Cause Advocacy Project: Advocating for the Removal of Toothettes or Foam Swabs in
Residential Facilities
Submitted by:
Trish Morales
Sharon Leung
Priscilla Kaljanac
Cause Advocacy: SWOT Report
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Aspiration pneumonia is one of of the main causes of death in residential care
facilities. (1,2) Developing aspiration pneumonia involves bacterial species normally found in
the oral cavity traveling into the lungs and becoming respiratory pathogens causing an infection.
(1) The need for better oral hygiene management in residential care facilities have been
established in the literature. (1-3) The use of toothettes or foam swabs have been popular
especially in such settings due to its convenience and reasonable price however, there is a
concern regarding its function. Due its inefficiency in removing plaque effectively, using
toothettes have been deemed inadequate for oral hygiene management. (4-6) This report
highlights the strengths, witnesses, opportunities and threats relating to the situation of residents
in care facilities that are still using toothettes.
The target population is residential care facilities in the Fraser Health Authority
(Burnaby/New Westminster area). This cohort has 15 residential care homes of which 5 currently
uses toothettes or foam swabs. The residential care facilities are: Normanna Rest Home, Dania
Home, St Michael’s Centre, Fair Haven United Church Homes and Buchanan Lodge.
Strength of the situation
Being situated in such a controlled setting such as a residential facility means that
the residents have a proper and convenient way to accessing health care. A residential facility
usually is staffed with a variety of health professionals who are skilled in their own practices. A
resident is also regularly seen by nurses and care staff who ensures that all their daily medical
needs are met. Since aspiration pneumonia is a huge concern especially for a vulnerable
population like seniors, an issue that involves this disease is going to be important not just for the
resident but for everyone who provides them care in the facility. (1,2) This could significantly
reduce any risk of harm that could develop from using toothettes or foam swabs for the residents.
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Weakness of the situation
Residents in care facilities lack the ability to manage their own oral health
therefore, this responsibility usually falls in the hands of the care staff. It has been mentioned
that one of the significant issues regarding oral health management for residents is the lack of
training and dental knowledge of the care staff. (7-9) Oftentimes, care providers in residential
facilities may not know how to properly implement oral hygiene to residents due to lack of
information. (7-9) There could also be lack of awareness regarding the implications of such
practices (ie. the use of toothettes) that could be harmful to the residents. One other factor is that
residents can oftentimes be resistant to the care, making it harder for the care staff to implement
proper oral care. (10)
Opportunities in the situation
Advocating for the completer removal of toothettes can reduce their risk of
developing aspiration pneumonia. It has been found that there is an association between oral
health status and incidence of aspiration pneumonia. (11,12) It has been shown that toothettes are
inefficient in completely removing bacterial plaque and debris in the oral cavity therefore
eliminating and replacing these products can greatly improve the health of the residents. (1,2)
Increasing the awareness then of the care staff in the targeted facilities is an important
opportunity to give light to the issue. Also, providing alternatives to toothettes or foam swabs is
ideal in order to make it easier for the care staff to replace them. A good replacement for
toothettes are small toothbrushes. It has been shown in the literature that toothbrushes are far
more effective than toothettes in removing oral debris and improving gingival health status. (4,5)
Threats in the situation
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A possible threat could be cost effectiveness. It may be that toothettes are an
inexpensive choice for an oral health product which may make residential care facilities more
hesitant to change. Residential care facilities that have not encountered health problems with
residents that have used toothettes may not be receptive to the idea right away. It can be that the
care staff also does not have the choice to what oral health products are supplied to their
residents which means that the issue has to be taken with the management of the residential care
facilities.
Advocacy Goal
Eliminating the use of toothettes within five residential care homes in the Fraser Health
sector. Namely, Normanna Rest Home, Dania Home, St Michael’s Centre, Fair Haven United
Church Homes and Buchanan Lodge.
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Rationale for Goal
Toothettes are one of the alternative oral health aids used in residential care. However,
toothettes are shown to be ineffective as oral health aids and are also a potential choking hazard.
(4,5) With the elimination of toothettes, paired with the introduction and education of alternative
oral healths aids to replace their use, health promotion in terms of building healthy public policy
and reorienting health services will be the focus of this advocacy issue.
Key Message
Protect the family you love, by better educating yourself about their oral health.
You want only the best health care possible for those that can no longer take care of themselves.
Part of overall health, is oral health.
A toothette, which is actually a stick with a sponge attached, may be used to clean an elder’s
mouth. But did you know that it it dangerous to use this? Toothettes are hazardous because the
sponge component presents a choking hazard if it detaches from the stick during cleaning..
There are many other alternatives which are more effective, such as toothbrushes, which do an
equally if not better job at cleaning the teeth and mouth.
3 Points to Support Key Message
1) Toothettes are hazardous because the heads can detach from the sticks during use and pose a
choking hazard. (13) They can also induce dysphagia and aspiration pneumonia, which is of
particular concern because it is one of the most common infections in seniors living in residential
facilities. (14,15,16)
2) Toothettes are not effective in removing plaque debris from teeth surfaces compared to a
manual toothbrush. (4,5,17)
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3) Toothettes could easily be replaced with small headed toothbrushes (kids toothbrushes) which
are safer and more effective.
Key groups/people who support initiative
Resident Care Manager (or person in charge of care at the operations level): Responsible for
residents’ care. Health of residents is his/her ultimate concern. This person would support
better/safer practices.
Care Director (Ultimate head of care decisions) – Makes the ultimate approval for policy
changes, but would be in favour of any policy change that reduces health risks and liability to the
facility.
In house/contracted Residental Dentist/Hygienists: Oral health is the primary concern. Dental
professionals would support better, more effective and safer practices.
Registered Nurses – Want patients to be healthy. Residents cannot be healthy if they cannot eat
properly. Would support safety of patients (avoid choking hazard). They would want to avoid
dealing with a medical emergency.
Care Aides – Attentive, caring staff that should be willing to make the change to make the
residents lives better.
Family – Health, comfort and well-being of their family is their primary concern. They would
support better care/safety.
Key groups/people who may oppose the issue
Care Director (Ultimate head of care decisions) – May be against change if staff such as care
aides raise concerns about changing policies, or if the change to toothbrushes are more expensive
and impact the budget negatively.
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Care Aides – May express some concern about changing policies. Aides may find it very
difficult to clean residents teeth with their limited time.
Toothette Manufacturers – May be against change if toothettes are a more profitable revenue
stream than toothbrushes.
Supplies clerk (or other person in charge of ordering supplies) – May have already established
supplier relationship and may not want to change
Actions
In order to advocate for the complete removal of toothettes in the five residential care
facilities under Fraser Health, there is a need to increase the awareness of everyone that is or
could be involved in the care of a resident. A letter is going to be sent to the administrative body
of each of these care facilities. This letter highlights the implications of using toothettes and
foam swabs as well as the recommended alternative option. This letter was made to increase the
awareness of the people in these care facilities who have the power to remove toothettes in the
facility. A possible newspaper article discussing the issue and its possible effect on the senior
population is also going to be published. This article was written in order to make the public
aware of the issue especially those who have family members who are in residential care
facilities that use these products. By making the family members of these residents aware, we are
increasing pressure in the care facilities to heed to our cause.
Communication Pieces
Letter to the Director of Care for each of the residential facilities
278 - 2199 Wesbrook Mall
Vancouver, BC V6T 1Z3
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March 8, 2012
Dear Resident Care Director,
We are fourth year dental hygiene students from the University of British Columbia. It has come
to our attention that your residential facility is using oral toothettes in the daily cleaning of
residents’ teeth. We commend you for your commitment to your residents’ oral care, but would
like to educate you on the risks of using toothetttes and recommend an alternative.
Toothettes, otherwise known as oral sponges or swabs, are unsafe for use as a tooth cleaning
tool. This is because the foam heads can detach from the sticks and present a choking hazard.
In fact, toothettes should never be used for cleaning teeth, but rather should only be used for
wiping the soft tissues of the oral cavity or to apply moisture in the mouth.
Second, toothettes are poor at removing bacterial plaque from teeth. Toothettes leave behind
more oral bacteria than manual toothbrushes, and this excess bacterium that builds up in the
mouth will lead to cavities and gum disease. Gum disease is a very serious condition. In the
latter stage of gum disease, which is called periodontitis, the supporting bone and gum that hold
the teeth in place are forever damaged. This causes the teeth to loosen or fall out, and affects how
a person bites and eats.
Oral bacteria may also aggravate heart conditions, cause conditions such as dysphagia
(swallowing difficulties), and ultimately find its way into the lungs, where it can cause an
infection called aspiration pneumonia. This should be of particular concern to your facility
because it is one of the most common infections afflicting seniors living in residential facilities.
For these reasons, we recommend that you remove toothettes from your facility and transition to
manual toothbrushes for cleaning residents’ teeth. We recommend the use of small headed
toothbrushes, such as children’s toothbrushes, especially for resistant residents who are most
likely to cause a foam head to detach from the stick. Once again, toothbrushes are much safer
and more effective alternative to toothettes.
Thank you for considering our proposal. For more information on how to make the switch to
manual toothbrushes, please do not hesitate to contact us by email:pkaljanac@interchange.ubc.ca
or by telephone: 778-9956870. We would definitely like to meet with you to discuss this matter
further. We hope to hear from you soon.
Sincerely,
Priscilla Kaljanac, Sharon Leung and Trish Morales
UBC Fourth Year Dental Hygiene Students
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Newspaper Article
Toothettes. A Friend or Foe to the Elderly?
In residential care, health care aides and nurses hold the majority of responsibility in
caring for the seniors which live in these homes. Included within their responsibilities, these
professionals are involved with oral care. Due to their physical limitations, elders oftentimes
find it difficult to clean their teeth and mouth properly.
A health care provider may use a toothette which appears as a stick with a small
sponge-like material attached to the tip and is used to clean the teeth and mouth of the senior.
However, this tool presents a choking hazard and is unnecessary since there are many other
alternatives which are safer and more effective. Also, toothettes do a poor job at removing the
bacteria and deposits which build-up on the tooth surfaces. These tools tend to leave more
bacteria and build-up than when using a regular toothbrush. Therefore, without proper cleaning
of the teeth and gums, this may eventually lead to the development of gum disease.
Research studies have found that gum disease may be associated with the development
of other diseases that may have a negative effect on the senior’s overall health. One disease in
particular which can lead to life threatening complications is aspiration pneumonia which is
when the lungs and airways become inflamed because of various irritants that become trapped
and build-up in these areas.
Aspiration pneumonia is particularly common in the elderly and therefore any
measures to prevent this form occurring should be pursued. Using alternative cleaning aides
help to further ensure the health and safety of the elders being cared for in these residential
homes.
Toothbrushes with smaller heads such as children-sized toothbrushes is a good
alternative to toothettes. They are not only safe but effective in removing the bacteria and buildup on the teeth and gums. The smaller head allows for easier access to elderly patients who have
difficulty in opening their mouth.
Your older relatives deserve to have the best health care available. The care given
includes taking care of their teeth and gums which now many are discovering how the health of
your mouth is closely linked with your overall health. Knowing the facts help to better care for
your elderly loved ones.
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