Finally, a colleague suggested that I try an electric wheelchair. That was it! These chairs are part taxi, part dental chair; I drive it down the hall to pick up my patients, then wheel them back to the operatory I’ve set up in an extra room at the care facility.
I also discovered that seniors tend to have swallowing problems and are much happier if you don’t tip them back far in the chair. So we do stand-up dentistry, which works because these electric chairs are designed to elevate up to a comfortable height for the dental team.
Although mobile headlights work, I think they’re on par with driving a Ford Pinto so I fashioned a mobile stand that holds a post-mounted dental light at the right height for doing dentistry in this setting (Fig. 4, p. 69). In the same photo, you see a delivery unit in the background; if you want to keep seniors happy while you’re doing stand-up dentistry, you must have a delivery unit that’s tall enough and has hoses that are long enough to easily reach the mouth. I use the ASI 2025, which is rugged and reliable. These bigger pieces of equipment can be moved in a van or equipment trailer, and typically stay at each nursing home for a couple of weeks at a time.

Rethinking how dentistry’s delivered
As I treated more patients, I learned other tricks to make the workflow more efficient. I learned that putting seniors on a schedule just wasn’t a good idea. When we told people they had an appointment the next day at 9 a.m., they wouldn’t sleep well, they’d pace, they’d show up way too early, and quite often their appointment didn’t go well.
So one day I tore up the schedule—instead, I just looked for who was awake and wasn’t playing bingo or watching Gunsmoke. They didn’t have time to stress, and the appointment was over before they knew it.
Another breakthrough came when I stopped using a hygienist. Hygienists do a great job, but most seniors cannot tolerate the kind of prophy that hygienists are accustomed to providing. (Not to mention the added overhead and downtime of herding seniors into the chair for multiple visits.)
I also found that once seniors were accustomed to the gentle vibration of a prophy cup, it was an easy transition to start excavating caries—very similar vibration, if the right technique is used. And often there is very little vitality left on older teeth, so restorative work is primarily done without anesthetic, which eliminates drama. Seniors who have advanced dementia or Alzheimer’s disease often don’t know they’ve had any restorative work done!
Over time, I also learned the best way to approach patients, administrators, staff and families—words, phrases and names matter. There are too many lessons learned to list them all, but with time everything became smooth and efficient.

Advantages and challenges
From a business perspective, there are several advantages to running this kind of practice.
• Profitability: $1,500–$2,500 net income per day.
• Flexibility: Work part time or full time.
• Low startup cost: $40,000–$60,000 and extremely low daily overhead (15 percent).
• Low stress: Primarily noninvasive care, with no set schedule.
More importantly, there is incredible job satisfaction in helping older patients and their families. When they know that you have their best interest in mind, they hose you down with love and appreciation every day. It is a dream job.
Now, back to the biggest challenge: prevention. (I told you I would get to it.) To fix this problem, one must understand the contributing factors, so here they are:
• The administrators and nurses who are ultimately responsible for a prevention program have little to no dental training, and are eternally distracted with their other responsibilities.
• The CNAs who are responsible for performing daily oral hygiene quite often have poor oral hygiene themselves and have received little to no training for this task, and also are multitasking constantly.
• There is incredible job turnover in this industry.
• There are too many CNAs “making the stew”; therefore, there’s no consistency or standard of care when it comes to daily oral hygiene.
• They aren’t using the right stuff, such as toothbrushes specifically designed to help caregivers brush a resident’s teeth.
• Aspirational pneumonia, caused from aspirating the oral bacteria, is literally killing some patients (and also costing taxpayers an average cost of $21,338 per hospital visit, per Katzan, et al. 2003).

Strategies for success
After many failures in trying to solve the prevention problem, I’ll tell you what finally worked for me.

1. I periodically overwhelm the administrators with good intraoral photos of the dental train wrecks who are under their care. I also gently remind them of state laws already on the books that mandate daily oral hygiene in their facility.
2. Every chance I get, I tell family members that their loved ones are at a stage where they need help with their brushing and flossing, and I encourage them to reach out to the administrator. (It’s like a political campaign!)
3. When they finally agree to a structured prevention program, we hand-select two or three of their best CNAs who could provide care on a daily basis. I equip them with the right toothbrushes (Collis Curve are my favorite), floss, interproximal cleaners and chlorhexidine (to prevent pneumonia)—and I train the heck out of them.
4. We maintain accountability. The hand-selected CNAs send my office a text every day, letting me know how many residents they saw. This lets me know if someone flakes out or when we need more training. We send the administrators a monthly report, and bill $500/month for maintaining the program. People don’t value what they don’t pay for.

That’s my story and I’m sticking to it. I’d love to see more dentists take an interest in serving seniors, and would love to hear from readers who have questions, comments or ideas!