Closing the Gaps: Improving Oral Health for Older Adults in Nursing Homes
The Mayor of Hollenbeck
I have known this patient since I was a dental student.
Back then, he was one of the most spirited residents at the long-term care facility. He was so well loved by the staff and neighbors alike that they gave him the nickname, “The Mayor of Hollenbeck.” He took pride in everything he did, including caring for his teeth. He came into our dental van every 3-4 months without fail, and for years, his diligence showed. He had great teeth for a person his age.
Then came the falls that led to a transfer to a skilled nursing facility for closer monitoring. Then the medications that brought on severe dry mouth. Without enough saliva to protect his mouth, he developed a fungal infection inside the mouth. Then tooth decay set in and spread faster than I could treat it. He could no longer reach the dental van reliably, and his fierce independence led him to resist help from nursing staff.
By the time we saw the full picture, the damage was irreversible. He needed a full mouth extraction with complete dentures – top and bottom.
His case stayed with me. Looking back, his oral health decline did not happen overnight – it unfolded gradually across multiple transitions of care, in the gaps between the systems that were never quite connected. The question I keep returning to is not who was at fault, but what structures could’ve caught this earlier and what systems can we build so this does not happen to the next patient.
The Silent Crisis
This story is not unique. It is, in fact, devastatingly common.
Oral health is one of the most neglected dimensions of care in long-term care settings. Study after study shows that nursing home residents have dramatically higher rates of tooth decay, periodontal disease, and oral infections than community-dwelling older adults. Yet, oral hygiene is not prioritized during daily care routines, rarely integrated into care plans, and almost never discussed in interdisciplinary team huddles. We chart blood pressures, track weight trends, and monitor HbA1c levels with precision, but we rarely ask, “when did this patient last have their teeth checked?”
Why Oral Health Matters More
Than We Think For clinicians working with geriatric populations, the stakes of neglecting oral health extend far beyond the mouth. The evidence is clear:
Aspiration pneumonia is one of the leading causes of death in nursing home residents, and poor oral hygiene is a well-established, modifiable risk factor (1, 2, 3). A 2022 Cochrane systematic review confirms that oral care intervention can meaningfully reduce the incidence of nursing home-acquired pneumonia, which is the leading cause of mortality among nursing home residents. (1)
Malnutrition and unintentional weight loss are directly linked to poor oral health. (4, 5) Dental pain, ill-fitting dentures, dry mouth, and oral infections make eating a miserable experience. Older adults who cannot chew comfortably will choose not to eat. A 2023 study in Scientific Reports found that nearly half of nursing home residents assessed were at risk for malnutrition, with poor oral health scores directly correlating with worse nutritional status. (4) When we investigate weight loss without examining the mouth, we are missing what could be the most obvious answer in the room. I think of the Mayor of Hollenbeck, who could no longer eat well after his stroke and whose new dentures never quite had the chance to become familiar. I think about many other residents who are sitting in the dining room, pushing food around a plate, for reasons we have simply not thought to ask about.
Poor oral health is also increasingly recognized as a contributor to systemic disease. Periodontal disease has been associated with cardiovascular disease, diabetes, respiratory disease, systemic inflammation, and increased mortality risk (6-8). These relationships underscore that oral health is not separate from overall health. It is an integral part of it.
The Problem is Structural and That Means it’s Solvable
Oral care falls through the cracks because the system is not designed to support it. Most nursing homes lack standardized oral health assessments, designated oral health champions, and formal oral care protocols. Certified nursing assistants (CNAs) who provide the most direct care often receive little training in oral hygiene, aspiration precautions, or caring for residents with dementia and severe functional dependence (9). A 2025 systematic review of 35 studies found that most caregivers reported receiving inadequate oral health training despite recognizing its importance, while a US study identified limited time and high staffing demands as major barriers to provide routine oral care. (9,10)
There is also the challenge of patient autonomy. My patient did not want help. He wanted to do things himself, on his own terms, the way he always had. His independence was something to be respected, not overridden. But honoring that independence also required a system capable of working with him—one that could find the least intrusive, most empowering approach to oral care. We do not have that system. Most nursing homes do not.
Addressing this problem does not mean asking caregivers to work harder or do more with fewer resources. The challenge is not a lack of commitment, it is a lack of practical tools, training, and support that fits into the day-to-day realities of nursing home care. Recognizing this gap, I have been working with partner organizations to develop a resource designed specifically for nursing home settings. The goal is to translate evidence into practical strategies.
The Caregiver Toolkit: Meeting the System Where It Is
The caregiver toolkit that is in development is not another laminated poster in a break room. It is a practical, evidence-based, implementation-ready resource designed around the real constraints of nursing home care. This is built with and for the CNAs, nurses, and caregivers who are doing the work every day.
The toolkit takes a multi-level approach:
For the direct caregiver: step-by-step oral hygiene protocols tailored to different functional levels with specific guidance on positioning, aspiration precautions, product selection, and behavioral approaches for residents with dementia who may resist care. Crucially, the toolkit addresses the discomfort many caregivers feel around providing oral care, normalizing it as a clinical skill as important as any other.
For nurses and charge nurses: a brief structured oral health assessment embedded into admission and quarterly reviews, designed to flag high-risk residents – including those on medications that may cause severe dry mouth, those with new mobility limitations, and those resisting assistance. This will trigger dental referrals or escalation to the care team before damage becomes irreversible.
For the interdisciplinary team: talking points and care planning language that integrate oral health goals into the same framework we use for fall prevention, skin integrity, and nutritional status, making this a team concern and not just a CNA-only task invisible to the rest of the clinical team.
For residents and families: accessible education on why oral health matters in this stage of life, what to look for, and how to advocate for oral care as part of the care plan, including how to have honest conversations with residents who, like my patient, prioritize their independence above all else.
The toolkit is designed to be low-barrier and adaptable to different nursing home contexts. It does not require additional staffing, new equipment, or dental professionals on-site to implement. It requires only what every nursing home already has: people who care about their residents and the knowledge and structure to turn that care into consistent action.
What We Owe Our Most Vulnerable Patients
The residents I care for in the nursing home are not abstract statistics. They are people who spent decades raising families, building careers, and navigating the full complexity of human life and who now, in a moment of profound vulnerability, depend on us to attend to their needs with the same dedication we would want for our own parents and grandparents.
One of the most meaningful parts of the Champion Provider Fellowship has been the reminder that this work does not have to happen in isolation. There are clinicians across disciplines who care deeply about this population and are looking for practical ways to do more.
The caregiver oral health toolkit is my contribution to that shared effort. It is not a complete solution, but it’s a starting point: something concrete that any care team can pick up, adapt to their setting, and begin using. Sometimes what is missing is simply the right structure to channel care more effectively. The Mayor of Hollenbeck deserved better. So does every resident in every facility we serve. Our residents cannot wait for a perfect system. They need us to act now — with what we have, where we are, and the urgency that is needed.
Dr. Lisa A. Hou is a Clinical Associate Professor at the Herman Ostrow School of Dentistry of the University of Southern California and a private practitioner dedicated to the oral health of older adults and medically vulnerable patients. She earned her BS in Gerontology, DDS, and MS in Geriatric Dentistry at USC and completed a General Practice Residency at Rancho Los Amigos Rehabilitation Center, specializing in the care of medically complex and special-needs populations. Dr. Hou is a recognized leader in geriatric and special care dentistry, serving on national professional boards and advocating for equitable, compassionate oral healthcare for aging communities.
References
1. Cao Y, Liu C, Lin J, et al. Oral care measures for preventing nursing home-acquired pneumonia. Cochrane Database of Systematic Reviews. 2022;11:CD012416. doi:10.1002/14651858.CD012416.pub3
2. Ashford JR. Impaired oral health: a required companion of bacterial aspiration pneumonia. Frontiers in Rehabilitation Sciences. 2024. doi:10.3389/fresc.2024.1337920
3. James A, et al. Aspiration pneumonia in nursing literature — a mapping review. Frontiers in Rehabilitation Sciences. 2024. doi:10.3389/fresc.2024.1393368
4. Chou KR, Huang MS, Chiu WC, et al. A comprehensive assessment of oral health, swallowing difficulty, and nutritional status in older nursing home residents. Scientific Reports. 2023;13:19914. doi:10.1038/s41598-023-47336-w
5. Associations among oral health, nutritional status, and care dependency in long-term care. Clinical Interventions in Aging. 2026. doi:10.2147/CIA (accessed via Dove Press)
6. Herrera D, Sanz M, Shapira L, et al. Periodontal diseases and cardiovascular diseases, diabetes, and respiratory diseases: summary of the consensus report by the European Federation of Periodontology and WONCA Europe. European Journal of General Practice. 2024;30(1):2320120.
7. Mendoza MF, et al. More than just a toothache: inflammatory mechanisms linking periodontal disease to cardiovascular disease and the protective impact of cardiorespiratory fitness. Biomedicines. 2025;13(7):1512. doi:10.3390/biomedicines13071512
8. Pink C, Holtfreter B, Völzke H, et al. Periodontitis and systemic inflammation as independent and interacting risk factors for mortality. BMC Medicine. 2023. doi:10.1186/s12916-023-03139-4
9. Pombo-Lopes J, Rodrigues I, Costa J, et al. Health professionals' perceptions, barriers and knowledge towards oral health care of dependent people in nursing homes: a systematic review. Frontiers in Public Health. 2025. doi:10.3389/fpubh.2024.1504542
10. Cluster randomized control trial of nursing home residents' oral hygiene following the Mouth Care Matters education program for certified nursing assistants. PMC. 2021. PMCID: PMC8248067