Dental care of frail older people and those caring for them

[Geriatric assessment in dentistry : A review of chewing function tests]

Due to increasing life expectancy and the associated demographic changes, more and more people are dependent on care. To identify a possible need for dental treatment, chewing function tests as assessment instruments have proven their effectiveness. In this article, the reader is given an overview of existing chewing function tests and their implementation. It is important that a patient with pain should be presented to a dentist immediately, regardless of whether a chewing function test is performed. Furthermore, chewing function tests are not a substitute for routine dental examinations, but they could provide information to (dental) laypersons as to whether an appointment should be arranged in a dental practice or whether a dental consultation is necessary.

Homebound oral care for older adults: A qualitative study of professional carers' perspectives in Perth, Western Australia

OBJECTIVE

To examine professional support workers and case managers' (professional carers) perspectives of what promoted or compromised oral health care in homebound adults aged over 65 years in Perth, Western Australia and identify professional carers' need for support in this context.

BACKGROUND

Accessing dental services can be difficult to navigate and unaffordable for homebound older adults. Paid carers often play a substantial role in facilitating access to services yet there is limited qualitative evidence of the perspectives of these stakeholders.

METHODS

Given limited evidence in this area, this simple qualitative study was informed by constructivist grounded theory. Participants comprised 15 professional carers of homebound older adults. Transcripts were analysed to identify participant perceptions of key barriers and enablers to providing oral health care.

RESULTS

Barriers to clients accessing dental care included participants' uncertainty around navigating the dental system, low priority of oral health care, affordability and confusion around who was responsible to provide oral care. Enablers included participants supporting clients' autonomy around oral care, better integration of oral care into primary health care and education and opportunity for training for professional carers.

CONCLUSION

Ensuring oral health is part of primary health plans, clarifying roles and responsibilities around delivering oral health care to homebound older adults and training carers were key findings. Inter-sectoral collaboration between the dental and aged care sectors can benefit dental practitioners and professional carers in shared learning and has likely flow-on effects for homebound older adults.

Comprehensive Geriatric Assessment and Quality of Life Aspects in Patients with Recurrent/Metastatic Head and Neck Squamous Cell Carcinoma (HNSCC)

To define frailty in older cancer patients, the aim of this study was to assess the geriatric status and quality of life (QoL) aspects in patients suffering from recurrent/metastatic head and neck squamous cell carcinoma (r/m HNSCC) under palliative treatment. A comprehensive geriatric assessment (CGA) was performed on 21 r/m HNSCC patients at two defined assessments, and the QoL aspects and the impact of descriptive data were evaluated. The Kolmogorov-Smirnov test, Spearman's rho correlation, and two-way mixed ANOVA were used for statistical analysis. All patients were found to be "frail". Pain, fatigue, and the burden of illness were the highest-rated symptoms. Oral function and orofacial appearance were highly impaired. A significant impact of descriptive data on the CGA and QoL results was found (all p ≤ 0.05). Thus, the CGA results revealed high frailty, severe comorbidities, and high impairments in QoL aspects. The CGA and QoL results were negatively affected by the primary HNSCC treatment approach, the need for prosthetic treatment, and worse oral functional capacity. Therefore, frailty in r/m HNSCC patients seems to be multidimensional. The evaluation of the CGA and QoL aspects in r/m HNSCC patients can be recommended to detect special needs, organize aftercare, and improve the support for frail and vulnerable cancer patients to create a multidisciplinary treatment approach.

[Oral health in nursing homes as an interprofessional task : Results of qualitative interviews with nurses and dentists on their current and future collaboration]

BACKGROUND

People with long-term care needs have significantly poorer oral health than their peers without care needs. Internationally, this is increasingly being addressed through interprofessional collaboration and expanded roles of nurses. This article investigates the perspectives of dentists and nurses in Germany on the current status and future of their collaboration in nursing homes.

METHODS

A total of eight expert interviews were conducted with four practising dentists and nurses from the Westphalia-Lippe region via Zoom or by telephone. The fully transcribed interview material was analyzed by thematic coding on a case-specific and cross-case basis.

RESULTS

From the perspective of the interviewees, collaboration of dentists and nurses is indispensable for promoting the oral health of nursing home residents. They describe a lack of time and competence in the oral and dental care of home residents, which should be countered with new roles of responsibility for specially qualified nurses in cooperation with dentists. At the same time, they advocate a stronger anchoring and embedding of (dental) medical care in the routines of nursing homes.

CONCLUSION

New forms of cooperation between dentists and nurses in nursing homes should be piloted and further developed in Germany.

Impact of an Oral Hygiene Intervention in People with and without Dementia on Oral Health Parameters-Results from the Oral Health, Bite Force, and Dementia (OrBiD) Pilot Study

This study aimed to assess the influence of an oral hygiene intervention on oral health, depending on the degree of dementia. A clinical evaluation of oral health parameters (index of decayed, missing, and filled teeth (DMFT-index), periodontal screening index (PSI), oral hygiene index (OHI), and bleeding on probing (BOP)) was performed in 120 subjects assigned to five groups, based on the mini mental state examination (MMSE) at baseline and after 12 months. Each MMSE group (no dementia (noDem, MMSE 28–30), mild cognitive impairment (mCI, MMSE 25–27), mild dementia (mDem, MMSE 18–24), moderate dementia (modDem, MMSE 10–17), and severe dementia (sDem, MMSE ≤ 9)) was split into control (no intervention) and experimental groups (intervention on oral hygiene: increased frequency, daily usage of high-fluoride toothpaste). In total, 99 out of 120 subjects were included in the analysis. The dropout rate was high in subjects with modDem and sDem due to death. In subjects with noDem, mCI, and mDem, no changes in the DMFT were found, but improvements in the OHI, BOP, and PSI were observed. Subjects with modDem or sDem demonstrated a deterioration in DMFT; however, in these patients, OHI improved in all control and experimental groups, BOP improved in the experimental group only, and PSI did not improve at all. The scope of improving oral health parameters by increasing the recall frequency and by continuously using high fluoride toothpaste is at its limits in people with severe dementia. Multidimensional approaches should be sought to improve the oral health of vulnerable older patients.

Development of a New Application-Based Chewing Efficiency Test (Mini Dental Assessment) and Its Evaluation by Nursing Staff in Geriatric Care: A Pilot Study

The increasing average life expectancy worldwide results in an elderly population with significant health care needs. However, dental care is often not a focus of care. It is well known that oral and overall health are directly related. Therefore, the Mini Dental Assessment (MDA) was developed to provide a simple analysis of oral health status, although it is currently only available in paper form, with all associated drawbacks, from illegible writing to the inability to quickly search the collected forms. This study aimed to develop a digital application (app) for mobile devices that can overcome the problems associated with paper forms. After the digital MDA was developed, its usability was evaluated by nurses, a questionnaire was answered, and it was compared to the analog MDA with patients in a pilot study. The usability of the app (System Usability Scale) was 95.18 ± 4.26, representing a very high usability. Furthermore, this app showed good clinical applicability. The results also showed that the digital MDA was accepted by nurses in their daily routine and was preferred to the analog MDA. A follow-up study with a higher number of subjects is highly recommended.

[Dental care for older people: opportunities and challenges]

Die Mundgesundheit der Bevölkerung in Deutschland konnte in den letzten Jahren verbessert werden; allerdings profitierten ältere und insbesondere gebrechliche sowie pflegebedürftige Menschen nicht adäquat von dieser Entwicklung. Dabei kann eine gute Mundgesundheit relevant dazu beitragen, die Herausforderungen bei Gebrechlichkeit und Pflegebedürftigkeit besser zu bewältigen. Der eingeschränkte Zugang zur zahnmedizinischen Betreuung, die manchmal eingeschränkte Kooperativität sowie die schlechtere Mundpflege in dieser Bevölkerungsgruppe erhöhen das Risiko für Karies, Parodontalerkrankungen, Zahnverlust und Zahnlosigkeit im Vergleich zur Durchschnittsbevölkerung.

Der vorliegende Beitrag gibt eine Übersicht über die zahnmedizinische Situation älterer Menschen anhand bereits publizierter Daten aus der bevölkerungsrepräsentativen Fünften Deutschen Mundgesundheitsstudie (DMS V), die im Jahr 2014 erhoben wurden. Die mittlere Anzahl der fehlenden Zähne betrug bei den 65- bis 74-Jährigen 11,1 Zähne. Bei älteren Seniorinnen und Senioren (75–100 Jahre) mit Pflegebedarf (äSmP) war die Mundgesundheit schlechter als bei denjenigen ohne Pflegebedarf (äSoP). So hatten äSoP durchschnittlich 11,8 Zähne, äSmP dagegen nur 5,7 Zähne. Der Anteil zahnloser 65- bis 74-Jähriger hatte sich seit 1997 halbiert auf 12,4 %. Bei den äS waren 32,8 % zahnlos (äSmP: 53,7 %, äSoP: 26,7 %). Mehr als 75 % der äSmP waren abnehmbar prothetisch versorgt (äSoP: 51,7 %). Vor diesem Hintergrund werden in diesem Beitrag Schnittstellen benannt, an denen eine chancengleiche Anbindung dieser Bevölkerungsgruppen an eine zahnmedizinische Versorgungsstruktur etabliert werden könnte. Diese beinhalten akutgeriatrische Krankenhausstationen und die Entwicklung weitergehender Konzepte in der aufsuchenden Versorgung zur besseren Versorgung der Betroffenen und zur Erleichterung der Pflege.

Frailty transitions and health care use in Europe

OBJECTIVE

There is relative consensus that chronic conditions, disability, and time-to-death are key drivers of age-related health care expenditures. In this paper, we analyze the specific impact of frailty transitions on a wide range of health care outcomes comprising hospital, ambulatory care, and dental care use.

DATA SOURCE

Five regular waves of the SHARE survey collected between 2004 and 2015.

STUDY DESIGN

We estimate dynamic panel data models on the balanced panel (N = 6078; NT = 30 390 observations). Our models account for various sources of selection into frailty, that is, observed and unobserved time-varying and time-invariant characteristics.

PRINCIPAL FINDINGS

We confirm previous evidence showing that frailty transitions have a statistically significant and positive impact on hospital use. We find new evidence on ambulatory and dental care use. Becoming frail has greater impact on specialist compared to GP visit, and frail elderly are less likely to access dental care.

CONCLUSIONS

By preventing transitions toward frailty, policy planners could prevent hospital and ambulatory care uses. Further research is needed to investigate the relationship between frailty and dental care by controlling for reverse causation.

Promotion of oral health by community nurses

AIM

To explore the enablers and barriers perceived by community nurses in the promotion of oral health in an adult community trust directorate.

BACKGROUND

Oral health care promotion in community care settings is being neglected. England and Wales have witnessed marked improvements in periodontal disease; however, no improvements have been seen in older people.

METHOD

A qualitative methodology was employed, where eight nurses from Band 5 to 7 were interviewed using a semi-structured approach. The data was analysed thematically.

FINDINGS

Data analysis was organised into four themes: professional self-concept and the development of knowledge, skills and attitudes necessary in the promotion of oral health; the impact an organisation has on the promotion of oral health and an exploration of the enablers and barriers identified by the community nurses while delivering care; the relationships between the nurse and patient and the potential impact on oral health promotion; the concept of self-regard in relation to the promotion of oral health and its overall impact. A commitment to improving oral health and requests for additional educational input were apparent. Organisational enablers and barriers were identified, alongside the crucial role a positive self-regard for oral health care may play in the promotion of oral health.

CONCLUSION

Nurses need relevant education, organisational support, adequate resources and support from a multidisciplinary team to deliver optimal oral health promotion.

Dental hygiene registration: development, and reliability and validity testing of an assessment scale designed for nurses in institutions

AIMS AND OBJECTIVES

To develop and test the dental hygiene registration, a dental hygiene assessment scale for nurses working in institutions.

BACKGROUND

Removal of dental plaque is a key factor in preventing oral health-related diseases. A simple, but reliable dental hygiene assessment scale that enables nurses to monitor residents' dental hygiene on a daily basis, will improve monitoring oral hygiene status and quality of dental health care.

DESIGN

Descriptive study on the development and evaluation of a dental hygiene registration instrument.

METHODS

The dental hygiene registration was developed and tested over several stages during the period of 2011-2014. Dental hygiene registration consists of a five-point plaque score scale. The score indicates whether measures are needed. A reference group comprising both medical and dental personnel designed dental hygiene registration. Dental plaque was used as a measure of dental hygiene. A pictorial series of teeth with varying amounts of plaque was used to achieve intra-examiner agreement. Dental hygiene registration assessments were scored 50 times to assess interexaminer reliability between one dental hygienist and one clinical nurse. Dental hygiene registration was validated against the plaque index score of the Simplified Oral Hygiene Index. The Regional Ethics Committee approved the study (2011/915).

RESULTS

Estimates for intra-examiner agreement on plaque score were good for the dental hygienist (κ = 0·7) and very good for the clinical nurse (κ = 0·8). Estimates for interexaminer reliability for dental hygiene registration between the dental hygienist and the clinical nurse were moderate (κ = 0·4). dental hygiene registration corresponded significantly with Simplified Oral Hygiene Index (Spearman's correlation coefficient = 0·8, p < 0·001) indicating good validity.

CONCLUSION

The developed dental hygiene registration appears to be reliable and valid.

RELEVANCE TO CLINICAL PRACTICE

Dental hygiene registration may contribute to the provision of daily oral care. Dental hygiene registration enables nurses to evaluate their own effort when assisting in dental hygiene and to register whether further effort is needed.

Oral health educational interventions for nursing home staff and residents

BACKGROUND

Associations between nursing home residents' oral health status and quality of life, respiratory tract infections, and nutritional status have been reported. Educational interventions for nurses or residents, or both, focusing on knowledge and skills related to oral health management may have the potential to improve residents' oral health.

OBJECTIVES

To assess the effects of oral health educational interventions for nursing home staff or residents, or both, to maintain or improve the oral health of nursing home residents.

SEARCH METHODS

We searched the Cochrane Oral Health Trials Register (to 18 January 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2015, Issue 12), MEDLINE Ovid (1946 to 18 January 2016), Embase Ovid (1980 to 18 January 2016), CINAHL EBSCO (1937 to 18 January 2016), and Web of Science Conference Proceedings (1990 to 18 January 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials to 18 January 2016. In addition, we searched reference lists of identified articles and contacted experts in the field. We placed no restrictions on language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster-RCTs comparing oral health educational programmes for nursing staff or residents, or both with usual care or any other oral healthcare intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened articles retrieved from the searches for relevance, extracted data from included studies, assessed risk of bias for each included study, and evaluated the overall quality of the evidence. We retrieved data about the development and evaluation processes of complex interventions on the basis of the Criteria for Reporting the Development and Evaluation of Complex Interventions in healthcare: revised guideline (CReDECI 2). We contacted authors of relevant studies for additional information.

MAIN RESULTS

We included nine RCTs involving 3253 nursing home residents in this review; seven of these trials used cluster randomisation. The mean resident age ranged from 78 to 86 years across studies, and most participants were women (more than 66% in all studies). The proportion of residents with dental protheses ranged from 62% to 87%, and the proportion of edentulous residents ranged from 32% to 90% across studies.Eight studies compared educational interventions with information and practical components versus (optimised) usual care, while the ninth study compared educational interventions with information only versus usual care. All interventions included educational sessions on oral health for nursing staff (five trials) or for both staff and residents (four trials), and used more than one active component. Follow-up of included studies ranged from three months to five years.No study showed overall low risk of bias. Four studies had a high risk of bias, and the other five studies were at unclear risk of bias.None of the trials assessed our predefined primary outcomes 'oral health' and 'oral health-related quality of life'. All trials assessed our third primary outcome, 'dental or denture plaque'. Meta-analyses showed no evidence of a difference between interventions and usual care for dental plaque (mean difference -0.04, 95% confidence interval (CI) -0.26 to 0.17; six trials; 437 participants; low quality evidence) or denture plaque (standardised mean difference -0.60, 95% CI -1.25 to 0.05; five trials; 816 participants; low quality evidence). None of the studies assessed adverse events of the intervention.

AUTHORS' CONCLUSIONS

We found insufficient evidence to draw robust conclusions about the effects of oral health educational interventions for nursing home staff and residents. We did not find evidence of meaningful effects of educational interventions on any measure of residents' oral health; however, the quality of the available evidence is low. More adequately powered and high-quality studies using relevant outcome measures are needed.

Mini dental assessment: a simple screening test for non-dental staff

OBJECTIVE

The objective of this study was to develop a simple tool for the assessment of possible dental treatment needs (DTN) for non-dental professionals (Mini Dental Assessment, MDA). To keep the assessment universal, we aimed to base it on the patient's history and a simple chewing efficiency test (CET) as the dental status is a known determinant for chewing efficiency.

MATERIALS & METHODS

The assessment was developed using data from 169 patients from two sites (University Hospital Giessen, St. Bonifatius Hospital Lingen, both Germany). In all patients, a dental examination was performed, the denture status was evaluated (based on the California Dental Association criteria; CDA criteria), and the DTN was determined. In addition, the time since the patient's last visit to a dentist (TLVD) and denture age (DA) were assessed. Furthermore, a CET was carried out and the comminution score was determined (CETS).

RESULTS

In total, 108 patients required dental treatment. The mean value (±SD) was 2.9 ± 0.9 score points for the DTN, 2.5 ± 3.8 years for the TLVD, and 10.8 ± 8.9 years for the DA. There was a significant correlation (Spearman, P < .05) between the DTN and degree of comminution (3.4 ± 1.8). Based on the results of the statistical analysis, the intended assessment tool was developed using the variables CETS, TLVD, and DA weighed by their respective regression coefficients (10:3:1). Subsequently, the resulting MDA score (51.32 ± 28.14) was calculated. A sensitivity/specificity analysis was conducted and a receiver operating characteristic curve was calculated (SPSS 17.0, area under curve 0.805; 95 % CI 0.738-0.873).

CONCLUSION

It can be concluded that the dental status of elderly patients is reflected in the outcome of the MDA. However, ongoing validation is needed.

TRIAL REGISTRATION

DRKS00003219.

Oral health care in residential aged care services: barriers to engaging health-care providers

The oral health of older people living in residential aged care facilities has been widely recognised as inadequate. The aim of this paper is to identify barriers to effective engagement of health-care providers in oral care in residential aged care facilities. A literature review was conducted using MEDline, CINAHL, Web of Science, Academic Search Complete and PsychInfo between 2000 and 2013, with a grey literature search of government and non-government organisation policy papers, conference proceedings and theses. Keywords included: dental/oral care, residential aged care, health-care providers, barriers, constraints, and limitations. A thematic framework was used to synthesise the literature according to a series of oral health-care provision barriers, health-care provider barriers, and cross-sector collaborative barriers. A range of system, service and practitioner level barriers were identified that could impede effective communication/collaboration between different health-care providers, residents and carers regarding oral care, and these were further impeded by internal barriers at each level. Findings indicated several areas for investigation and consideration regarding policy and practice improvements. While further research is required, some key areas should be addressed if oral health care in residential aged care services is to be improved.

[Oral health in dementia: Results of a telephone helpline]

BACKGROUND

The complexity of dental care and oral hygiene for people with dementia increases with increasing numbers of residual teeth.

AIM

This study was carried out to determine whether the offer of a telephone helpline on oral health and dementia would be utilized.

MATERIAL AND METHODS

Over a period of 1 year contacts received by a telephone helpline manned by three oral healthcare staff were collected and analyzed.

RESULTS

From 01 June 2012 to 31 May 2013 a total of 355 callers (180 healthcare staff and 175 relatives) presented and discussed 2535 problems. The average duration of a call was 21 min. Almost one quarter of the callers were looking for mobile dental care services and 14.4 % were looking for a dentist specialized in caring for patients with dementia. Oral disease, oral care and conflicts between stakeholders on aspects of oral health were discussed. Of the healthcare staff three quarters asked about training to improve the oral health of people with dementia.

CONCLUSION

The demand on the specialists of the helpline showed a substantial knowledge deficit of healthcare staff and relatives. The study confirmed a wide range of oral health issues of people with dementia. Knowledge on oral and denture hygiene and on oral disease could be introduced into primary training and continued professional education. In addition to the lack of knowledge, deficits also exist in the oral healthcare system for people with dementia. Politicians and healthcare stakeholders are encouraged to incorporate oral healthcare for people with dementia into strategies and dementia networks.