ORAL HEALTH OF OLDER ADULTS IN BRAZILIAN NURSING HOMES: CASE REPORT INVOLVING THE DEPARTMENT OF PUBLIC PROSECUTION SAÚDE BUCAL DE IDOSOS EM INSTITUIÇÕES DE LONGA PERMANÊNCIA NO BRASIL: RELATO DE CASO ENVOLVENDO A ATUAÇÃO DO MINISTÉRIO PÚBLICO

The poor oral health of older adults, living in nursing homes (NH), affects their quality of life, requiring government protection in favor of the collectivity and to defend the social and individual rights of Brazilians. citizens This study reports a case investigated by the Department of Public Prosecution of Rio Grande do Sul/Brazil, which received complaints about the care provided to the residents of a nursing home, including oral care, which was unsatisfactory. A multidisciplinary team carried out visits to the institution and analysis, with professionals in the medical, nursing and dental fields. No mistreatment was confirmed, but dental healthcare revealed poor hygiene conditions that leaded to the confection of a Term of Conduct Adjustment (TCA), to be implemented in the inspected institution. Nevertheless, some of the elder residents still presented unsatisfactory oral health conditions, with some necessary action inside the institution to enhance the quality of life for this group.


INTRODUCTION
The number of older adults living in nursing homes (NH) has been increasing in many countries (JUNGES et al., 2014). Therefore, the Department of Public Prosecution (DPP) has an important civil role, protecting collective interests, and guaranteeing and defending the social and individual rights of the Brazilian society (2) (3) (4).
Oral diseases associated or not with systemic diseases are common in NH. Loss of dexterity inherent to ageing directly hinders dental and denture hygiene, facilitating the development of many diseases in older adults (Chalhoub et al., 2014) since specific microorganisms are associated with aspiration pneumonia and vascular diseases (ADACHI et al., 2002) (EL-SOLH et al., 2003).
In addition to pneumonia, the rates of partial or complete edentulism, periodontal disease, and xerostomia in older adults is high (Leung et al., 2014), hence the need of reexamining the oral hygiene practices of this population (LEIBOVITZ et al., 2003).
Considering the need to inform and communicate scientific approach and good results achieved between the multidisciplinary health professional task force and the responsible for the ILP, together with the participation of Public Ministry in situations of collective an social interests, the objective of this case report is to discuss the oral health conditions of older adults living in NH in Rio Grande do Sul (RS), Brazil (BR), listing the reasons for poor oral health and proposing measures that improve the oral health of this population.

CASE REPORT
The present study was approved by the Research Ethics Committee of FOP-UNICAMP (OF.CEP/FOP Nº 003/2011). It reports the action of the Department of Public Prosecution (DPP) of the State of Rio Grande do Sul against a NH. The DPP had received complaints of nighttime sedation and possible abuse from the residents' family members.
The first assessment was made by a multidisciplinary health team consisting of two physicians, one nurse, and one dentist. The study NH housed 26 older adults aged 60 to 101 years with various degrees of dependence, two of which were entirely dependent. All older adults were examined and their daily drug prescriptions reviewed.
The older adults' physical and mental health was compatible with their ages. The use of excessive sedation or signs of abuse were not confirmed. However, oral health assessment revealed poor hygiene, unsafe storage of tooth brushes and paste (Figure 1).
After the first assessment, the team proposed the implementation of an oral hygiene protocol integrated with the other services, to compose the NH's list of activities. A document called Term of Conduct Adjustment (TCA) forces the NH to implement and follow the protocol and to keep specific individual dental records.
The protocol proposes included the following procedures: A. Tooth brushing twice a day and cleaning the tongue once a day, by the caregivers or older adult himself; B. Extraoral denture cleaning at least once a day; C. Denture removal after each meal to rinse in tap water and remove debris; D. Denture removal at night to allow tissue relief and aeration. The denture should be placed in cup with water; E. Edentulous adult's mouth and tongue cleaning with moist gauze; F. Weekly complementary denture cleaning by immersing denture overnight in a 0.02% sodium hypochlorite solution in a lidded container. The denture must be rinsed before use and the hypochlorite solution discarded; G. Individual tooth brush cleaning, drying, and storage in a safe place.
After the TCA was signed, the NH was inspected by technical assistants (dentists) two more times at roughly 45-day intervals. The new assessments again found poor oral hygiene evidenced by food debris on the dentures, partly disagreeing with the proposed protocol. Some protocol items were re-explained to the caregivers. But improvements were also noticed, such as better storage of dentures, and tooth brushes and paste (

DISCUSSION
TCA implementation, legally supported by the DPP, was a practical and functional option for the NH, considering its socioeconomic status. The NH has depended for years on the monthly payments made by the older adults' family members and on the voluntary help of drugstores, which donated pharmaceuticals. Issues, such as, abandonment, loss of close relatives, family conflicts and the necessity of constant health supervision are frequent motives that lead older citizens to seek for shelters. (DE LARGA;DE ADAPTACIÓN, 2008).
The Brazilian Constitution of 1988 (BRASIL, 1988 ) which aims to protect and ensure service quality and to control the sector responsible for older adult health, affirms that not only the family, but also the society and the State, are responsible for sheltering their older adults and for guaranteeing the dignity and wellbeing of people older than 60 years (CAMARANO; KANSO, 2010;DE CARVALHO, 2014). In other countries, such as the United States, government reports show the inefficiency of NH rules in promoting better health care in many nursing homes, resulting in lawsuits (LOLLI et al.;TROYER;THOMPSON, 2004;DE CASTRO PINTO;VON SIMSON, 2012).
Another legal instrument, Board Resolution (RDC) nº 283/05 of the National Sanitary Surveillance Agency, responsible for regulating NH in Brazil, requires NH to establish a minimum service standard for older adults, such as employment contracts and resident care, and to have enough employees to meet the degree of dependency of its residents (ANVISA, 2007). The number of employees of the study NH was inadequate: only two for 26 older adults with various degrees of dependence. At least two more employees should be hired for proper care.
Malnutrition, abuse, and incorrect pharmaceutical use are factors strongly associated with progressive health deterioration (Poisson et al., 2014), which increases dependence in activities of daily living and care cost (SINGH et al., 2014). Although the presence of these factors was not confirmed, the oral condition of the residents was unsatisfactory, evidenced by poor denture maintenance and clinical condition of the remaining teeth. These findings may have a negative impact on resident health because of the possible association between poor oral hygiene in institutionalized older adults and the occurrence of anaerobic aspiration pneumonia (EL-SOLH et al., 2003).
It is a fact that older adults need assistance in all aspects of daily living and it could not be different with respect to oral hygiene, making the presence of properly trained professionals critical (MEHL et al., 2014;DOS SANTOS TAVARES et al., 2017). Even though many of the cases of abuse are difficult to be noticed by general dental surgeons, (SILVA et al., 2017), the multidisciplinary team has recorded, after clinical and physical exams, insufficient practices of basic oral care, despite the fact that the caregivers considered that the proper care was being offered with adequate regularity.
Many dental problems present in older adults are complications caused by the accumulation of pathological processes that occur throughout life. The main oral changes found in the Brazilian population are dental caries, periodontal diseases, abrasion, various lesions, oral cancer, and tooth loss (Roncalli, 2011). These changes may vary according to the institutionalization status of these individuals (CARNEIRO et al., 2005).
In face of the findings, the study NH was forced by the DPP to implement the TCA, distributing functions and responsibilities to their staff, which included: advising the residents about oral and denture cleaning, performing mechanical cleaning to remove plaque followed by chemical cleaning using specific products to remove and kill microorganisms (Nishi et al., 2014); storing tooth brushes individually; recording of all dental events in specific forms.
Although the activities proposed by TCA can be relatively easily performed by the employees, subsequent inspections found partial noncompliance with the protocol. One explanation is that improved oral health in nursing homes requires changing the behavior of residents and especially, of caregivers, in addition to implementing educational and assistance strategies that promote a multidisciplinary intervention in the health-disease process of vulnerable individuals (ROCHA; MIRANDA, 2013), which is a challenge for NH.
O presente relato traz uma solução viável em relação à adequação das ações e cuidados com a saúde de idosos que vivem em instituições, por meio da implementação do TAC, resultando não somente na recuperação de saúde bucal dos indivíduos residentes, mas também gerando um impacto positivo na qualidade de vida dos mesmos. The present report, provides a valuable solution, concerning the adjustment of actions and oral care to older residents of institutions, by using the TCA to both educate and enhance services with the aim on better health. Performing a rigorous oral hygiene protocol could not only reduce the colonization of the oral cavity by potentially pathogenic organisms but also provide caregivers with technical data for the gradual and continuous improvement of their skills, so that they may provide the residents with more comprehensive care.

CONCLUSION
Using an oral hygiene protocol, the DPP intervention improved the quality of care provided to the residents of the study nursing home. However, the oral hygiene of the residents remained unsatisfactory. Improving the quality of life of this group requires ongoing educational activities, including actions that promote oral health and prevent problems; training caregivers so that they can carry out the proposed protocol; and adjustment of the number of health-related human resources in compliance with the legislation.