Oral hygiene and periodontal disease in Victorian nursing homes

A comparative analysis of oral hygiene in nursing homes with and without a structured oral healthcare programme

OBJECTIVE

The objective of this study is to compare the oral hygiene (dental and denture plaque) among residents in nursing homes that have implemented an oral healthcare programme (Gerodent) with that of residents in nursing homes that provide standard oral care.

BACKGROUND

Gerodent is a comprehensive oral healthcare programme introduced in 2010, which includes mobile on-site professional oral care. Sixty-two nursing homes have actively implemented Gerodent between 8 and 12 years preceding this study.

METHODS

A cross-sectional study compared a cluster random sample of Gerodent nursing home residents to residents of matched control nursing homes. Residents' dental (Turesky Index) and denture plaque (Augsburger & Elahi Index) scores were collected as primary outcome variables. Data on tongue plaque, oral hygiene aids and demographic characteristics were recorded. Data were collected between 2020 and 2023. Generalised estimating equations were used to compare the oral hygiene between both study groups.

RESULTS

Residents in the Gerodent group (n = 171) had significantly lower mean dental and denture plaque scores than their counterparts in the non-Gerodent group (n = 159; dental plaque 1.68 vs. 2.71; RR 0.32; 95% CI: 0.23-0.44; and denture plaque 1.60 vs. 2.21; RR 0.55; 95% CI: 0.42-0.72). While basic oral hygiene aids were available to most residents in both groups, denture brushes were more common in the Gerodent group.

CONCLUSION

Residents in Gerodent nursing homes had significantly better oral hygiene than those older people residing in non-Gerodent nursing homes, although plaque scores were insufficient to prevent oral conditions. Oral health professionals need to work with and provide ongoing support in long-term care facilities to further improve oral hygiene.

Oral Health Problems Among Flemish and Dutch Nursing Home Residents Assessed by Nondental Caregivers Using the Novel Oral Health Section for Inclusion in interRAI

Background and Objectives

Oral health of older adults in nursing homes is poor, which can negatively affect general health and well-being. Most oral health problems are preventable with good oral hygiene and regular dental check-ups. Caregivers can help improve residents' oral health through regular oral health assessments. The interRAI instrument used in Long-Term Care Facilities to evaluate older adults' health and well-being, has the potential to integrate oral care into general care planning. The recently optimized Oral Health Section for inclusion in the interRAI instruments (OHS-interRAI) enables nondental caregivers to identify residents requiring help with oral hygiene and/or a dental referral. This study reports the first data obtained using the OHS-interRAI, describing the oral health situation of older adults in Flemish and Dutch nursing homes.

Research Design and Methods

In this cross-sectional study, interRAI Long-Term Care Facilities data, including OHS-interRAI data, were collected from October 2020 to January 2023 and analyzed from 417 and 795 persons aged 65 years or older in Flemish and Dutch nursing homes, respectively.

Results

Most common oral health problems were poor oral hygiene and compromised teeth. Differences in oral health were found between Flemish and Dutch residents. Flemish residents had significantly more problems with chewing, dry mouth, oral and denture hygiene, and tongue condition than their Dutch counterparts. They also had a higher need for help with oral hygiene (19.4% vs 14.0%), and a dental referral (36.8% vs 20.9%). Older adults in Flemish nursing homes (20.3%) had significantly fewer dental check-ups than those in Dutch nursing homes (73.5%).

Discussion and Implications

The use of the OHS-interRAI by nondental caregivers identified at least one-third of the residents requiring help with oral hygiene and/or a dental referral. By means of trigger algorithms (Collaborative Action Points), the OHS-interRAI enables the integration of oral care into general care planning.

Impaired oral health: a required companion of bacterial aspiration pneumonia

Laryngotracheal aspiration has a widely-held reputation as a primary cause of lower respiratory infections, such as pneumonia, and is a major concern of care providers of the seriously ill orelderly frail patient. Laryngeal mechanical inefficiency resulting in aspiration into the lower respiratory tract, by itself, is not the cause of pneumonia. It is but one of several factors that must be present simultaneously for pneumonia to develop. Aspiration of oral and gastric contentsoccurs often in healthy people of all ages and without significant pulmonary consequences. Inthe seriously ill or elderly frail patient, higher concentrations of pathogens in the contents of theaspirate are the primary catalyst for pulmonary infection development if in an immunocompromised lower respiratory system. The oral cavity is a complex and ever changing eco-environment striving to maintain homogeneity among the numerous microbial communities inhabiting its surfaces. Poor maintenance of these surfaces to prevent infection can result inpathogenic changes to these microbial communities and, with subsequent proliferation, can altermicrobial communities in the tracheal and bronchial passages. Higher bacterial pathogen concentrations mixing with oral secretions, or with foods, when aspirated into an immunecompromised lower respiratory complex, may result in bacterial aspiration pneumonia development, or other respiratory or systemic diseases. A large volume of clinical evidence makes it clear that oral cleaning regimens, when used in caring for ill or frail patients in hospitals and long-term care facilities, drastically reduce the incidence of respiratory infection and death. The purpose of this narrative review is to examine oral health as a required causative companionin bacterial aspiration pneumonia development, and the effectiveness of oral infection control inthe prevention of this disease.

Influence of cognitive impairment and dementia on oral health and the utilization of dental services : Findings of the Oral Health, Bite force and Dementia Study (OrBiD)

BACKGROUND

The aim of this study was to show the influence of cognitive impairment and dementia on oral health and on the utilization of dental services.

METHODS

A cross-sectional analyzation of data of the OrBiD (Oral Health, Bite Force and Dementia) pilot study was conducted. 137 subjects were stratified into five dementia groups on the basis of the Mini Mental State Examination (MMSE) (1-no dementia (MMSE 28-30), 2-mild cognitive impairment (MMSE 25-27), 3-mild dementia (MMSE 18-24), 4-moderate dementia (MMSE 10-17), and 5-severe dementia (MMSE < 10)). Information on the utilization of dental services and oral health parameters (DMFT index, degree of restoration, Periodontal Screening Index, Bleeding on Probing, Oral Hygiene Index, Denture Hygiene Index) were collected.

RESULTS

An increase in dementia resulted in significant reduction in utilization. Moreover, with increasing cognitive impairment/dementia there was a significant difference in the number of teeth that were decayed, but not in the number of filled or missing teeth or the DMF/T index itself. With increasing dementia, the degree of restoration decreased and oral/denture hygiene deteriorated significantly. Nevertheless, periodontal therapy was required for all subjects independent of their degree of dementia while bleeding on probing was increasing with increasing dementia.

CONCLUSIONS

An influence of cognitive impairment and dementia on oral health and on the utilization of dental services was shown. However, no conclusions about the influence of the utilization behavior of people with dementia on oral health parameters can be drawn. Further longitudinal studies are needed. Trial registration ClinicalTrials.gov NCT03775772. Registered 14th December 2018, https://clinicaltrials.gov/ct2/show/NCT03775772 .

Oral hygiene and health-related quality of life in institutionalized older people

Aim

We evaluated oral hygiene level and its association with oral health and general health-related quality of life (HRQoL) among older residents in long-term care facilities.

Findings

Only one-fifth of residents had good oral hygiene. Poor oral hygiene was associated with poor oral health and diminished HRQoL.

Message

Oral hygiene, oral health, and HRQoL may be improved with oral care education of caregivers, professional cooperation, and regular oral healthcare of older residents in long-term care facilities.

Purpose

We evaluated the level of oral hygiene and its association with oral health status and need for oral treatment among older residents in long-term care facilities. In addition, the association between oral hygiene level and health-related quality of life (HRQoL) was explored.

Methods

This cross-sectional study assessed 231 dentate residents in long-term care facilities (71% female, mean age 81 years, 70% had dementia). Nurses assessed residents and completed questionnaires on participants’ background information, diagnoses, oral healthcare habits, and HRQoL with the 15D instrument. Two qualified dentists performed clinical oral examinations (number of teeth, plaque index, periodontal condition, open caries lesions, and dry mouth). We used a modified plaque index (PI) to measure the level of oral hygiene (good, moderate, and poor) and calculated the clinical Asymptotic Dental Score (ADS) to determine the oral inflammation burden.

Results

Of the residents, 21% had good, 35% moderate, and 44% poor oral hygiene according to PI. Poor oral hygiene was associated with poorer cognitive status (P = 0.010) and higher oral inflammation burden (P < 0.001). Moreover, poor oral hygiene was associated with poorer HRQoL in a correlation analysis adjusted for age and gender.

Conclusions

Oral hygiene of older individuals in long-term care is insufficient. Poor oral hygiene is a marker for poor HRQoL. Residents also have a high burden of oral inflammatory diseases and a need for dental care. Older residents’ oral hygiene and HRQoL may be improved with oral care education of caregivers and regular dental check-ups.

The Effects of Prednisone/Ketoprofen Administration in Association with Amoxicillin Clavulanate Following Periodontal Surgical Therapy in Patients with Severe Chronic Periodontitis

Background and Objectives: The aim of this study was to evaluate and compare the effects of two different anti-inflammatory drugs (ketoprofen and prednisone) combined with an antibiotic (amoxicillin + clavulanic acid) and periodontal surgery on dental and periodontal parameters in patients with severe chronic periodontitis. In addition, salivary stress expressed by cortisol levels was assessed. Materials and Methods: An interventional study was performed on 22 periodontal subjects and 19 clinical healthy controls. The patients were divided in four groups, depending on treatment planning, as follows: eight patients received prednisone and antibiotherapy, associated with surgical periodontal therapy; seven patients received ketoprofen and antibiotherapy, associated with surgical periodontal therapy (group II); seven patients received only prednisone. Periodontal healthy patients underwent routine scaling and polishing. Bleeding on probing (BOP), dental mobility and salivary cortisol (ng/mL) were assessed before and after treatment. The means and standard deviations for the salivary cortisol levels (SCLs), dental and periodontal parameters were calculated for all groups using each patient as a unit of analysis. Results: Data analyses showed that the two different anti-inflammatory drugs associated with or without surgical therapy were efficient on inflammation periodontal parameters (BOP, dental mobility). Prednisone treatment alone was associated with a significant decrease of SCLs between pretreatment and post-treatment. Conclusions: In the present study, the effects of either of the anti-inflammatory drugs on inflammation evolution and salivary stress were comparable in patients undergoing antibiotherapy and surgical periodontal therapy.

First Data in the Process of Validating a Tool to Evaluate Knowledge, Attitude, and Practice of Healthcare Providers in Oral Care of Institutionalized Elderly Residents: Content Validity, Reliability and Pilot Study

Background: Oral health of elderly people is a global concern. Poor oral health in institutionalized elderly people has been attributed to poor knowledge, attitude, and practice (KAP) of healthcare providers. However, no validated KAP tool is available yet. Objective: To develop and validate a tool to measure knowledge, attitude, and practice of healthcare providers in oral care of institutionalized elderly people. Methods: The development and validation of the tool was based on literature reviews, comments from professional experts, and statistical analytic methods. Content validity in the instrument psychometric property and its relevance with reliability are essential. Content validity ratio and content validity index were performed. Then, a pilot study was conducted in 20 institutionalized healthcare providers for testing applicability, feasibility, and reliability. Results: A total of 43 items were developed in three domains, knowledge (19 items), attitude (13 items), and practice (11 items). Content validity analysis revealed the KAP tool with high values of the I-CVI (score 1.00) and S-CVI (S-CVI/UA result 1.00). The test-retest reliability with Cronbach’s alphas of knowledge, attitude, practice, and overall KAP were 0.67, 0.93, 0.92, and 0.94, respectively. Conclusions: The developed and validated tool is appropriate to measure KAP of healthcare providers in oral care of institutionalized elderly people. It can be used to measure KAP of institutionalized healthcare providers in order to develop appropriate strategies to improve KAP of healthcare providers.

Oral health matters in cognitive impaired aged residents in geriatric care facilities: A cross-sectional survey

AIMS

To investigate the oral health status of aged residents and explore the possible factors associated with oral health and the effect of cognitive impairment (CI) on it in geriatric care facilities (GCF) using oral health assessment tool (OHAT) in Shanghai, China.

BACKGROUND

Oral health is closely associated with overall health. Problems like missing teeth, dental caries, dental pain, periodontal diseases, oral infections and dysphagia are common in GCFs. Furthermore, residents in GCFs with CI are becoming a dominant group and this prevalence increases with age. Detection of oral problems earlier and taking oral care actions is required for these special populations.

METHODS

The study was an observational cross-sectional study conducted in 42 GCFs. Data were collected from 657 subjects, including oral health assessment (OHAT), cognitive impairment (Mini-Mental State Examination, MMSE) and respondents' characteristics. The subjects were divided into CI group and non-CI group based on MMSE. Oral health conditions were compared between the two groups.

RESULTS

Oral health status in the CI group was significantly worse than that in the non-CI group (p < .001) with four OHAT dimensions (tongue (p = .0007), saliva (p = .0011), natural teeth (p = .0155) and oral cleanliness (p < .001)). The worst dimension was natural teeth. Debris and plaque index (p < .001), oral odour (p < .001), chewing function (p = .0151) and swallowing function (p = .0405) were worse in CI group than those in non-CI group. In the CI group, providing oral care was a protective factor in oral health (OR = 0.600 95CI% (0.39-0.92)) and wearing dentures was a risk factor (OR = 2.09, 95CI% (1.31-3.32)), while the similar effects were not found in non-CI group.

CONCLUSIONS

Oral health status among aged residents in GCFs in China was worse among individuals with CI. Caregivers in GCFs should focus more on seniors' oral health with CI.

RELEVANCE TO CLINICAL PRACTICE

Residents who are suffering from CI are more vulnerable to have oral problems. Regular and proper oral health check-ups in daily nursing work to define oral problems of residents are significant. Nursing staff should pay more attention to oral assessment and effective intervention.

Factors Associated with Knowledge, Attitudes, and Practices Related to Oral Care Among the Elderly in Hong Kong Community

Background: The oral health of elderly populations is a significant concern, as it is closely linked to general health and health-related quality of life. Poor oral health exacerbates oral diseases, leading to an increased risk of non-communicable diseases and self-care dependence, particularly in the elderly, worldwide. Knowledge, attitudes, and practices (KAP) play influential roles in individual oral care. However, the evidence of KAP related to oral care among the elderly is still inadequate. Objective: This study aimed to examine KAP and their associated factors related to oral care among the elderly community. Methods: A cross-sectional descriptive design was used. The eligible subjects were recruited, using convenience sampling and snowball sampling. Results: A total of 385 elderly individuals were included, and 51.4% were women. The mean age was 71.66 (SD 6.28). Knowledge was reportedly poor, as more than 50% elderly answered several questions incorrectly. The mean attitude and practices scores were 44.94 (SD 6.33) and 68.90 (SD 10.44), respectively. There was a significant correlation among knowledge, attitudes, and practices (p < 0.001). Multivariable regression analysis revealed numerous factors had remarkably significant association with knowledge [R² = 0.30, F (4,380) = 11.96, p < 0.001], attitudes [R² = 0.28, F (6,378) = 9.27, p < 0.001], and practices [R² = 0.31, F (5,379) = 12.34, p < 0.001], particularly education levels, full-time employment, and self-care independence. Conclusions: Based on the KAP theoretical model, KAP are closely interrelated. Identified factors associated with KAP are useful to understand at-risk groups. Elderly individuals at lower education levels, with poor family support and inadequate self-care independence, have poor KAP related to oral care. Therefore, this study improves insight for health promotion developers, suggesting that more attention should be paid to at-risk elderly groups’ oral health. To enhance participation in dental care and improve oral care performance in the elderly, educational program containing oral health knowledge should be offered to at-risk groups. Family support and involvement are also important for improving oral care among elderly individuals.

Oral Health and Its Associated Factors Among Older Institutionalized Residents-A Systematic Review

The oral health of an ageing population, especially that of the institutionalized elderly population, constitutes a significant concern because it is closely linked to general health and the quality of life. Shared common risk factors drive the development and worsening of poor oral health and non-communicable diseases, which eventually lead to self-care inability. Several studies have reported on the poor oral health of the institutionalized elderly population. However, few comprehensive reports exist regarding the relationship between poor oral health, the oral health-related quality of life (OHRQoL) and the associated factors in this specific population. Objective: The objective is to describe recently reported oral health levels, the OHRQoL and the associated factors among older institutional residents. Methods: Studies published between July 2009 and June 2019 in MEDLINE, EMBASE and CINAHL were searched. The population, intervention, comparison and outcome (PICO) strategy was used as a guide. The reported factors related to poor oral health were identified (i.e., age, gender, educational level, acquired systemic conditions or dementia/cognitive impairment). Results: Twenty-five surveys (or study series) from 19 countries were included. The level of evidence reported by these studies was generally moderate to strong. The reported oral cleanliness and health of the surveyed institutionalized elderly were poor (>50% of residents had calculus; denture hygiene index > 80%). Gum (approximately 30% of dentate residents had moderate to severe periodontitis), teeth (decayed, missing or filled teeth >20), mucosa (>10% had mucosal lesions) and denture problems (up to 40%) were prevalent and were associated with a poor OHRQoL, especially in females, socially deprived residents or those with mild or above cognitive impairment. Those with a poor OHRQoL might show signs of poor nutrition. Conclusions: This report reviewed evidence-based knowledge on oral health, the OHRQoL and the associated factors among elderly institutional residents. Further research is needed to confirm these observations. For improved oral health, a better OHRQoL and the general well-being of older residents, clinical trials are needed, targeting modifiable factors, such as social inequality, oral healthcare accessibility, and/or nursing home service quality. The relationship between oral health, the OHRQoL and nutrition in this at-risk population also warrants exploration.

Can oral healthcare for older people be embedded into routine community aged care practice? A realist evaluation using normalisation process theory

BACKGROUND

An intervention 'Better Oral Health in Home Care' was introduced (2012-2014) to improve the oral health of older people receiving community aged care services. Implementation of the intervention was theoretically framed by the Promoting Action on Research Implementation in Health Services framework. Process outcomes demonstrated significant improvements in older people's oral health.

OBJECTIVE

To evaluate the extent to which the intervention has been embedded and sustained into routine community aged care practice 3 years after the initial implementation project.

DESIGN

A Realist Evaluation applying Normalisation Process Theory within a single case study setting.

SETTING

Community aged care (home care) provider in South Australia, Australia.

PARTICIPANTS

Purposeful sampling was undertaken. Twelve staff members were recruited from corporate, management and direct care positions. Two consumers representing high and low care recipients also participated.

METHODS

Qualitative methods were applied in two subcases, reflecting different contextual settings. Data were collected via semi-structured interviews and analysed deductively by applying the Normalisation Process Theory core constructs (with the recommended phases of the Realist Evaluation cycle). Retrospective and prospective analytic methods investigated how the intervention has been operationalised by comparing two timeframes: Time 1 (Implementation June 2012-December 2014) and Time 2 (Post-implementation July 2017-July 2018).

RESULTS

At Time 1, the initial program theory proposed that multi-level facilitation contributed to a favourable context that triggered positive mechanisms supportive of building organisational and workforce oral healthcare capacity. At Time 2, an alternative program theory of how the intervention has unfolded in practice described a changed context following the withdrawal of the project facilitation processes with the triggering of alternative mechanisms that have made it difficult for staff to embed sustainable practice.

CONCLUSION

Findings concur with the literature that successful implementation outcomes do not necessarily guarantee sustainability. The study has provided a deeper explanation of how contextual characteristics have contributed to the conceptualisation of oral healthcare as a low priority, basic work-ready personal care task and how this, in turn, hindered the embedding of sustainable oral healthcare into routine community aged care practice. This understanding can be used to better inform the development of strategies, such as multi-level facilitation, needed to navigate contextual barriers so that sustainable practice can be achieved.

Orofacial pain and its potential oral causes in older people with mild cognitive impairment or dementia

Background

The number of people with dementia and natural dentition is growing. As dementia progresses, the degree of self‐care decreases and the risk of oral health problems and orofacial pain increases.

Objectives

To examine and compare the presence of orofacial pain and its potential causes in older people with Mild Cognitive Impairment (MCI) or dementia.

Methods

In this cross‐sectional observational study, the presence of orofacial pain and its potential causes was studied in 348 participants with MCI or dementia with all levels of cognitive impairment in two outpatient memory clinics and ten nursing homes.

Results

Orofacial pain was reported by 25.7% of the 179 participants who were considered to present a reliable pain self‐report (Mini‐Mental State Examination score ≥14 points), while it could not be determined in people with more severe cognitive impairment. The oral health examination of the 348 participants indicated that potential painful conditions, such as coronal caries, root caries, tooth root remnants or ulcers were present in 50.3%. There was a significant correlation between the level of cognitive impairment and the number of teeth, r = 0.185, P = 0.003, teeth with coronal caries, r = −0.238, P < 0.001, and the number of tooth root remnants, r = −0.229, P = 0.004, after adjusting for age.

Conclusions

This study indicated that orofacial pain and its potential causes were frequently present in participants with MCI or dementia. Therefore, a regular oral examination by (oral) healthcare providers in people with MCI or dementia remains imperative, even if no pain is reported.

Aged care staff's experiences of 'Better Oral Health in Residential Care Training': a qualitative study

BACKGROUND

The The Better Oral Health in Residential Care (BOHRC) Training was rolled out to Residential Aged Care Facilities (RACF) across Australia in 2010.

AIM

To examine aged care staff's views on the implementation of the BOHRC Training at their facilities; challenges that they faced in the provision of oral health care to residents and their training needs.

METHODS

A qualitative study using semi-structured interviews was conducted with 20 staff across Tasmania. Interview data was thematically analysed.

RESULTS

Major barriers reported were a lack of time, competing priorities, workload and staffing issues. The majority of participants did not receive the BOHRC training directly. Participants preferred to have practical, 'hands-on' training delivered on site at least every 12 months.

CONCLUSIONS

Oral hygiene training should be provided regularly to equip staff with knowledge and skills to overcome some of the challenges they face and to improve oral hygiene care provision to residents.

An integrated oral health program for rural residential aged care facilities: a mixed methods comparative study

BACKGROUND

People in residential aged care facilities (RACF) are at very high risk of developing complex oral diseases and dental problems. A multidisciplinary approach incorporating oral health professionals and RACF staff is important for improving and sustaining oral health in RACFs. However, difficulties exist with access to oral health services for RACFs, particularly those in regional and rural areas. This study investigated the impact and experience of an integrated oral health program utilising tele-dentistry and Oral Health Therapists (OHT) in RACFs in a rural setting within Australia.

METHODS

A mixed method comparison study was undertaken. Two hundred fifty-two clinical audits were completed across nine facilities with and without access to the integrated oral health program. Twenty-seven oral health quality of life surveys were completed with eligible residents. One focus group discussions (FGD) and eight interviews were completed with RACF staff. Thematic analysis was conducted on the transcribed FGDs and IDIs. Quantitative data were analysed using descriptive statistics.

RESULTS

Audits showed an improved compliance to Australian Aged Care Quality Accreditation Standards for oral health in the facilities with access to the integrated program compared to those without the program. Thematic analysis revealed that facilities with the integrated program reported improvements in importance placed on OH, better access to OH services and training, and decreased disruption of residents, particularly those with high care needs.

CONCLUSIONS

The integrated oral health program incorporating OHTs and tele-dentistry shows potential to improve the oral health outcomes of residents of RACFs. Improvements for managing oral health of residents with high care needs were observed. RACFs without easy access to an oral health service will also likely benefit from the increased support and training opportunities that the program enables.

Integrated approach to oral health in aged care facilities using oral health practitioners and teledentistry in rural Queensland

PROBLEM

Residents of residential aged care facilities are at very high risk of developing complex oral diseases and dental problems. Key barriers exist in delivering oral health services to residential aged care facilities, particularly in regional and rural areas.

DESIGN

A quality improvement study incorporating pre- and post chart audits and pre- and post consultation with key stakeholders, including staff and residents, expert opinion on cost estimates and field notes were used.

SETTING

One regional and three rural residential aged care facilities situated in a non-metropolitan hospital and health service in Queensland.

KEY MEASURES FOR IMPROVEMENT

Number of appointments avoided at an oral health facility Feedback on program experience by staff and residents Compliance with oral health care plan implementation Observations of costs involved to deliver new service.

STRATEGIES FOR CHANGE

The model developed incorporated a visit by an oral health therapist for screening, education, simple intervention and referral for a teledentistry session if required.

EFFECTS OF CHANGE

Results showed an improvement in implementation of oral health care plans and a minimisation of need for residents to attend an oral health care facility. Potential financial and social cost savings for residents and the facilities were also noted.

LESSONS LEARNT

Screening via the oral health therapist and teledentistry appointment minimises the need for a visit to an oral health facility and subsequent disruption to residents in residential aged care facilities.

Oral hygiene and oral health in older people with dementia: a comprehensive review with focus on oral soft tissues

BACKGROUND

The number of older people with dementia and a natural dentition is growing. Recently, a systematic review concerning the oral health of older people with dementia with the focus on diseases of oral hard tissues was published.

OBJECTIVE

To provide a comprehensive literature overview following a systematic approach of the level of oral hygiene and oral health status in older people with dementia with focus on oral soft tissues.

METHODS

A literature search was conducted in the databases PubMed, CINAHL, and the Cochrane Library. The following search terms were used: dementia and oral health or stomatognathic disease. A critical appraisal of the included studies was performed with the Newcastle-Ottawa scale (NOS) and Delphi list.

RESULTS

The searches yielded 549 unique articles, of which 36 were included for critical appraisal and data extraction. The included studies suggest that older people with dementia had high scores for gingival bleeding, periodontitis, plaque, and assistance for oral care. In addition, candidiasis, stomatitis, and reduced salivary flow were frequently present in older people with dementia.

CONCLUSIONS

The studies included in the current systematic review suggest that older people with dementia have high levels of plaque and many oral health problems related to oral soft tissues, such as gingival bleeding, periodontal pockets, stomatitis, mucosal lesions, and reduced salivary flow.

SCIENTIFIC RATIONALE FOR STUDY

With the aging of the population, a higher prevalence of dementia and an increase in oral health problems can be expected. It is of interest to have an overview of the prevalence of oral problems in people with dementia.

PRINCIPAL FINDINGS

Older people with dementia have multiple oral health problems related to oral soft tissues, such as gingival bleeding, periodontal pockets, mucosal lesions, and reduced salivary flow.

PRACTICAL IMPLICATIONS

The oral health and hygiene of older people with dementia is not sufficient and could be improved with oral care education of formal and informal caregivers and regular professional dental care to people with dementia.

Evaluating student learning outcomes in oral health knowledge and skills

AIMS AND OBJECTIVES

To evaluate whether a set of oral health resources designed for workforce training was relevant for students undertaking an entry-level nursing or aged care qualification.

BACKGROUND

Oral health is one of the most neglected aspects of nursing care experienced by older people. Despite efforts to improve aged care worker oral health knowledge and skills, one-off training and rapid staff turnover have hindered the success of workplace programmes. Inadequate oral health content in entry-level nursing and aged care qualifications has perpetuated this.

DESIGN

Kirkpatrick's training and evaluation model was used to evaluate the resources developed by a project called Building Better Oral Health Communities. Students used them as prescribed study materials and completed pre- and postintervention questionnaires. Educators were interviewed to obtain their feedback. Quantitative data were analysed using descriptive and inferential statistics. Qualitative data were collated according to relevance to learning, presentation style and interest.

RESULTS

Evaluation showed high levels of student and educator satisfaction. Student learning outcomes demonstrated consistently positive attitudes and significant self-reported improvements in oral health knowledge and skills. Irrespective of course type, students gained similar levels of oral health knowledge and skills following use of the resources.

CONCLUSION

Nurses and care workers must be able to provide consistent standards of oral health care as a fundamental part of caring for patients. Validated as an effective learning and teaching package, it is recommended that these resources be used to strengthen the oral health content of entry-level nursing and aged care qualifications.

RELEVANCE TO CLINICAL PRACTICE

Building the oral health capacity of nurses and care workers is one way of reversing oral health neglect and improving the quality of care provided to older people.

Residential age care and domiciliary oral health services: Reach-OHT-The development of a metropolitan oral health programme in Sydney, Australia

OBJECTIVE

To describe an oral health care programme for older people in Residential Aged Care Facilities (RACFs) to improve access to care and support facilities.

INTRODUCTION

Different models of residential care have been proposed, but few have been comprehensive (providing on-site health promotion and service delivery) or sustainable.

METHODS

A partnership model of oral health care, with dental services plus oral health education, was integrated into the community outreach services of a metropolitan hospital department of aged care. The programme provided annual oral health education and training to staff, and on-site dental care to 10 (RACFs).

RESULTS

None of the RACFs had received organised education or on-site dental service care prior to the programme. At the completion of the third year of the programme, 607 residents (75% of the total bed capacity for the 10 RACFs) had received an annual oral health assessment, and 271 (46.5%) had received on-site dental care. More than 120 nursing and allied health staff had received education and training in oral health support to residents. Oral cleanliness, the proportion not experiencing dental pain and referral for additional care decreased significantly over the period, but dental caries experience and periodontal conditions remained a concern.

CONCLUSIONS

Sustainable domiciliary oral health services and oral health education are feasible and practical using a partnership model within the Australian health system. Adaptability, continuity and the use of oral health therapists/dental hygienists in the coordination and management of the programme further contribute to viability.

A Systematic Review Examining the Oral Health Status of Persons with Dementia

While the oral health of persons with dementia has been shown to be poor, no systematic reviews have been published that examined the topic in depth, including participants with dementia representing the full spectrum of disease severity, and evaluating a broad scope of oral health assessments. The aim of this study was to conduct a current literature review to fill this gap in knowledge. A systematic search of 5 databases (CINAHL, PubMed, EMBASE, Scopus, and ISI Web of Science) was conducted to identify all relevant studies published up to May 2016. There were no exclusions related to study type, severity of dementia, dentate status, or living arrangements. Results were reported descriptively and summarized. Meta-analyses were performed where possible and reported as mean difference (MD) or standardized mean difference (SMD), with a 95% confidence interval (CI). Twenty-eight studies were identified. Assessments were conducted of tooth status, active dental caries, hygiene (plaque/calculus) of natural and artificial teeth, periodontal diseases, denture status (retention, stability, denture-related mucosal lesions), and oral health-related quality of life. Across all evaluations, persons with dementia generally had scores/results suggestive of poor oral health. In meta-analyses, compared with persons without dementia, those with dementia had a significantly fewer number of teeth (MD, -1.52; 95% CI, -0.2.52 to -0.52; P = 0.003; n = 13 studies), more carious teeth (SMD, 0.29; 95% CI, 0.03 to 0.48; P = 0.028; n = 9), significantly worse oral hygiene evaluated using a broad range of assessment tools (SMD, 0.88; 95% CI, 0.57 to 1.19, P < 0.0001; n = 7), and significantly poorer periodontal health (SMD, 0.38; 95% CI, 0.06 to 0.70; P = 0.02; n = 6 studies). The oral health status of persons with mild to severe forms of dementia, who were living in both the community and residential care facilities, was found to be poor across a broad range of dental assessments. Knowledge Transfer Statement: The results of this study define the scope of oral issues and quantify the degree of impairment in individuals with dementia, evaluated using a variety of oral health measures. The results revealed that poor oral health is associated with dementia.

Oral Health and nutritional status in nursing home residents-results of an explorative cross-sectional pilot study

Background

This study was performed to assess oral and nutritional status of nursing home residents in a region of Lower Saxony, Germany. The aim was to show potential associations between oral status (dentate or edentulous), further anamnestic factors (dementia, age, smoking) and the risk for malnutrition in this population.

Methods

In this observational cross-sectional pilot study of residents from four nursing homes Mini Nutritional Assessment (MNA), Body-Mass-Index (BMI), dental status (DMF-T) and periodontal situation (PSR^®/PSI) were recorded. Associations of recorded factors with oral health and nutritional status were examined in univariate and multivariate analysis.

Results

Eighty-seven residents participated in the study (mean age: 84.1 years; female: 72%, demented: 47%). Average BMI was 26.2 kg/m²; according MNA 52% were at risk for malnutrition. 48% of the residents were edentulous, and the average DMF-T of dentulous was 25.0 (3.7) (D-T: 2.0 [3.1], M-T: 15.0 [8.3], F-T: 8.0 [7.4]); PSR^®/PSI 3 and 4 (need for periodontal treatment) showed 79% of residents. In univariate analysis dementia (OR 2.5 CI₉₅ 1.1–5.6) but not being edentulous (OR 2.0 CI₉₅ 0.8–5.8) were associated with being at risk for malnutrition. Dementia remained associated in multivariate analysis adjusting for age and sex, (OR 3.1 CI₉₅ 1.2–8.2) and additionally being edentulous (OR 2.8 CI₉₅ 1.1–7.3) became associated significantly. Furthermore, nursing home residents with dementia had more remaining teeth (OR 2.5 CI₉₅ 1.1–5.9).

Conclusion

Dementia was a stronger predictor for risk of malnutrition in nursing home residents than being edentulous. Further studies to elucidate the possible role of oral health as cofactor for malnutrition in dementia are needed.

Effect of 12-month weekly professional oral hygiene care on the composition of the oral flora in dentate, dependent elderly residents: A prospective study

OBJECTIVE

To study the effect of weekly professional oral hygiene care on the proportion of micro-organisms associated with good oral health, caries, and periodontal and soft tissue diseases in oral biofilms in dentate, dependent elderly residents.

BACKGROUND

Assisted oral hygiene care reduces the plaque score and number of micro-organisms in the oral biofilms in elderly residents. Less is known about the effect on the quality/composition of the remaining oral flora.

MATERIALS AND METHODS

Participants comprised 33 residents in the study and 35 in the control group. Dental status (≥10 natural teeth and no removable dentures to be included), plaque score, salivary secretion rate and prescription medicines were recorded. Duplicate samples, collected from supragingival plaque and tongue, were analysed using cultivation technique. Differences between and within groups were analysed using one-way and two-way ANOVA, respectively.

RESULTS

At the baseline, the number of teeth in the participants (mean age, 83.7 ± 7.4 years) was 22.0 ± 4.5. The number of prescription medicines was 9.4 ± 4.5. Seventy-six per cent had low salivary secretion rate. Fifty per cent had "visible thick" supragingival plaque. At the 12-month registration, "no visible" or "visible but thin" plaque was recorded in 92% in the study group. The proportions of bacteria associated with good oral health and periodontal diseases were decreased over time, while the frequency and proportions of micro-organisms associated with caries and soft tissue infection were unaffected or increased.

CONCLUSION

The results indicate that assisted oral hygiene care alone is not sufficient to regain an oral microbial flora associated with good oral health in dentate, dependent elderly residents.

Nurses' oral hygiene care practices with hospitalised older adults in postacute settings

AIM AND OBJECTIVE

The purpose of this study was to explore how nurses provide bedtime oral hygiene care, how they decide on interventions provided, and what factors influence their ability to provide oral care.

BACKGROUND

Current evidence links poor oral hygiene to systemic and infectious diseases such as pneumonia. Hospitalised patients, who now retain their teeth into older adulthood, often rely on nurses to provide oral hygiene care. Nurses have the potential to impact oral health outcomes and quality of life by controlling plaque. However, oral hygiene care practices of nurses in postacute hospital settings are relatively unknown.

DESIGN

A qualitative, exploratory multiple-case study was conducted with 25 nurses working on five inpatient units at different hospitals.

METHODS

Nurses were accompanied on their evening rounds to observe oral care practices, the physical environment and workflow. Thematic analysis was used to analyse the case study data including transcripts of guided conversations, field notes and documents. Within-case analysis was followed by cross-case analysis.

RESULTS

Findings indicate that (i) nurses often convey oral hygiene care to their patients as being optional; (ii) nurses are inclined to preserve patient autonomy in oral hygiene care; (iii) oral hygiene care is often spontaneous and variable, and may not be informed by evidence; and (iv) oral hygiene care is not embedded into bedtime care routines.

CONCLUSIONS

Oral hygiene care is discretionary and often missed care.

IMPLICATIONS FOR PRACTICE

Nurses need knowledge of the health benefits of oral care, and skills related to assessment and approaches to oral care. Availability of effective products and supplies facilitates provision of oral care. The evidence for oral hygiene care practices, outcomes of nurse-administered oral care and nursing's role in influencing the oral health literacy of patients require further study.

Poor dental hygiene and periodontal health in nursing home residents with dementia: an observational study

Poor oral health conditions are well documented in the institutionalized elderly, but the literature is lacking research on relationships between dementia and periodontal health in nursing home residents. The purpose of this cohort study, therefore, was to assess whether dementia is associated with poor oral health/denture hygiene and an increased risk of periodontal disease in the institutionalized elderly. A total of 219 participants were assessed using the Mini Mental State Examination (MMSE) to determine cognitive state. According to the MMSE outcome, participants scoring ≤20 were assigned to dementia group (D) and those scoring >20 to the non-dementia group (ND), respectively. For each of the groups D and ND, Gingival Bleeding Index (GBI) and Denture Hygiene Index (DHI) linear regression models were used with the confounders age, gender, dementia, number of comorbidities and number of permanent medications. To assess the risk factors for severe periodontitis as measured by the Community Index of Periodontal Treatment Needs, a logistic regression analysis was performed. Statistical analysis revealed no significant differences of GBI as well of DHI for demented and healthy subjects (p > 0.05). Severe periodontitis was detected in 66 % of participants with dementia. The logistic regression showed a 2.9 times increased risk among demented participants (p = 0.006). Oral hygiene, denture hygiene and periodontal health are poor in nursing home residents. The severity of oral problems, primarily periodontitis, seems to be enhanced in subjects suffering from dementia. Longitudinal observations are needed to clarify the cause-reaction relationship.

Engaging dental professionals in residential aged-care facilities: staff perspectives regarding access to oral care

The limited access to oral care for older people living in residential aged care facilities (RACFs) has been noted repeatedly in the literature. The aim of this study was to explore RACF staff perspectives on how to engage dental professionals in the provision of oral care for RACF residents. Semi-structured interviews were conducted with 30 staff from six purposively selected RACFs located in high socioeconomic areas to gain understanding of the multidimensional issues that influenced the engagement of dental professionals from a carer perspective. Analysis revealed that staff perceived tensions regarding affordability, availability, accessibility and flexibility of dental professionals as significant barriers to better oral care for their residents. Participants raised a series of options for how to better engage dental professionals and reduce these barriers. Their ideas included: the engagement of RACF staff in collaborative discussions with representatives of public and private dental services, dental associations, corporate partners and academics; the use of hygienists/oral health therapists to educate and motivate RACF staff; the promotion of oral health information for troubleshooting and advice on how to deal with residents’ dental pain while waiting for support; the encouragement of onsite training for dental professionals; and the importance of gerodontology (geriatric dentistry). Findings highlighted the need to explore alternative approaches to delivering oral care that transcend the model of private clinical practice to focus instead on the needs of RACFs and take into account quality of end-of-life oral care.

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.

Prevalence and association of smokeless tobacco use with the development of periodontal pocket among adult males in Dawan Valley, Yemen: a cross-sectional study

BACKGROUND

The traditional type of smokeless tobacco used in the Arabian Peninsula, particularly common in Yemen, is called shammah. This study aims to determine the prevalence of shammah use and its association with the development of periodontal pockets. Other associated factors with the development of periodontal pocket were also determined.

METHODS

This cross-sectional study included 346 adult males aged 18 years old to 68 years old. Socio-demographic characteristics, oral hygiene practices, and shammah use history were surveyed by using a structured interview questionnaire. The clinical assessment for the presence or absence of periodontal pockets was assessed on the basis of community periodontal index. The chi-square test was used to assess significant differences in study groups in terms of the presence of periodontal pockets. Multivariable logistic regression was selected to assess potential associated factors with the development of periodontal pockets.

RESULTS

Among the 346 adult males, 248 (71.7 %), 30 (8.6 %), and 68 (19.7 %) males never used shammah, were former shammah users, and were current shammah users, respectively. The significant associated factors with the development of periodontal pocket were age group (30 years old and above) (Adjusted Odds Ratio (AOR) = 2.03, 95 % CI: 1.13, 3.65; P = 0.018), low family income category (AOR = 2.35, 95 % CI: 1.39, 3.99; P = 0.001), former shammah user (AOR = 2.66, 95 %: CI: 1.15, 6.15; P = 0.022), and current shammah user (AOR = 6.62, 95 %: CI: 3.59, 12.21; P = 0.001).

CONCLUSIONS

The results revealed that periodontal pockets were significantly associated with age group (30 years old and above), low family income category, former shammah use, and current shammah use. The findings of the current study highlighted the need to develop comprehensive shammah prevention programs and reduce periodontal disease and other shammah-associated diseases.

Dental demographics and metrics of oral diseases in the ageing Australian population

One of the biggest challenges currently facing the dental profession in Australia is the provision of quality and timely dental care to the elderly. Adults aged 65+ years are an exponentially growing section of the community with rapidly changing dental needs, thanks in part to improvements in oral health over the past 60 years that have resulted in a dramatically decreased rate of edentulism and subsequently an increased number of teeth present. This is a challenge not only for the public dental services, but also public health policy makers, private dental practitioners, professional organizations and dental education providers. It is an issue that crosses a range of dental care providers, not only dentists but also dental prosthetists and dental hygienists, whose role in the provision of dental services has been slowly growing in Australia. Furthermore, with evidence of links between oral and systemic health, this issue has significant impacts for the broader health system.

Periodontal considerations in older individuals

In the next few years there will be a great increase in the percentage of the population aged over 65. Not only will they have more teeth than previous generations, but also a large number of implants. The increase in age is accompanied by an increase in the prevalence and incidence of periodontal diseases. In addition, there is a decrease in manual dexterity and an increase in co-morbidity and medications affecting the oral cavity. Dental care in aged care facilities can be poor and access to dental professionals difficult. This article discusses these issues.

Factors affecting institutionalized older peoples' self-perceived dry mouth

Purpose

The purpose of this study was to determine the factors affecting institutionalized older peoples’ self-perceived dry mouth.

Methods

This cross-sectional study was conducted on elderly residents at 22 long-term care facilities. A total of 165 questionnaires were returned from 13 senior citizen welfare institutions (SCWIs) and nine nursing homes. Multiple logistic regression analysis was used to analyze the data obtained.

Results

The results showed that the type of long-term care (LTC) facility, regular oral examinations, wearing dentures, and the ability to chew sticky foods affected self-perceived dry mouth. This study determined an association between the type of LTC facility where the participants lived and self-perceived dry mouth.

Conclusions

The results indicated the importance of providing oral care in order to improve and prevent dry mouth among institutionalized older people living in SCWIs who do not undergo regular oral examinations, wear dentures, and have difficulty chewing sticky foods.