Dentists, Dentures and Eating Support: Notes from the Front Lines of Eating Support (1)

Written by: 五島 朋幸 (Dentist)

Dentists and eating: how do you connect the two?

Take the complaints people have about their dentures, for example: “It hurts when I bite,” “I can’t bite things off properly,” “They come out while I’m eating.” When you think about it, all of these are complaints about eating. And it isn’t only dentures; people say the same things about their natural teeth. That’s right: dentistry is the profession of eating.

I started making home visits as a dentist in Shinjuku, Tokyo, in 1997. I was a young man of 31. Even so, I was in my seventh year as a dentist and could handle a fair range of treatment, yet I had never imagined how closely dentistry is tied to eating. Complaints such as “it hurts,” “I can’t bite through” and “they come out” all got reduced to denture problems; I never thought of them as problems of eating, something that shapes a person’s daily life and even their whole life. Only when I visited people at home, stepped inside and sensed the smells and the atmosphere did I begin to see their lives, and beyond that, the problems with eating.

I have now been working at the front lines of eating support for more than 20 years. Let me say this first: simply taking in a little of the knowledge I share here and becoming a little more aware of eating will certainly change how you and your family eat. Eating is living. Please take an interest.

Dentures that had been taken out

I started making home visits in November 1997. It began with something quite small.

At the time, I was working in the Department of Prosthodontics at the university hospital of my alma mater. It specialized in dentures, and I hoped one day to become a dentist who was good at making them. Then I happened to meet an internist who made home visits in the community. He said to me, “Doctor, there are no dentists in home healthcare. Won’t you please get involved?”

To be honest, I didn’t really understand what he meant. Today you often hear about dentists making house calls and home visits, but back then there was almost nothing of the kind, and my own view was little more than, “Is there anything a dentist can do for bedridden older people?” Still, I was curious, so I decided to accompany the internist on his visits for a few days.

My first experience of home healthcare was a shock. Every one of the so-called “bedridden” people had had their dentures taken out. One hundred percent of them.

At that time, it was standard practice to remove dentures as soon as a patient was admitted to hospital, “because it’s dangerous.” Hospital stays were also long, unlike in today’s acute care hospitals, so dentures stayed out for months and were handed back only at discharge.

Dentures that have been out for a long time no longer fit and can’t be used. When someone’s health changes suddenly enough to need hospitalization, dentures can stop fitting after just one week out. Once, when I visited to adjust the full dentures of someone who had just been discharged, they fit so badly that I asked the family to check whether the hospital might have mixed them up with someone else’s. Of course, they were the patient’s own. That is how much things can change.

If the person recovered after discharge and their regular dentist repaired, adjusted or remade the dentures, they could use dentures again. But if they remained bedridden, they had to live without their dentures.

In fact, there were two problems with dentures at the time. One was the problem of “dentures that had been taken out,” described above. The other was the problem of “dentures nobody noticed.” The mouth is a private space, not something we show others without reason. The same is true within the family: people don’t tell even their families what state their teeth are in or what treatment they have had. As a result, it often happened that when someone became bedridden, their caregivers didn’t even know they wore dentures. Some dentures had not been taken out for years.

Behind “There’s no particular problem”

But there was an even bigger problem. At each home, the internist I accompanied kindly asked, “This gentleman is a dentist. Is there anything you need help with?” Every answer was, “There’s no particular problem” or “We’re fine.” This was despite the fact that denture problems were clearly there.

Back then, the thinking was: “Eat what you can eat. When you can’t eat anymore, blend it and drink it. If that doesn’t work, an IV drip, and if that doesn’t work either, a tube through the nose…” In other words, if you had no dentures, you could just have puréed food. That was because the reality was that once you were bedridden, you couldn’t go to the dentist, and dentists didn’t make house calls.

As someone working in prosthodontics, I thought, “If it’s a denture problem, I can solve it. I’ll make home visits!” I was working Monday through Saturday at the time, so I started home visits using only my days off, never imagining that from that day on I would go more than a decade without a day off…

Of course, I remember the first person I visited. She was an elderly woman with full dentures in both the upper and lower jaws. The air was fresh and different from a clinic; I was right there in the place where she lived. And the first thing I asked her was:

“Once your dentures are fixed, what would you like to eat?”

“Abalone.”

“…Abalone, you say…”

It was a start full of challenges from the very beginning.

Oral care and eating

When I began making home visits, Japan was at a major turning point. Amid the shift “from hospital to home,” the Long-Term Care Insurance Act was passed, and exams for care managers began in preparation for its implementation. Against this backdrop, oral care began to attract attention because it was expected to help prevent aspiration pneumonia.

I had started visiting to put taken-out dentures back in, but oral care soon became part of our role as well. We were professionals at brushing to prevent tooth decay and gum disease, but we had never even heard the terms “aspiration pneumonia” or “oral care,” and at first we didn’t know what to do.

Even so, the mouths of patients at home were in a dreadful state. They received no oral care at all in hospital, and as the function of the mouth declined, it became dirtier and dirtier. Many people had not only plaque and tartar but also food that seemed to be several days old still left in their mouths.

Today, oral care has become established and mouths are far cleaner than they were then, but the level of care still can’t be called sufficient. There are two problems.

In old age, brushing becomes difficult surprisingly early

The first is that older people lose the ability to brush their teeth thoroughly on their own surprisingly early. Picture the movement of your hand when you brush your teeth. You move the brush from right to left and turn it around quickly, don’t you? These movements are surprisingly difficult for older people. Even people who were very conscientious about brushing become unable to control the brush well and can no longer care for their teeth properly. The family may think, “Mom brushes for five whole minutes every day,” when in fact she isn’t really brushing her teeth clean.

No one is looking inside the mouth

The second is a problem with the system for supporting brushing. The mouth is a private space, and people may not want to show it. Awareness of oral care among family caregivers and care workers also still can’t be called high. As a result, situations arise in which no one provides care even though the mouth is in poor condition.

The real reason oral care can prevent aspiration pneumonia

So why can oral care prevent aspiration pneumonia? In fact, there is a widespread misunderstanding about this. Most people believe that “oral care reduces bacteria in the mouth, so it prevents pneumonia.” That effect certainly exists, but in fact stimulating the mouth thoroughly through oral care improves the ability to swallow.

When the ability to eat has not declined, chewing food well stimulates the mouth. But people who are not eating by mouth for some reason receive little stimulation, and their ability to swallow also declines. Stimulating the mouth through oral care improves that function again and helps prevent aspiration. That is how oral care helps prevent aspiration pneumonia. In other words, oral care means improving the environment of the mouth and enhancing the ability to eat.

From eating support to multi-professional collaboration

My home-visit practice started with putting taken-out dentures back in, but I soon took on care for dysphagia (difficulty eating and swallowing by mouth) as well.

Dysphagia began to attract attention in Japan in the mid-1990s. At the time, the field was in its infancy; it was a discipline that had only just arrived. In dentistry we learn a great deal about mastication (chewing), but I had never even heard about swallowing disorders as a student, so I started from zero.

What’s more, rehabilitation for eating and swallowing at the time focused mainly on hospital inpatients, and there was almost no training that could be done at home. So, at the front lines of home visits, I gradually achieved results by devising training that fit people’s daily lives and could be done at home. And I became convinced that what dentistry can offer in home healthcare rests on three pillars: dental treatment centered on dentures, oral care, and rehabilitation for dysphagia.

Then one day, a woman caring for her husband said something to me that came as a shock.

“Dr. Goto, thank you. When you feed my husband jelly, that is the only joy he has in life.”

Of course, when I visit, I can judge whether he is able to eat and help him eat with proper assistance. But on days when I wasn’t there, no one had been able to feed him. That was when I first felt the limits of what dentistry alone can do.

Supporting eating requires much more than the environment of the mouth and the ability to eat. Many elements are involved: managing the person’s overall health, posture during meals, the surroundings (such as tables and chairs), food texture, and even preparing meals and helping the person eat. There is no way dentistry alone can cover all of this.

In fact, there were professionals to support each of these: doctors and nurses to manage overall health, physical therapists to adjust posture during meals, welfare equipment specialists to arrange the surroundings, registered dietitians to adjust food texture, and others. When these professionals who support eating work together in the community, the community’s eating is protected.

Today, Shinjuku in Tokyo, where we work, has the Shinjuku Eating Support Study Group (Shinjuku Shoku Shien Kenkyukai), made up of 160 members from more than 20 professions (at the time of writing). Eating is life itself. Eating support is support for life.

---

About the author: 五島 朋幸 (Dentist)

Born in Hiroshima in 1965. Graduated from the School of Dentistry at The Nippon Dental University in 1991 and began providing home-visit dental care in 1997. Head of Fureai Shika Goto (Fureai Dental Clinic Goto) since 2003. PhD in dentistry. His roles have included clinical associate professor in the Department of Oral Rehabilitation at The Nippon Dental University Hospital, lecturer in the Department of Dental Hygiene at The Nippon Dental University College at Tokyo, and part-time lecturer at Tokyo Medical and Dental University. Representative of the Shinjuku Eating Support Study Group. Since 2003, he has hosted the radio program “Doctor Goto’s Passionate Home-Visit Clinic.” His books (in Japanese) include Oral Care: Dos and Don’ts (Chuohoki Publishing) and Home-Visit Dentist Doctor Goto 1: The Dentist Comes to Your Home! (Osumi Shoten). (Profile as of the time of writing.)

This article is a contribution from a medical or care professional, re-edited by our editorial team. It provides general information as of the time of writing, and symptoms and circumstances differ from person to person. For specific decisions, please consult your doctor, dentist, pharmacist or another professional.

This is an English translation of a column originally published in Japanese by Next Co., Ltd.

About Next Co., Ltd. We are a Tokyo-based company working in Japan’s senior care and end-of-life planning field. Alongside these expert columns, we publish professional training textbooks and support businesses entering Japan’s eldercare market. More expert columns | Our English textbook | Contact us