Evaluation of an oral health education program for nursing personnel in special housing facilities for the elderly. Part II: Clinical aspects

Oral health care in older people in long-term care facilities: An updated systematic review and meta-analyses of implementation strategies

Introduction

Oral health care of older people in long-term care facilities is insufficient, stressing the need for clear evidence-based implementation strategies to improve oral care. In 2013, a systematic review was performed and new evidence was published. This study aimed to gain insights into implementation strategies used to promote or improve oral health care for older people in long-term care facilities, explore their effectiveness and uncover strategy content in behavioral change techniques, and report the differences between the current results and those of the 2013 study.

Methods

A systematic review of the literature according to PRISMA guidelines and meta-analyses of implementation strategies were performed. Cochrane Library, PubMed, and CINAHL databases were searched for papers published between 2011 and 2023. Strategies were identified using the Coding Manual for Behavioral Change Techniques. Meta-analyses of oral health outcomes ("plaque" and "denture plaque") were performed with random-effects models using R language for statistical computing.

Results

16 studies were included in the current results; 20 studies were included in the 2013 findings. More high-quality studies (67 %) were included in this review than in 2013 (47 %). Dental care professionals were involved in 14 of the 16 studies. Fourteen of the 16 studies used and/ or combined five or more different implementation strategies: knowledge, intention, awareness, self-efficacy, attitude, and facilitation of behavior. Implementation positively affected the knowledge and attitudes of the nursing staff; however, the oral health of older people did not necessarily improve. In the 2013 review, more studies indicated combined oral health measurements were effective (71 %) than in the current review (20 %-33 %). Meta-analysis of four studies on dental plaque (0-3 scale) showed a significant, statistically small mean difference of -.21 (CI -.36; -.07, Cohen's d -.29) between the control and treatment group. Meta-analysis of three studies on denture plaque (0-4 scale), showed a significant, statistically large mean difference of -.76 (CI -1.48; -.05, Cohen's d -.88).

Conclusions

In this review, more implementation strategies and combinations were used to implement oral care in long-term care. Implementation strategies positively affected the knowledge and attitudes of nursing staff; however, the oral health of older people did not necessarily improve. Meta-analyses on plaque showed that oral care implementations are effective; for denture plaque, the effect size was large and thus may have more clinical value than for dental plaque.

Policy Options to Complement the New Canadian Dental Program Enabling High Quality Care for People With Disabilities and Older Adults

BACKGROUND

The newly announced Canadian Dental Care Plan (CDCP) particularly aims to reduce financial barriers to dental care for individuals living below a family income threshold. The Canadian government has also launched an "Oral Health Access Fund" to support projects aiming to address financial barriers to dental care for older adults, those with disabilities and other groups. Evidence from programs implemented elsewhere in the world could inform policy decisions and address such non-financial barriers for older Canadians and those with disabilities.

AIM

To identify dental programs and policies in OECD countries focusing on people with disabilities and older people, and to outline how they might be applied to the Canadian context.

METHODS

The strategy for this narrative literature review comprised a combination of Medical Subject Headings (MeSh) or their equivalent, title/abstract keywords, truncations, and Boolean operators. Medline (Ovid), Embase (Ovid), CINAHL and Scopus were used. The searches were limited to English language publications involving programs and policies in all OECD countries. All searches ran from inception to January 25, 2023, with no restrictions on publication time.

RESULTS

The search identified 129 articles eligible for review. Findings were categorized as (1) interventions at the institutional-level (subdivided into patient-, professional- and community-focused programs) and (2) interventions at the governmental-level (subdivided into universal, population-specific, and community-based programs). Evidence suggests that targeted, integrated coaching or education programs for oral health care are beneficial, especially when programs are constantly evaluated and improved. Programs with a unified network system that integrates various relevant organizational and health domains have demonstrated to be most effective in the improvement of oral health care and overall health. Dental and medical healthcare workers play a crucial role in improving oral health outcomes and need motivation and fair compensation when caring for older people.

CONCLUSIONS

There is limited quality evidence supporting approaches to improving oral health care and oral health for older people and those with disabilities. It is important for policymakers and stakeholders to consider programmes from other countries when expanding the CDCP.

Cluster randomized control trial of nursing home residents' oral hygiene following the Mouth Care Matters education program for certified nursing assistants

Aims

The purpose of this study was to determine if the number of certified nursing assistants (CNAs) trained with the Mouth Care Matters (MCM) oral health educational program had an impact on nursing facility (NF) resident oral health.

Materials and methods

Three NFs participated in a cluster randomized control trial. In NF‐A: all CNAs were offered the MCM program, NF‐B: 3 CNAs were offered the MCM program, and NF‐C: Control (no CNAs were offered the MCM program). Demographic information, systemic health data, and oral health data at baseline, 3‐month, and 6‐month intervals were collected and analyzed using Kruskal‐Wallis, Wilcoxon signed‐rank and Wilcoxon rank‐sum tests. A total of 24 dentate residents participated in this study. Plaque control record scores for NF‐A were significantly reduced compared to NF‐B and NF‐C (P < .001 and P = .002 respectively) and gingival bleeding index for NF‐A were significantly reduced compared to NF‐B and NF‐C (P = .002 and P < .001 respectively).

Conclusion

Increasing the number of CNA's trained in the Mouth Care Matters educational program positively impacted NF residents’ oral hygiene.

Implementation and evaluation of an oral health education programme for caregivers in nursing homes

AIM

The aim was the design, implementation, and evaluation of an oral health education program for nursing home caregivers.

METHODS AND RESULTS

Fifty-five formal caregivers working in the three units of a nursing home were allocated to either a control (n = 27) or an intervention group (n = 28). A knowledge and attitudes questionnaire about oral health was developed and completed by the caregivers. Then, an education program about oral heath in older people was applied to the intervention group, and the completion of the questionnaire was repeated by both the intervention and control groups. Two months after the intervention, the questionnaire was completed again by the intervention group. Within groups analyses revealed a statistically significant increase in knowledge and attitudes only in the intervention group after the implementation of the education program (P < .001). Between-group analyses showed that the total knowledge and attitudes score in the intervention group were statistically significantly higher than in the control group (P < .001 and P = .02, respectively). In the intervention group, knowledge and attitudes were maintained in the measurement recorded 2 months later (P = .11 and P = .21, respectively).

CONCLUSION

The education program was effective in improving the caregivers' knowledge and attitudes toward nursing home residents' oral health and maintaining them 2 months after implementation.

An evaluation of health workforce models addressing oral health in residential aged care facilities: A systematic review of the literature

BACKGROUND

In Australia and globally, there is an increasing problem of unmet oral health needs of older people above 65 residing in aged care facilities. Various workforce models have been trialled to implement oral health care programmes in aged care facilities, but the evidence behind these programmes and their underlying workforce models is not known.

OBJECTIVE

To systematically review the literature on the effectiveness, and economic feasibility of the current workforce models addressing oral care in aged care facilities.

METHODS

CINAHL, Cochrane CENTRAL, MEDLINE, EMBASE, EMB Reviews, NHS Economic Evaluation Database and grey literature were searched. Studies were included if they described an oral health workforce model with a clinical intervention and defined oral health outcome measures. Analysis was conducted using the NHMRC guidelines for scientific and economic evaluations.

RESULTS

Twenty-eight studies were included. Four distinct workforce models of care were identified. 60% of the studies demonstrated short-term effectiveness in clinical measures. Workforce models were similar in their effectiveness, with varying levels of quality within each model. Although three studies considered individual components of economic feasibility, only one provided a comprehensive economic analysis of both the costs and health outcomes.

CONCLUSIONS IMPLICATIONS OF FINDINGS

All workforce models of care had some positive impact on oral health for residents of aged care. Oral health should be included as a health focus in age care facilities. Future studies should include longer-term health outcomes with rigorous economic analysis to ensure sustainably delivered workforce models of care for oral health management within aged care.

Readily Identifiable Risk Factors of Nursing Home Residents' Oral Hygiene: Dementia, Hospice, and Length of Stay

BACKGROUND/OBJECTIVES

The poor oral hygiene of nursing home (NH) residents is a matter of increasing concern, especially because of its relationship with pneumonia and other health events. Because details and related risk factors in this area are scant and providers need to be able to easily identify those residents at most risk, this study comprehensively examined the plaque, gingival, and denture status of NH residents, as well as readily available correlates of those indicators of oral hygiene, including items from the Minimum Data Set (MDS).

DESIGN

Oral hygiene assessment and chart abstract conducted on a cross-section of NH residents.

SETTING

NHs in North Carolina (N = 14).

PARTICIPANTS

NH residents (N = 506).

MEASUREMENTS

Descriptive data from the MDS and assessments using three standardized measures: the Plaque Index for Long-Term Care (PI-LTC), the Gingival Index for Long-Term Care (GI-LTC), and the Denture Plaque Index (DPI).

RESULTS

Oral hygiene scores averaged 1.7 (of 3) for the PI-LTC, 1.5 (of 4) for the GI-LTC, and 2.2 (of 4) for the DPI. Factors most strongly associated with poor oral hygiene scores included having dementia, being on hospice care, and longer stay. MDS ratings of gingivitis differed significantly from oral hygiene assessments.

CONCLUSIONS

The findings identify resident subgroups at especially high risk of poor oral health who can be targeted in quality improvement efforts related to oral hygiene; they also indicate need to improve the accuracy of how MDS items are completed.

Knowledge and practices of diabetes care providers in oral health care and their potential role in oral health promotion: A scoping review

AIM

Oral health complications are common in people with diabetes yet very little is reported about the oral health care provided in diabetes care setting. This study reviewed global evidence on the oral health care knowledge and practices of diabetes care providers and the role of non-dental health professionals in oral health promotion.

METHODS

A systematic search of five databases was undertaken with key search terms using a scoping review framework. Relevant studies published till October 2016 in the English language were included (n=30) and no restrictions were placed on the study design, quality or setting.

RESULTS

Most diabetes care providers are not addressing oral health care with the main barriers being time constraints and limited oral health knowledge. Diabetes educators (DEs) could engage in oral health promotion with few studies showing this model of care can translate into improved patient outcomes. However, no appropriate oral health training programs and assessment tools exist for DEs. With proper training, non-dental professionals like nurses have successfully incorporated oral healthcare in other settings.

CONCLUSIONS

DEs are well placed to promote oral health in diabetes care setting. Further research is needed to identify barriers and oral health resources to support DEs in this role.

Improving oral health of institutionalized older people with diagnosed dementia

OBJECTIVE

Previous research has revealed poor oral hygiene and health among older people suffering from dementia. To evaluate the oral health and denture hygiene of older people with and without dementia, six months after carer have followed a dental education programme.

METHOD

Ninety-three older people living in four long-term care homes in south-western Germany were included in this longitudinal cohort study. All participants were allocated into two groups on basis of the medical dementia diagnosis extracted from the medical records in the care documentation: suffering from dementia (n = 33) or not (n = 60). For each participant plaque control record, gingival bleeding index (GBI), community periodontal index of treatment needs (CPITN), and denture hygiene index (DHI) were assessed at baseline and six months after carer have followed a dental education programme, and after use of ultrasonic devices for denture cleaning. Differences between all target variables from baseline to follow-up, and between participants with and without dementia, were evaluated by bivariate and multivariate testing.

RESULTS

In bivariate testing, participants with dementia had a significantly lower DHI (p < 0.001), a lower GBI (p < 0.05), and a lower CPITN (p < 0.01) at follow-up. In participants without dementia, only for DHI (p < 0.001) a significant improvement was observed. In multivariate analyses, the significant association could not be reproduced (p > 0.05).

CONCLUSIONS

Use of ultrasonic baths can be a successful means for improving denture hygiene among older people in long-term care with and without dementia. Education for carer in order to improve oral hygiene, however, seems to be of minor significance and to be more effective for people with dementia.

Practice Change Interventions in Long-Term Care Facilities: What Works, and Why?

Over the past three decades, there has been a notable increase in studies of practice change interventions in long-term care (LTC) settings. This review, based on a modified realist approach, addresses the following questions: What practice change intervention characteristics work? And, in what circumstances do they work and why? A modified realist approach was applied to identify and explain the interactions among context, mechanism, and outcome. We searched electronic databases and published literature for empirical studies of practice change interventions that (a) were conducted in LTC settings, (b) involved formal care staff members, and (c) reported a formal evaluation. Ninety-four articles met the inclusion criteria. Interventions that included only predisposing factors were least likely to be effective. Interventions that included reinforcing factors were most likely to produce sustained outcomes. We concluded that interventions aimed at practice change in LTC settings should include feasible and effective enabling and reinforcing factors.

Improving Oral Hygiene in Institutionalised Elderly by Educating Their Caretakers in Bangalore City, India: a Randomised Control Trial

Background

The population of older people, as well as the number of dependent older people, is steadily increasing; those unable to live independently at home are being cared for in a range of settings. Practical training for nurses and auxiliary care staff has frequently been recommended as a way of improving oral health care for functionally dependent elderly. The aim was improve oral hygiene in institutionalized elderly in Bangalore city by educating their caregivers.

Methods

The study is a cluster randomized intervention trial with an elderly home as unit of randomization in which 7 out of 65 elderly homes were selected. Oral health knowledge of caregivers was assessed using a pre-tested pro forma and later oral-health education was provided to the caregivers of the study group. Oral hygiene status of elderly residents was assessed by levels of debris, plaque of dentate and denture plaque, and denture stomatitis of denture wearing residents, respectively. Oral-health education to the caregivers of control group was given at the end of six months

Results

There was significant improvement in oral-health knowledge of caregivers from the baseline and also a significant reduction of plaque score from baseline score of 3.17 ± 0.40 to 1.57 ± 0.35 post-intervention (p < .001), debris score 2.87 ± 0.22 to 1.49 ± 0.34 (p < .001), denture plaque score 3.15 ± 0.47 to 1.21 ± 0.27 (p < .001), and denture stomatitis score 1.43 ± 0.68 to 0.29 ± 0.53 (p < .001).

Conclusions

The result of the present study showed that there was a significant improvement in the oral-health knowledge among the caregivers and oral-hygiene status of the elderly residents.

Oral Hygiene Status of Institutionalised Dependent Elderly in India - a Cross-Sectional Survey

Background/Introduction

For various reasons, the care demand from elderly people is low and difficult to determine, whereas their oral hygiene status would need urgent care.

Objective

To assess the oral hygiene status of institutionalized dependent elderly in Bangalore City, India.

Methods

A cross-sectional study of 322 dependent elderly patients was conducted at seven elderly homes of Bangalore City, India. The oral hygiene status recorded includes dental and prosthetic hygiene.

Results

The mean Debris Index and Plaque Index scores of dentate elderly were 2.87±0.22 and 3.17±0.40, respectively, the mean Denture Plaque and Denture Stomatitis scores were 3.15±0.47 and 1.43±0.68, respectively.

Conclusion

The dental hygiene was inadequate. This study emphasizes the care demand and the need for help in oral hygiene procedures for the dependent institutionalized elderly.

Oral health care in older people in long term care facilities: a systematic review of implementation strategies

OBJECTIVES

Oral hygiene is necessary to maintain oral health and quality of life. However, the oral hygiene and the oral health care of older people in long term care facilities are poor. This indicates that care is not in compliance with the available guidelines and protocols, and stresses the importance of a clear evidence-based implementation strategy to improve oral health care. The aim of this study is to review implementation strategies used to promote or improve oral health care for older people in long term care facilities from the perspective of behaviour change, to code strategy content at the level of determinants, and to explore their effectiveness.

DESIGN

Systematic review of literature.

DATA SOURCES

The digital databases of the Cochrane Library, PubMed and Cinahl have been searched up to September 2011 for relevant articles.

REVIEW METHODS

After a systematic selection process, included studies were quality assessed by three researchers. We extracted the study characteristics using the EPOC Data Collection Checklist and Data Abstraction Form. Strategy content was extracted and coded by using the Coding Manual for Behavioural Change Techniques. This manual groups the behaviour change techniques under relevant behavioural determinants.

RESULTS

Twenty studies were included in this review. Implementation strategies were delivered by dental hygienists or dentists. Oral health care was performed by nurses and nurse assistants in all studies. All studies addressed knowledge, mostly operationalized as one educational session. Knowledge was most often combined with interventions addressing self efficacy. Implementation strategies aimed at knowledge (providing general information), self-efficacy (modelling) or facilitation of behaviour (providing materials to facilitate behaviour) were most often identified as successful in improving oral health.

CONCLUSIONS

Knowledge, self-efficacy and facilitation of behaviour are determinants that are often addressed in implementation strategies for successful improvement of oral health care in older patients. Strategies addressing increasing memory, feedback of clinical outcomes, and mobilizing social norm are promising and should be studied in the future. However, as the quality and heterogeneity of studies is a reason for concern, it is not possible to unequivocally recommend strategies or combinations of strategies for improving oral health care in the older population. When choosing strategies to improve oral health care, care professionals should thoroughly examine the setting and target group, identify barriers to change and tailor their implementation strategies to these barriers for oral health care.

Prevention of aspiration pneumonia (AP) with oral care

AP is a major cause of morbidity and mortality in elderly patients, especially frail elderly patients. The aim of this article is to review effect of oral care, including oral hygiene and improvement of oral function, on the prevention of AP among elderly people in hospitals and nursing homes. There is now a substantial body of work studying the effect of oral care on the prevention of respiratory diseases. Oral hygiene, consisting of oral decontamination and mechanical cleaning by dental professionals, has resulted in significant clinical effects (decreased incidence of pneumonia and decreased mortality from respiratory diseases) in clinical randomized trials. Moreover, studies examining oral colonization by pneumonia pathogens have shown the effect of oral hygiene on eliminating these pathogens. In addition, swallowing training has been shown to improve the movement and function of swallowing-related muscles, also resulting in decreased incidence of pneumonia. These findings support the contention that oral care is effective in the prevention of AP.

Attitudes and perceptions towards oral hygiene tasks among geriatric nursing home staff

OBJECTIVES

To assess attitudes and perceptions towards oral hygiene tasks among geriatric nursing home staff, before and after a dental hygiene education.

METHODOLOGY

A survey questionnaire was distributed to the nursing staff (n = 105), at a geriatric nursing home in Stockholm, Sweden.

RESULTS

The response rate to the questionnaire was 83%. A vast majority (87%) of the nursing staff considered oral hygiene tasks unpleasant. The main reason for considering oral care unpleasant was a perceived unwillingness from the residents. The perceived unwillingness from the residents among the nursing staff was reduced after the dental hygiene education (chi-square test, P = 0.02). A vast majority of the nursing staff experienced, always or sometimes, resistance from the residents towards oral care.

CONCLUSIONS

Nursing home staff members consider oral care tasks unpleasant, and frequently experience resistance from the nursing home residents towards oral care. The perceived unwillingness from the residents is reduced after an advanced dental hygiene education. Further studies are needed to evaluate the effects of education on nursing staff's attitudes and perceptions towards oral care tasks, with the overall aim of improving the oral health among older people in hospitals and nursing homes.

Home oral health practice: the foundation for desensitization and dental care for special needs

As oral health is increasingly recognized as a foundation for health and wellness, caregivers for special needs patients are an essential component of the oral health team and must become knowledgeable and competent in home oral health practice. Education and training for caregivers should become a standard of care early in the first year of life for any child with developmental delay or any person, regardless of age, who experiences an illness or event that compromises their ability to provide self oral health care. Given the implication of poor oral health to general health and health care costs, home oral health practice is a significant factor in dental care, general health, quality of life, and controlling health care costs.

Improving the oral health of older people in long-term residential care: a review of the literature

Background.  Unrefutable evidence now links poor oral health with the development of preventable systemic illnesses and debilitating conditions that threaten quality of life and life itself. This is especially significant for an increasing older population who are dependent on others for care. Aims and objectives.  The majority of studies analysing the oral health of older dependent people in long-term residential care have been undertaken by dental professionals. This critical literature review examines the issue from a nursing perspective because nursing care providers have a fundamental role in daily oral health provision for dependent residents. Conclusions.  Multiple barriers were found to negatively impact on daily oral healthcare provision, including lack of care provider education, oral health values, availability of resources, implementation of supportive policies, documentation and oral health assessment tools. Relevance to clinical practice.  The nursing profession, at all levels, must become pro-active in removing financial, political and workforce barriers that impact negatively on oral health outcomes. A multi-faceted approach is required to address these barriers, including development and implementation of oral health education programmes, assessment screening tools, care plans, documentation, supply of oral hygiene aids and the appointment of oral care 'champions'.

Effects of 11-month interventions on oral cleanliness among the long-term hospitalised elderly

OBJECTIVES

This trial studied the effects of interventions on the oral cleanliness of the long-term hospitalised elderly.

BACKGROUND

Oral cleanliness is mostly poor in long-term facilities. While many agree on the importance of oral hygiene education for nursing personnel, little information and agreement exists on how to organise this education in geriatric institutions.

MATERIALS AND METHODS

This is a longitudinal study with interventions. After a baseline clinical examination, the patient wards were divided into three groups (A, B and C) and the type of intervention was randomly assigned. In group A, dental hygienists provided oral hygiene measures for the subjects once every 3 weeks. In group B, the nursing staff first received hands-on instructions after which they assumed responsibility for the subjects' daily oral hygiene. Group C served as a control. Denture hygiene and dental hygiene were recorded at baseline and in the end of the 11-month study period. In total, 130 subjects completed the interventions; their mean age was 82.9 years.

RESULTS

The best outcome in both denture and dental hygiene occurred when nursing staff at the wards took care of hygiene (group B). The increase in the proportion of those with good denture hygiene was the most prominent in group B (from 11% to 56%). The proportion of subjects with poor overall dental hygiene decreased from 61% at baseline to 57% in the end, for group B from 80% to 48%.

CONCLUSIONS

Organised oral health education of the nursing staff should receive more attention.

The knowledge of healthcare professionals regarding elderly persons' oral care

OBJECTIVE

The aim of this study was to compare the knowledge and views of nursing staff on both acute elderly care and rehabilitation wards regarding elderly persons' oral care with that of carers in nursing homes.

SUBJECTS

One hundred nurses working on acute, sub-acute and rehabilitation wards for elderly people (Group 1) and 75 carers in nursing homes (Group 2) were surveyed.

DESIGN

A semi-structured questionnaire.

RESULTS

Similar percentages of each group of nurses were registered with a dentist (86% and 88% respectively), although more hospital-based nurses were anxious about dental treatment compared with the nursing home group (40% and 28% respectively). More carers in nursing homes gave regular advice about oral care than the hospital-based nurses (54% and 43% respectively). Eighteen per cent of each group thought that edentulous individuals did not require regular oral care. Eighty-five per cent of hospital-based nurses and 95% of nursing home carers incorrectly thought that dentures were 'free' on the NHS. Although trends were observed between the two groups, no comparisons were statistically significant (Chi-square; level p < 0.05).

CONCLUSIONS

Deficiencies exist in the knowledge of health care workers both in hospital and in the community setting, although the latter were less knowledgeable but more likely to give advice to older people.

A Systematic Review of Oral Health Assessment by Nurses and Carers for Residents with Dementia in Residential Care Facilities

This paper presents systematic review findings to best summarize the assessment of oral health and the use of oral assessment tools by nurses and carers for adults with dementia living in residential aged care facilities. The systematic review searched electronic databases for articles in English (1980 to 2002) and supplemented these with a secondary search of references cited in articles meeting the review inclusion criteria. Delineation is needed between a comprehensive dental examination conducted by a qualified dentist and a dental assessment screening by a carer, nurse, allied health professional or medical practitioner. Dental examinations should be supplemented with oral health assessments and screenings by trained nurses and carers to monitor residents' oral health, evaluate oral hygiene care interventions, act as a trigger to call in a dentist when required, assist with residents' individualized oral hygiene care planning and assist with triaging and prioritization of residents' dental needs. To date, the most comprehensive, validated and reliable assessment screening tool for use by nurses and carers with cognitively impaired institutionalized residents is the Brief Oral Health Status Examination. Other less comprehensive oral assessment tools that are useful for nurses and carers of institutionalized dementia populations include the Index of Activities of Daily Oral Hygiene and the Mucosal Plaque Score. These review findings presented evidence to support the use of oral assessment screening tools by nurses and carers for cognitively impaired residents living in residential aged care facilities. Few validated and reliable tools have been published for use by carers in the cognitively impaired residential care population, and continued evolution of oral assessment screening tools needs to embrace the complete spectrum of residents' levels of cognitive impairment.

Nursing home executive directors' perception of oral care in long-term care facilities

Oral health in long-term care (LTC) facilities has been repeatedly documented as less than ideal. The complex nature of this environment has made it difficult to understand and improve the oral health status of residents through education and training. The purpose of the study was to investigate how the executive directors (EDs) of LTC facilities value oral health and to determine facility variables, which may influence how oral care is delivered. A mail survey of the EDs of all LTC facilities in Ohio (n = 1018) was conducted with 338 responses received after secondary follow-up (33.2% response rate). The 30-item survey included information concerning the nursing facility, the EDs, the EDs' perception of the level of oral health care, and value statements rated on a Likert-like scale. The results of the survey showed that more than two-thirds of the EDs were female and that most facilities were proprietary (70.3%). ED gender was not statistically associated with any of the oral health variables. Fifty-three percent of the EDs rated their residents' oral health as fair or poor but were still satisfied with the oral care provided at their facilities. The apparent discontinuity between perceived levels of oral health and satisfaction with oral care suggests that EDs are distanced from the oral care of their residents or they do not acknowledge oral health care needs. While the survey results revealed important facility characteristics and administrators' perceptions about oral health, the most important aspect of this project was the low response rate despite secondary follow-up. That, coupled with the negativity expressed upon follow-up, suggests a larger issue that may affect oral health in nursing facilities: oral health continues to have a low priority in this setting. Continuing efforts to improve oral health and educate LTC professionals about oral health's influence on general health is critical for managing the oral health of future generations of aging adults.

[Domiciliary assistance dental programs: a current demand]

INTRODUCTION

The growing demand of dental treatment by institutionalised and community-dwelling older adults has made necessary to develop and to evaluate domiciliary dental care programmes.

OBJECTIVE

Delivering and economic evaluation of comprehensive oral health care treatment to older adults living at home or in geriatric centres, with problems of transportation.

PROGRAM

A domiciliary dental care program in a nursing home and in a group of people receiving domiciliary care has been develop. During a 10 and 5 month period and working with 210 and 47 patients respectively, a dentist and hygienist treated the basic dental needs with portable instruments.

DISCUSSION

In spite of the advantages of those programmes, they have a lot of problems such as the economic costs (25,000 Euros in the nursing home and 16,700 in their own house), the dental treatment limitations and the few patients you can visit in one day. The development of domiciliary dental care treatment programmes suppose high economics cost that we must pay attention.

Oral hygiene and oral symptoms among the elderly in long-term care

Dental teams examined 1910 elderly adults living in long-term care settings (1358 institutionalized, 552 homebound) from all 19 counties in Norway to document oral hygiene, oral symptoms and ability to receive dental treatment. The Mucosal-Plaque Score (MPS) was used to assess oral status. The MPS was significantly better in women than in men, in individuals with dentures than in those with any remaining teeth, and in people who were homebound rather than those who lived in institutions. The MPS did not differ between age groups or geographic regions. According to the Treatment Ability Index, nearly a quarter of the sample was able to receive comprehensive dental care. Reports of "any oral symptom" and "eating/chewing problems" decreased with age and were most prevalent for individuals who had dentures. The MPS had only slight impact on oral symptoms, chewing ability and dry mouth (p > 0.05). Dry mouth was found in 16.9% and was most prevalent in individuals with dentures.

Oral health problems in elderly rehabilitation patients

A combination of poor oral hygiene and dry mouth may be hazardous to the oral health status. However, systematic assessments in order to detect oral health problems are seldom performed in the nursing care of the elderly. The aims of this study were to investigate the occurrence of oral health problems measured using the Revised Oral Assessment Guide (ROAG) and to analyse associations between oral health problems and age, gender, living conditions, cohabitation, reason for admission, number of drugs, and functional and nutritional status. One registered nurse performed oral health assessments using ROAG in 161 newly admitted elderly patients in rehabilitation care. Oral health problems were found in 71% of the patients. Thirty per cent of these patients had between four and eight problems. Low saliva flow and problems related to lips were the most frequent oral health problems. Problems in oral health status were significantly associated with presence of respiratory diseases (problems with gums, lips, alterations on the tongue and mucous membranes), living in special accommodation (low saliva flow, problems with teeth/dentures and alterations on the tongue), being undernourished (alterations on the tongue and low saliva flow) and being a woman (low saliva flow). The highest Odds ratio (OR) was found in problems with gums in relation with prevalence of respiratory diseases (OR 8.9; confidence interval (CI) 2.8-27.8; P < 0.0005). This study indicates the importance of standardised oral health assessments in order to detect oral health problems which can otherwise be hidden when the patients are admitted to the hospital ward.

Oral hygiene care for adults with dementia in residential aged care facilities

OBJECTIVE

The objective of this systematic review was to report on the best available evidence relating to oral hygiene for adults with dementia in residential aged care facilities, including: INCLUSION CRITERIA: This review considered any randomised or non-randomised controlled studies, cohort studies, case-control studies, multiple time series studies, uncontrolled studies, descriptive studies and opinions of respected authorities (including theses and other publications) related to residents with dementia living in residential aged care facilities in Australia and overseas; community-dwelling adults with dementia; and special needs adult populations (for preventive oral hygiene care strategies and interventions).The review considered studies and publications designed to:1 quantify the oral health status of older adults living in residential aged care facilities;2 quantify the oral health status of adults with dementia living in the community and in residential aged care facilities;3 evaluate tools used to assess the oral health of residents by staff and carers working in residential aged care facilities;4 evaluate preventive oral hygiene care strategies and interventions used in special needs adult populations (including adults with dementia); and5 evaluate oral health care training and oral hygiene care provision, staff and carers working in residential aged care facilities.Dental outcome measures of interest were those relating to the prevalence, incidence, experiences and increments of oral diseases and conditions including: denture problems, coronal and root caries, periodontal diseases (plaque accumulation, gingivitis, loss-of-attachment), oral mucosal conditions, xerostomia and salivary gland hypofunction, tooth loss, difficulty chewing, behavioural problems and pain/discomfort. Related characteristics and outcomes of interest included: medical conditions, medications, cognitive status, functional status, nutritional status and sociodemographics.

SEARCH STRATEGY

The aim of the search was to locate relevant English-language studies and publications appearing between 1980 and 2002. The search utilised a two-step approach, involving an initial search of electronic databases using combinations of key words followed by a second extensive search carried out using the identified key words. This was supplemented with a secondary search of the references cited in the identified studies. Electronic database searched were: Cinahl, Embase, Psycinfo, Medline and Current Contents.

METHODOLOGICAL QUALITY

All selected studies were critically appraised by two reviewers prior to inclusion in the review.

RESULTS

In regards to relevance, incidence, experiences, and increments of oral diseases and conditions, possible risk factors identified included: saliva dysfunction, polypharmacy, comorbid medical conditions, swallowing and dietary problems, increased functional dependence, need for assistance with oral hygiene care, and poor access and utilisation of dental care.Evidence on the use of assessment tools by carers to evaluate residents' oral health showed that successful assessment of residents with and without dementia by nursing staff requires appropriate staff training by a dental professional. Coupled with appropriate training, an oral assessment screening tool designed for residents with dementia has been successfully used by nursing and care staff to identify residents requiring further review by dental professionals. Expert opinion in the field indicates that oral assessment screenings by a staff member and then by a dentist would ideally be undertaken upon admission to a facility, and regularly thereafter by staff and/or dentists as required.Clinicians and researchers suggested that oral hygiene care strategies to prevent oral diseases and conditions were found to be effective in preventing oral diseases, and thus are relevant for use in the resident with dementia.In regards to the provision of dental treatment and ongoing management of oral diseases and conditions, the use of adjunctive and preventive aids were found to be effective when introduced in conjunction with a staff training program:Expert opinion suggests that behaviour management techniques will increase the potential of performing oral hygiene care interventions.

CONCLUSIONS

This review suggests that the training of staff in the form of a comprehensive practically oriented program addressing areas such as oral diseases, oral screening assessment, and hands-on demonstration of oral hygiene techniques and products is likely to have a positive impact on the management of oral hygiene care within residential aged care facilities. The review also identified that regular brushing with fluoride toothpaste, use of therapeutic fluoride products and application of therapeutic chlorhexidine gluconate products are validated by research as effective for the general population and some populations with special needs.

Effectiveness of continuing education in long-term care: a literature review

PURPOSE

This review of the literature examines the effectiveness of continuing education programs in long-term care facilities.

DESIGN AND METHODS

A comprehensive literature search was made for evaluation studies and included computerized bibliographic databases, manual searches of journals, the bibliographies of retrieved articles, and information from key informants.

RESULTS

Forty-eight studies met our selection criteria. Rigorous research in this area has been limited. Because of the lack of follow-up evaluation, there is minimal evidence that knowledge gained from training programs is sustained in the long term. Most studies do not consider organizational and system factors when planning and implementing training initiatives. This may account for difficulties encountered in the sustained transfer of knowledge to practice.

IMPLICATIONS

There is a need for further rigorous research on the effectiveness of continuing education in long-term care, with systematic attention to the role of organizational and system factors.

Oral health and nutritional status in a group of geriatric rehabilitation patients

The aims of this study were to evaluate the oral health status and nutritional status in a group of geriatric rehabilitation patients, and to analyse the relationship between these two parameters. Nurses at the ward performed structured assessments of oral and nutritional status using the Revised Oral Assessment Guide and the Subjective Global Assessment form in 223 newly admitted patients. Most oral health problems were found among patients who stayed longer at the hospital and were more dependent on help as compared with the healthier patients. Thirty-four per cent of the patients were either severely undernourished, at risk or suspected to be undernourished (UN). Oral health problems were more common among UN patients (p < 0.0005) compared with well-nourished patients. The most frequent oral health problem was found on teeth or dentures (48%). Problems related to the tongue and lips were also common among UN patients (56 and 44%, respectively). Oral health status was correlated (r = 0.32) to nutritional status. Problems with swallowing had the strongest association to the nutritional status (OR 6.05; 95% CI 2.41-15.18). This study demonstrated that poor oral health status was related to undernourishment.

Recall of an oral health education programme by nursing personnel in special housing facilities for the elderly

OBJECTIVES

To investigate the recall of oral health knowledge and confidence by nursing personnel in special housing facilities for the elderly, three years after an education programme.

DESIGN

A cross sectional design using a questionnaire.

SAMPLE

All nursing personnel, a total of 2,901 subjects, in five municipalities in south-western Sweden; of whom 950 had attended the programme. The response rate was 67% (1930 subjects).

INTERVENTION

An oral health education programme consisting of four one-hour lessons.

RESULTS

The oral health education programme still had an effect on the participants' attitudes towards oral health three years later. When comparing the trained group (OHEP+) which attended the programme with those who did not have training (OHEP-), the perceived ability, opportunity and the knowledge of oral health were significantly better in the former group, p < 0.01 Further, within the OHEP- group who did not attend the programme there was a significant difference in the perceived ability, opportunity and the knowledge of oral health between those with a higher level of health care education, p < 0.01.

CONCLUSIONS

The effect of an oral health education programme on the participants' attitudes towards oral health persists at least for three years. The data indicate that trainees with a low level of health care education benefit most.