Katherine Ford visited her father, Dean Piercy, a World War II veteran with dementia, at a nursing home in Roanoke, Va., for months before she noticed the dust on his electric toothbrush. His teeth, she found, had not been recently brushed, so she began doing it herself after their lunches together.
But after he complained of a severe, unrelenting headache, she said, she badgered the staff to make an appointment with his dentist. The dentist found that a tooth had broken in two, and he showed Ford the part that had lodged in the roof of her father's mouth.
"I was livid," said Ford, 57, a court reporter. "I'm there every day, pointing out he's in pain and he had dental insurance. So there's no reason this wasn't addressed."
Many nursing home residents suffer from cavities, gum disease and cracked teeth, in part because their mouths are not kept clean.
While residents require more dental care than in the past, nursing home employees are rarely prepared to provide it. Aides are swamped with other tasks, and when elderly charges must be helped to the toilet, fed or repositioned in bed, brushing teeth often falls to the bottom of the to-do list.
Even when care is available, few staff members are trained to cope with the rising numbers of residents with dementia who resist routine dental hygiene.
"I always say you can measure quality in a nursing home by looking in people's mouths, because it's one of the last things to be taken care of," said Dr. Judith A. Jones, head of the department of general dentistry at Boston University.
The neglect can lead to terrible pain for the residents. Worse, studies suggest that this problem might be contributing to another: pneumonia, a leading killer of the institutionalized elderly.
The lack of daily oral care in nursing facilities is "an epidemic that's almost universally overlooked," said Dr. Sarah J. Dirks, a dentist who treats nursing home residents in San Antonio.
There are no current national assessments of oral health in nursing homes, but since 2011, at least seven states have evaluated residents using a survey developed by the Association of State and Territorial Dental Directors. One was Kansas, where dental hygienists examined 540 elderly residents in 20 long-term care facilities. Nearly 30 percent of the residents had "substantial oral debris on at least two-thirds of their teeth," according to a Kansas Bureau of Oral Health report.
More than a third had untreated decay.
The screeners saw plenty of fillings and crowns but concluded that "regular dental care has become a thing of the past" for many of the elderly residents.
In Wisconsin, nearly 1,100 residents from 24 homes were examined. About 31 percent had teeth broken to the gums, with visible roots; 35 percent had substantial oral debris.
The problem has been graphically documented in state and federal inspections of nursing homes. In Texas, inspectors noted one resident in too much pain to eat, her lower gums red, swollen and packed with food.
A 2006 study of five facilities in upstate New York found that only 16 percent of residents received any oral care. Among those who did, average tooth brushing time was 16 seconds. Supplies such as toothbrushes were scarce, the report said.
At the Raleigh Court Health and Rehabilitation Center in Roanoke, where Piercy was a resident, administrator Mark Tubbs, said in a statement that he could not discuss Piercy's case because of federal privacy laws.
"All patients receive medically necessary, high-quality care, including oral care and hygiene," Tubbs said.
Just as nursing home workers are expected to help residents bathe, or reposition them to avoid bed sores, they are supposed to brush the teeth of residents who can't do it themselves. This is so important that it was federally mandated in the Omnibus Budget Reconciliation Act of 1987, which set new nursing home standards.
"They should be getting their care, but a lot of people don't," acknowledged Dr. David Gifford, the senior vice president of quality at the American Health Care Association, a trade group representing two-thirds of nursing homes nationwide.
Nearly two-thirds of those who stay in a facility long-term have dementia, and many resist oral care, clenching their mouth shut or even trying to hit aides. The National Institutes of Health is financing research to address such resistance among nursing home residents with dementia.
Many prescription drugs - including antidepressants, medications for high blood pressure, and anti-seizure medications can reduce saliva and dry out the mouth.
Without daily oral care, elderly people taking such drugs are especially prone to "a relatively rapid deterioration," said Dr. Ira Lamster, a dentist and a professor of health policy at the Mailman School of Public Health at Columbia University in New York.
But even when elderly residents and their families know that better oral care is needed, paying for it can be a challenge. Medicare does not cover routine dental care like cleanings and fillings. Most states provide at least some dental services to adults on Medicaid, but coverage varies widely and finding a local dentist who accepts Medicaid payments can be difficult.
Some companies are offering new solutions. Apple Tree Dental, a nonprofit practice in Minnesota that serves about 100 nursing homes, provides routine cleanings by dental hygienists for residents. More than 30 states let dental hygienists provide some treatment without specific authorization from a dentist, according to the American Dental Hygienists Association.