The Proof is in the Pudding!
We southerners love our idioms and for good reason; they convey wisdom. “THE PROOF IS IN THE PUDDING” is the modern variant of an old proverb that was originally phrased “the proof of the pudding is in the eating.” It means that the worth of something can only be judged within its use. We hope by the end of this article you’ll agree with our title.

Our practice, Mobile Dental Care, is limited to providing dental services to the frail and elderly residents of nursing homes. We use portable equipment and provide treatment bedside. We have been in business since 1982 and, with our present associate dentists, have over 80 years of clinical nursing home experience. We are experienced and thoughtful of the service we provide and how we deliver that service. The question we will try to answer in this article is, “Should we be providing dental services to the residents of long-term care facilities during the COVID-19 pandemic?”

Let’s begin by giving our answers to the following questions: Do they need dental care? Can they medically handle the treatment? These may seem to be rhetorical questions, but they are not. 

The frail and elderly residents of nursing homes are in a natural state of systemic decline. Most of this population suffer from poor dental health/care, which adversely affects their medical presentation through the oral-systemic link.

A high percentage of the nursing home population suffer from periodontal disease and more are suffering from active infection, rampant decay, tooth loss, neuromuscular/TMJ/bite issues, and bone loss, which all contribute/affect the patient’s ability to eat, breathe and swallow. Especially critical are periodontal issues like Porphyromonas gingivalis which contribute mightily to aspiration pneumonia (a leading cause of hospitalization and death in nursing homes) (Benedyk). Untreated, the diseases of the oral cavity further contribute to a patient’s medical decline, co-morbidities, and immunodeficiency. This decline is not easily recognized because it can take months or years for the full effects to manifest. 

So, we are providing medically necessary dentistry to improve the residents’ medical presentation and oral health quality of life (OHQoL). The literature is rather replete in the support of those concepts now, but it was not 38 years ago when we started the practice. 

Older adults are… a growing patient demographic for dental practices. Although around 5% of adults older than 65 years are edentulous, increased numbers of older adults are retaining their natural teeth compared with previous cohorts. 2  According to a 1999-2004 National Health and Nutrition Examination Survey (NHANES), approximately 18% of adults aged 65 years or older with retained natural teeth have untreated caries 3  while a 2009-2012 NHANES found that 68% of these patients have periodontitis. 4  Consideration of the overall clinical and oral health context of aging patients is important in order to provide optimum dental care (Department of Scientific Information, ADA Science Institute).

Realistically, you also might be amazed by how much ageism, ignorance, and inattention exists toward this population. Additionally, the elderly population have low expectations, their pain status is a mystery due to cognitive compromise and an inability to express themselves, and oral healthcare, especially daily oral hygiene, is, at best, difficult on a medically complicated/compromised patient, and, unfortunately, usually an after-thought in frequently understaffed nursing facilities.

As to the question: “Can they medically “handle” the treatment? The answer is, surprisingly: extremely well! “While thousands of patients benefitted from restored teeth, improved oral function and appearance, none suffered a significant general health set-back as a result of routine or emergency dental treatment. Nursing home residents generally tolerate both the processes and outcomes of routine oral care services very well” (Michael J. Helgeson DDS).

Now, let’s answer the question: “Why are we seeing residents on-site (within a nursing facility); why not take them to a local dentist?” It is our opinion that most of the residents of a skilled nursing facility cannot, will not, or should not travel to a private dental practice or dental clinic. Our decision to see the patient on-site and bedside, therefore, was/is made based on necessity, not convenience. Not only does this population not travel well, it’s also prudent that their medical status remain under the management of the facility medical and nursing staff, and the cost of transportation would be cost-prohibitive.

We have provided on-site care since the founding of Mobile Dental Care. We have evolved over the years; improving our equipment, techniques and continuing to develop better, safer standard operating procedures that meet the needs of our setting. Because we helped pioneer this vocation, we have made it a priority to create a safe environment for our patients and our staff. We always use Universal Protection concepts and Personal Protective Equipment and have standard operating procedures that address infection prevention and cross-contamination issues.

We believe we are on the right path by providing on-site dental care within the facility. We are advocates for this population and have witnessed time and time again, the benefits of the care we provide. 

So, back to our main question, “Should we be providing dental services to the residents of long-term care facilities during the COVID-19 pandemic?”
Providing essential dental services for nursing home residents is as relevant now as any other time! Additionally, providers and their teams must follow well thought out standard operating procedures:
  • Screen to begin each day by taking their temperature/fill out symptom questionnaires.
  • Follow all of the nursing home’s screening procedures on entry. 
  • Limit the number of facilities and patients seen each day.
  • Continue to use universal precautions, appropriate PPE.
  • Address infection prevention and cross-contamination issues.

If the dental providers follow these steps, the risk they present will be much lower than many of the other caregivers within the facility.
The proof is in the pudding!

For nearly eight weeks, we have been providing essential dental services to our patients. We have had no COVID-19 related cases within our staff or patients. The care we deliver has improved the lives of our patients by reducing infection/dysfunction, allowing them to eat, breathe, and swallow better. It may be that one of our patients will contract the SAR-COV-2 virus, and our hope and prayer is that, because of the care we’ve provided, they will be able to survive.

POSTSCRIPT: We realize there are debatable concepts in this article, so, we welcome responses/reactions from the SCDA members. SCDA editors would also like to share your reaction to our point of view, as well. Thank you!

Benedyk, Mydel, Delaleu, et al. "Gingipains: Critical Factors in the Development of Aspiration Pneumonia Caused by Porphyromonas gingivalis." Journal of Innate Immunity (2016): 185-198. Web access.
Department of Scientific Information, ADA Science Institute. Aging and dental health (Geriatrics) . 2 July 2019. 6 May 2020.
Michael J. Helgeson DDS, Barbara J. Smith RDH, MPH. "Dental care in nursing homes: Guidelines for mobile and on‐site care." Special Care in Dentistry 18.4 (1996): 153-164. Document.

Article presented by:
1)     Michael J. Reed, DDS, FAGD, FASGD, Diplomate ABSCD
-President-Elect ABSCD
-At Large Member SCDA Board of Directors
2)     Eric A. Northey
-COO/IT Mobile Dental Care
-an Air force veteran, has been in the dental industry since 1992. His emphasis and passion are the oral health systemic link and oral health quality of life (OHQoL).