Improving Nursing Home Residents' Oral Hygiene: Results of a Cluster Randomized Intervention Trial

Effect of oral health interventions for dependent older people-A systematic review

BACKGROUND

There is an increasing proportion of older people in the population worldwide, with a large group being dependent on the care of others. Dependent older people are more vulnerable to oral diseases, which can heavily impact their quality of life (OHRQoL) and general health.

OBJECTIVE

The purpose of this systematic review was to comprehensively assess interventions to improve oral health or guarantee access and adherence to dental treatment of dependent older people.

METHODS

We searched MEDLINE, EMBASE, CENTRAL and clinical trial registries. Two reviewers performed the selection, data extraction, risk of bias evaluation using the Cochrane Risk of Bias tool and assessment of certainty of the evidence. When possible, we conducted a meta-analysis to calculate effect estimates and their 95%CIs. Primary outcomes were OHRQoL, oral/dental health, and use of the oral care system.

RESULTS

We included a total of 30 randomised clinical trials assessing educational and non-educational interventions for community-dwelling older people (n = 2) and those residing in long-term care facilities (n = 28). Most studies assessed oral hygiene and showed that interventions may result in a reduction in dental plaque in the short term (with low certainty of evidence), but there is limited evidence for long-term effectiveness. Only one study assessed OHRQoL, and none evaluated changes in the use of the oral health care system.

CONCLUSION

Our findings do not provide strong conclusions in favour of any specific intervention, mainly due to study quality and imprecision. There is limited information about the long-term effect of interventions, and further research is needed, especially targeting community-dwelling older people.

PROSPERO ID

CRD42021231721.

Oral health status of institutionalized older adults receiving domiciliary dental care: A cross-sectional retrospective study

AIM

This study aimed to evaluate the oral health of care-dependent institutionalized older adults receiving domiciliary dental care.

METHODS AND RESULTS

Dental health records of institutionalized adults receiving regular domiciliary dental care were examined (observation period: 5 years). Relevant demographic and oral health information were extracted. Statistical analyses included descriptive and non-parametric tests (α = .05). Records of 398 nursing home residents (mean-age: 84.9 ± 6.4 years) were included. Average time spent by the residents in the institution was 2.8 ± 1.5 years. The mean number of teeth present and the overall DMF-T score was 14.7 ± 9.1 and 27.4 ± 6.2, respectively. The DMF-T score increased until the 3-year recall, with a significant increase in the number of decayed teeth (2-year: p = .013; 3-year: p = .010). An improvement in the residents' periodontal health was seen during the observation period but was not statistically significant.

CONCLUSION

The findings of this cross-sectional study confirmed that regular domiciliary dental care provision to institutionalized older adults helps maintain gingival and periodontal health. However, the incidence of dental caries might still be a problem that needs to be addressed with effective measures that improve the daily oral care provision to these older adults.

Researchers' experiences of the design and conduct challenges associated with parallel-group cluster-randomised trials and views on a novel open-cohort design

BACKGROUND

Two accepted designs exist for parallel-group cluster-randomised trials (CRTs). Closed-cohort designs follow the same individuals over time with a single recruitment period before randomisation, but face challenges in settings with high attrition. (Repeated) cross-sectional designs recruit at one or more timepoints before and/or after randomisation, collecting data from different individuals present in the cluster at these timepoints, but are unsuitable for assessment of individual change over time. An 'open-cohort' design allows individual follow-up with recruitment before and after cluster-randomisation, but little literature exists on acceptability to inform their use in CRTs.

AIM

To document the views and experiences of expert trialists to identify: a) Design and conduct challenges with established parallel-group CRT designs,b) Perceptions of potential benefits and barriers to implementation of open-cohort CRTs,c) Methods for minimising, and investigating the impact of, bias in open-cohort CRTs.

METHODS

Qualitative consultation via two expert workshops including triallists (n = 24) who had worked on CRTs over a range of settings. Workshop transcripts were analysed using Descriptive Thematic Analysis utilising inductive and deductive coding.

RESULTS

Two central organising concepts were developed. Design and conduct challenges with established CRT designs confirmed that current CRT designs are unable to deal with many of the complex research and intervention circumstances found in some trial settings (e.g. care homes). Perceptions of potential benefits and barriers of open cohort designs included themes on: approaches to recruitment; data collection; analysis; minimising/investigating the impact of bias; and how open-cohort designs might address or present CRT design challenges. Open-cohort designs were felt to provide a solution for some of the challenges current CRT designs present in some settings.

CONCLUSIONS

Open-cohort CRT designs hold promise for addressing the challenges associated with standard CRT designs. Research is needed to provide clarity around definition and guidance on application.

Denture Plaque Biofilm Visual Assessment Methods: A Systematic Review

Denture plaque, a biofilm that develops on denture surfaces, could contribute to many oral and systemic afflictions. Hence, a quantitative assessment of denture plaque is important to evaluate the denture hygiene of denture wearers, particularly to prevent plaque biofilm-associated diseases. The aim of this systematic review, therefore, was to review and summarize the visual denture hygiene assessment methods using denture plaque indices and with planimetries published in the literature. English language studies published up to March 2022 in four electronic databases, PubMed, Medline, Embase, and Cochrane Library, were searched, followed by a manual search of Google Scholar by two assessors. The review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) whenever possible. Details of the visual assessment methods, including the types of denture assessed, its materials and its surfaces, as well as the use of a disclosing agent, were the main outcomes. Of 492 screened studies, 74 were included per the inclusion and exclusion criteria. Of these, 60 studies utilized various denture plaque indices while 18 used planimetries. 43 out of 60 studies with indices and 17 out of 18 studies with planimetries used disclosing agents for visual evaluation of plaque. A total of 21 indices were described in the included studies, of which seven graded a divided denture surface, while the remainder graded entire denture surface. Of the 18 planimetric assessments, one study quantified squares of the disclosed plaques on denture images, 16 studies quantified such pixels with computer programs, and a single study quantified points, pixels, and contour of plaque areas. In summary, denture plaque indices appear to be popular in denture plaque assessment due to their simplicity. Computerized planimetric assessment, though more time-consuming, provides a more accurate assessment of plaque load as it is less prone to subjectivity and assessor errors.

Knowledge, attitudes and practices of nurses regarding oral hygiene of dependent inpatients

OBJECTIVE

Assess nurses' knowledge, attitudes and practices towards oral hygiene of dependent inpatients.

METHODS

Quantitative, descriptive, and cross-sectional study. Data were collected through a self-administered questionnaire applied to 100 nurses from internal medicine wards of two hospitals in Northern Portugal, which assessed three dimensions: knowledge, attitudes, and practices regarding oral hygiene. Knowledge, attitudes, and practices in oral care were summarized in statistical descriptions including percentages, frequencies, means, and standard deviations using SPSS version 23 for data analysis.

RESULTS

The mean total knowledge score was 13.98 out of 22 and the participants' mean score of the attitudes towards oral care was 48.35 out of 60 points. All participants acknowledge the importance of oral care for inpatients, with 96% associating poor oral hygiene with systemic disease. As for practices, 90% of participants assess the need for oral care of inpatients in the first 24 h, and 61% document the result of this assessment.

CONCLUSION

The results show that although participants are aware of the importance of oral care, knowledge and practices are not consistent. Concerning oral health practices, it is urgent to narrow the gap between evidence and practice and promote oral care standardization.

Oral care measures for preventing nursing home-acquired pneumonia

BACKGROUND

Pneumonia in residents of nursing homes can be termed nursing home-acquired pneumonia (NHAP). NHAP is one of the most common infections identified in nursing home residents and has the highest mortality of any infection in this population. NHAP is associated with poor oral hygiene and may be caused by aspiration of oropharyngeal flora into the lung. Oral care measures to remove or disrupt oral plaque might reduce the risk of NHAP. This is the first update of a review published in 2018.

OBJECTIVES

To assess effects of oral care measures for preventing nursing home-acquired pneumonia in residents of nursing homes and other long-term care facilities.

SEARCH METHODS

An information specialist searched CENTRAL, MEDLINE, Embase, one other database and three trials registers up to 12 May 2022. We also used additional search methods to identify published, unpublished and ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated the effects of oral care measures (brushing, swabbing, denture cleaning mouthrinse, or combination) in residents of any age in nursing homes and other long-term care facilities.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed search results, extracted data, and assessed risk of bias in the included studies. We contacted study authors for additional information. We pooled data from studies with similar interventions and outcomes. We reported risk ratios (RRs) for dichotomous outcomes, mean differences (MDs) for continuous outcomes, and hazard ratios (HRs) or incidence rate ratio (IRR) for time-to-event outcomes, using random-effects models.

MAIN RESULTS

We included six RCTs (6244 participants), all of which were at high risk of bias. Three studies were carried out in Japan, two in the USA, and one in France. The studies evaluated one comparison: professional oral care versus usual oral care. We did not include the results from one study (834 participants) because it had been stopped at interim analysis.  Consistent results from five studies, with 5018 participants, provided insufficient evidence of a difference between professional oral care and usual (simple, self-administered) oral care in the incidence of pneumonia. Three studies reported HRs, one reported IRRs, and one reported RRs. Due to the variation in study design and follow-up duration, we decided not to pool the data. We downgraded the certainty of the evidence for this outcome by two levels to low: one level for study limitations (high risk of performance bias), and one level for imprecision. There was low-certainty evidence from meta-analysis of two individually randomised studies that professional oral care may reduce the risk of pneumonia-associated mortality compared with usual oral care at 24 months' follow-up (RR 0.43, 95% CI 0.25 to 0.76, 454 participants). Another study (2513 participants) reported insufficient evidence of a difference for this outcome at 18 months' follow-up. Three studies measured all-cause mortality and identified insufficient evidence of a difference between professional and usual oral care at 12 to 30 months' follow-up. Only one study (834 participants) measured the adverse effects of the interventions. The study identified no serious events and 64 non-serious events, the most common of which were oral cavity disturbances (not defined) and dental staining. No studies evaluated oral care versus no oral care.

AUTHORS' CONCLUSIONS

Although low-certainty evidence suggests that professional oral care may reduce mortality compared to usual care when measured at 24 months, the effect of professional oral care on preventing NHAP remains largely unclear. Low-certainty evidence was inconclusive about the effects of this intervention on incidence and number of first episodes of NHAP. Due to differences in study design, effect measures, follow-up duration, and composition of the interventions, we cannot determine the optimal oral care protocol from current evidence.  Future trials will require larger samples, robust methods that ensure low risk of bias, and more practicable interventions for nursing home residents.

Ill Effects and Complications Associated to Removable Dentures With Improper Use and Poor Oral Hygiene: A Systematic Review

The importance of oral care and its relationship with an individual’s well-being has been identified over the past few decades. As there is a drastic increase in the aging population, so did the use of removable dentures more than ever before. The use of dentures among the elderly provides functional advantages and esthetic benefits. However, improper use and poor oral hygiene with removable dentures come with complications, including denture stomatitis, ulcerations, pneumonia, and many more. The study aims to determine the complications associated with inappropriate use and poor oral care and bring forth evidence-based dentist-recommended guidelines for denture maintenance.

Articles were systematically screened in PubMed/Medline (Medical Literature Analysis and Retrieval System Online), PubMed Central (PMC), and Cochrane Library using keywords. Medical Subject Heading (MeSH) was also utilized to identify relevant articles. Inclusion and exclusion criteria were applied, duplicate articles were discarded, and then the articles were reviewed by title and abstract screening. The remaining articles went through a detailed full-text review. A quality appraisal check was conducted for each unique type of research publication, after which a total of 22 articles were finalized.

In this study, we have seen pathological biofilm formation on dentures, life-threatening pneumonia, denture stomatitis, and accidental ingestion/aspiration of dentures amongst the elderly population. The study also identified members with low literacy rates, minorities, and low-income families seem to be at higher risk of poor oral care and denture hygiene. We identified that most of these complications could be prevented with proper guidance and education. In the future, a further detailed study is important as no clear consensus exists in terms of best practices of denture cleaning methods. In addition, measures should be initiated to encourage regular dentist appointments and increase accessibility among members of low socioeconomic status and minorities.

Factors affecting provision of oral health care for people with special health care needs: A systematic review

Background

Special health care needs (SHCNs) individuals experience higher levels of dental problems including accessing oral health (OH) facilities. Improving standard of OH care in SHCNs requires identifying barriers and enablers. The aim of this study was to perform a systematic review of prior researches to identify OH care barriers and enablers for SHCN individuals.

Methods

Electronic searching was conducted systematically in PubMed and Cochrane databases. The PICOS parameters were formulated for the inclusion of studies, and the PRISMA method was used to select the articles. Two reviewers independently screened the articles for eligibility and to minimise the risk of bias in the studies and also searched the contents of key articles, quality of methodology, outcomes and reference lists of all the studies included.

Results

A total of 1316 (PubMed 956, Cochrane 360) studies were found initially and after title and abstract screening and also removal of duplication, reviewers selected 53 papers from PubMED and 19 articles from Cochrane to go through full articles and led to the final confirmation of 21 studies. Common challenges included lack of OH knowledge and awareness, difficulty in accessing treatment, transportation problem, treatment cost, and lack of inter-professional collaboration for specialized services. Potential solutions included OHE training and services for patients and caregivers, easy access to dental services, specialized dental practitioners and use of a combination of expertise to meet the demands of SHCN individuals.

Conclusion

This brief analysis will establish dental obstacles to the provision of information to policymakers for SHCN population at organizational, individuals and policy levels. It will help in effective planning for providing and improving OH care quality in caregivers.

Study protocol for a randomised controlled trial of a care partner assisted intervention to improve oral health of individuals with mild dementia

INTRODUCTION

Individuals with mild dementia are at high risk of poor oral health outcomes. To address this issue, we describe an intervention to teach care partners skills to guide individuals with mild dementia in proper oral hygiene techniques and provide reminders to practice oral hygiene care. By providing support to perform these tasks successfully, we aim to delay oral health decline among this vulnerable population.

METHODS AND ANALYSIS

This multisite study is a three-arm randomised controlled trial. The primary objective is to evaluate the efficacy of an intervention to improve oral hygiene outcomes by promoting positive oral hygiene behaviours and skills among individuals with mild dementia. Care partners' behaviour factors, such as oral care self-efficacy and implementation of the care plan, serve as mediators of the intervention. Participant-care partner dyads will be randomly assigned to either Treatment Group 1, Treatment Group 2 or the Control Group. All groups will receive an educational booklet. Treatment Group 1 and Treatment Group 2 will receive a smart electronic toothbrush. Treatment Group 2 (the intervention group) will also receive an oral hygiene care skill assessment, personalised oral hygiene instruction and treatment plan; and care partners will receive in-home and telephone coaching on behaviour change. Oral health outcomes will be compared across the three groups. The duration of the active intervention is 3 months, with an additional 3-month maintenance phase. Data collection will involve three home visits: baseline, 3 months and 6 months. The study enrollment started in November 2021, and the data collection will end in Spring 2024.

ETHICS AND DISSEMINATION

The study has been approved by the Institutional Review Board of the NYU Grossman School of Medicine and Duke University, and is registered at Clinicaltrials.gov. A Data Safety Monitoring Board has been constituted. The study findings will be disseminated via peer-reviewed publications, conference presentations and social media.

TRIAL REGISTRATION NUMBER

NCT04390750.

The impact of additional payments on functional decline among long-term care health facility residents in Japan

Background

Additional payment approach has been one of the most important incentives in long-term care (LTC) systems for the past 20 years in Japan.

Objective

To estimate the effect of additional payments on functional decline in long-term care health facility (LTCHF) residents of Japan.

Design

A 24-month retrospective cohort study.

Setting and subjects

Residents aged ≥65 years who were newly admitted to LTCHFs in the 2014 fiscal year.

Methods

National LTC claims data were linked to the survey of institutions and establishments for LTC. Competing risk regression was performed with functional decline as the primary outcome, and additional payments as exposure, controlling for individual and facility characteristics. The level of LTC needs certified in the LTC insurance system was applied as a proxy of functional ability. Death, hospitalisation, discharge to home and transfer to other LTC facilities were treated as competing events. Individual- and facility-level additional payments were presented as binary variables: being reimbursed or not during the follow-up period.

Results

At baseline, 146,311 residents from 3,724 LTCHFs were included. The vast majority of additional payments were associated with a lower risk of functional decline at follow-up. At the individual level, additional payment for pre/post admission instructions had the strongest association with a lower risk of functional decline. Despite this, only 8% of residents were reimbursed for this additional payment. At the facility level, residents in LTCHFs with additional payments for support for home-life resumption and nutritional management were associated with a decreased risk of functional decline.

Conclusions

The results of our study may be of particular interest to policymakers in monitoring and evaluating additional payment approaches and provide insight into improving quality of care.

Oral Care in Hospital Settings: Breaking the Vicious Circle of Older Adult Deconditioning

Hospitalized older adults frequently develop aspiration pneumonia, swallowing dys-function (dysphagia), and sarcopenia. In the current study, we propose a framework that incorporates these three factors into a vicious circle that leads to deconditioning, a condition frequently experienced by this vulnerable population. Viewing aspiration pneumonia, dysphagia, and sarcopenia, along with their interrelationships through the lens of this vicious circle, illuminates the critical role that oral health plays in deconditioning. Moreover, this framework highlights oral care as a key nursing intervention for reducing deconditioning in hospitalized older adults. Supporting this view, several studies have shown that oral care can improve health outcomes for hospitalized older adults. However, despite oral care being an essential nursing intervention that restores oral function and promotes patient wellness, it is one of the most neglected nursing interventions. Missed oral care occurs due to staff's limited awareness of its significance for care-dependent older adults in hospital settings. We hope that this vicious circle paradigm helps raise awareness of the significance of oral care to prevent deconditioning in hospitalized older adults. [Journal of Gerontological Nursing, 47(6), 7-12.].

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.

Effects of a Caregiver Training Program on Oral Hygiene of Alzheimer's Patients in Institutional Care

OBJECTIVES

To investigate the effects of a caregiver training program on the oral hygiene of caregivers and patients with Alzheimer's disease (AD) and to identify program components and parameters for accurate assessment of outcomes.

DESIGN

Single-blinded prospective cohort study.

SETTING AND PARTICIPANTS

Patients with AD and caregivers in nursing homes in the Greater Zhengzhou Area, China.

METHODS

Initially 168 AD patient/caregiver pairs were recruited and randomly assigned to control, limited training, and comprehensive training groups. The mini-mental state examination, global deterioration scale, and Katz activities of daily living scale were conducted for patients with AD. Information on participants' oral hygiene habits and general oral health was collected. The modified Quigley-Hein Plaque Index (PI) and Gingival Index (GI) were used to assess oral hygiene and gingival health. Intervention included (1) an educational video showing the role of dental plaque and the modified Bass technique; and (2) caregivers practicing toothbrushing on themselves and patients with AD under professional guidance. Changes in oral hygiene and correlations between patient PI/GI and caregiver PI/GI were analyzed.

RESULTS

After 6 weeks, complete data for 146 AD patient/caregiver pairs were collected. Before enrollment, most patients with AD had very poor oral hygiene. Compared with controls and limited training, only comprehensive training was able to achieve steady reduction in PI and GI scores in patients with AD, which still fell short of desirable levels (PI: 2.46 ± 0.52, GI: 1.24 ± 0.24, week 6). PI and GI scores in caregivers saw steady improvement only through comprehensive training (PI: 1.41 ± 0.38, GI: 0.88 ± 0.19, week 6). Number of training sessions had the greatest influence on both patient PI and GI scores.

CONCLUSIONS AND IMPLICATIONS

Comprehensive caregiver training on toothbrushing skills is effective in improving the oral hygiene of caregivers and patients with AD in nursing homes. Additional evidence is needed to establish the optimal program structure.

Mouth Care in Assisted Living: Potential Areas for Improvement

BACKGROUND

Poor oral care may lead to systemic disease, and there is evidence that assisted living (AL) residents lack quality oral care; in AL, poor care may be due to staff knowledge and attitudes, as well as organizational barriers to providing care.

OBJECTIVES

Determine AL staff knowledge and attitudes regarding mouth care and barriers to changing care.

DESIGN

Self-administered repeated-measures questionnaires completed before and after oral care training.

SETTING AND PARTICIPANTS

A total of 2012 direct care staff and administrators from 180 AL communities.

METHODS

Nine knowledge questions and 8 attitude and practice intention questions, and open-ended questions regarding training and obstacles to providing oral care.

RESULTS

Overall, 2012 participants completed pretraining questionnaires, and 1977 completed posttraining questionnaires. Baseline knowledge was high, but staff were not uniformly aware of the systemic-oral link whereby mouth care affects pneumonia and diabetes. Almost all staff reported learning a new technique (96%), including for residents who resist care (95%). Suggested areas to improve mouth care included having more hands-on experience. The primary perceived obstacles to care centered around residents who resist care and a lack of time.

CONCLUSIONS AND IMPLICATIONS

Based on reports of having benefitted from training, AL staff overwhelmingly noted that new knowledge was helpful, suggesting the benefit of skills-based training, especially in dementia care. Mouth care in AL has been sorely understudied, and merits additional attention.

Introducing Standardized Assessment and Management of Oral Cares in a Rehabilitation Unit: Patient Outcomes and Experiences

PURPOSE

The aim of this study was to improve patient oral hygiene outcomes in a rehabilitation unit by implementing a nursing education package and oral hygiene assessment tool.

DESIGN

A case-control design with 50 rehabilitation patients was performed.

METHODS

Nursing staff received education and training in applying the Modified Oral Health Assessment Tool. Clinician assessment of patient oral hygiene occurred on admission and at days 5-7. Each patient reported their perceptions of oral hygiene and comfort prior to hospitalization, while in the hospital, and after transfer to the rehabilitation unit.

FINDINGS

Oral hygiene rating scores improved significantly from admission to the rehabilitation unit to days 5-7 (p = .00). The mean score of patient perceived cleanliness improved from hospital admission to admission to the rehabilitation unit.

CONCLUSION

Oral hygiene was improved following admission to a rehabilitation unit with a consistent and individualized approach to oral hygiene.

CLINICAL RELEVANCE

The introduction of a consistent and individualized approach to oral hygiene demonstrates positive patient outcomes and high patient acceptance.

Clinical Oral Disorders in Adults Screening Protocol (CODA-SP) from the 2019 Vancouver IADR Consensus Symposium

BACKGROUND

The Clinical Oral Disorder in Elders (CODE) index was proposed in 1999 to assess the oral health status and treatment needs of older people who typically were edentate or had few natural teeth. Since then, more people are retaining natural teeth into old age and have oral disorders similar to younger adults. In addition, there has been further guidance on screening for disease that includes changes to the clinical indicators of several oral disorders and greater sensitivity to people's concerns about their oral health and care needs.

METHODS

Experts in dental geriatrics assembled at a satellite symposium of the International Association of Dental Research in June 2019 to revise the objectives and content of the CODE index. Before the symposium, 139 registrants were asked for comments on the CODE index, and 11 content experts summarised current evidence and assembled reference lists of relevant information on each indicator. The reference lists provided the base for a narrative review of relevant evidence supplemented by reference tracking and direct searches of selected literature for additional evidence.

RESULTS

Analysis of the evidence by consensus of the experts produced the Clinical Oral Disorders in Adults Screening Protocol (CODA-SP).

CONCLUSIONS

The CODA-SP encompasses multiple domains of physical and subjective indicators with weighted severity scores. Field tests are required now to validate its effectiveness and utility in oral healthcare services, outcomes and infrastructure.

Oral health improvement for nursing home residents through delegated remotivation and reinstruction (MundZaRR Study): study protocol of a cluster-randomised controlled trial

INTRODUCTION

Oral health and oral health-related quality of life (OHrQL) of residents in German long-term residential care (LRC) are poor. We will develop an evidence-based catalogue of interventions ('Oral Health Toolbox') and provide care-accompanying reinstruction and remotivation of nursing staff by dental assistants (DA). We hypothesise that such intervention will significantly improve OHrQL, daily oral hygiene/care behaviour and is cost-effective.

METHODS AND ANALYSIS

A scoping review will be used to identify possible intervention components. Mixed methods will be used to identify barriers and enablers of oral hygiene and care in German LRC. The result will be the 'Oral Health Toolbox', a two-phased instrument supporting both initial intervention allocation to improve oral health/hygiene and reinstruction/remotivation. A two-arm clustered, randomised controlled trial (ratio of 1:1 via block randomisation) will be performed in LRC in Rhineland-Palatinate, Germany. Each nursing home represents a cluster. Based on a feasibility study, considering clustering and possible attrition, we aim at recruiting 618 residents in 18 clusters. In the intervention group, dentists will assign one or more intervention component from the box (phase 1). During follow-up, nursing staff will be reinstructed and remotivated by DA, who use the box to decide how to maintain the intervention (phase 2). In the control group residents will receive care as usual. The primary outcome, OHrQL, will be measured using the General Oral Health Assessment Index. Secondary outcomes include pain condition, general health-related quality of life, caries increment, oral/prosthetic hygiene and gingival status, incidence of dental emergencies and hospitalisations, and cost-utility/effectiveness. The endpoints will be measured at baseline and after 12 months. For our primary outcome, a mixed-linear model will be used within an intention-to-treat analysis. A process evaluation using mixed methods will be conducted alongside the trial.

ETHICS AND DISSEMINATION

Ethical approval by the University of Kiel was granted (D480/18).

TRIAL REGISTRATION NUMBER

NCT04140929.

Guideline for oral care of dependent elders: mapping review and cross-cultural adaptation to Portuguese-Brazil

This study aimed to map evidence-based guidelines for oral care of the dependent elders and perform the cross-cultural adaptation to Brazilian Portuguese. Initially, a systematized review was conducted in Medline, Scielo, Scopus, Web of Science, and Google Scholar databases without restrictions in search period or type of study. Articles in English, Spanish, and Brazilian Portuguese describing evidence-based guidelines for oral care, including oral hygiene recommendations, of institutionalized dependent elders were included as long as they presented an evaluation of evident quality. The guideline that met inclusion criteria was submitted to cross-cultural adaptation after obtaining permission from the original authors. Two hundred and nineteen references were found. Three selected articles described evidence-based guidelines for oral care, but the Oral Health Care Guideline for Older People in Long-term Care Institutions (OGOLI), originally developed and implemented in the Netherlands, was selected. It was based on evidence level A2 and consensus of experts and met the quality requirements of the Appraisal of Guidelines for Research & Evaluation (AGREE). This guideline presents oral care recommendations for elders with different levels of dependence in activities of daily living to be performed by caregivers and nursing staff. The adaptation of the OGOLI was mainly on the attributions of care providers, given the differences in professional regulations between Brazil and the Netherlands. The cross-cultural equivalence between OGOLI and its Brazilian Portuguese version was verified.

Fidelity and sustainability of Mouth Care Without a Battle and lessons for other innovations in care

There are countless efficacious interventions that improve outcomes when conducted in controlled situations. Many fewer are effective when implemented in real-world situations, largely because they are not implemented with fidelity. Still fewer are sustained over time, for reasons including lack of institutional support and fit with existing values, among others. It is especially important to examine fidelity and sustainability when efficacious interventions are being implemented, because these interventions are the ones that hold the most promise. This project examined the fidelity and sustainability of Mouth Care Without a Battle (MCWB), an evidence-based program conducted in a two-year cluster randomized trial in 14 nursing homes. Results that triangulated two sources of data indicated that fidelity decreased after the first year; they provide guidance to promote fidelity and sustainability of this and other new care practices in nursing homes, including ongoing education, coaching, evaluation, feedback, and sufficient resources.

Effectiveness of a Mouth Care Program Provided by Nursing Home Staff vs Standard Care on Reducing Pneumonia Incidence: A Cluster Randomized Trial

Importance

Pneumonia affects more than 250 000 nursing home (NH) residents annually. A strategy to reduce pneumonia is to provide daily mouth care, especially to residents with dementia.

Objective

To evaluate the effectiveness of Mouth Care Without a Battle, a program that increases staff knowledge and attitudes regarding oral hygiene, changes mouth care, and improves oral hygiene, in reducing the incidence of pneumonia among NH residents.

Design, Setting, and Participants

This pragmatic cluster randomized trial observing 2152 NH residents for up to 2 years was conducted from September 2014 to May 2017. Data collectors were masked to study group. The study included 14 NHs from regions of North Carolina that evidenced proportionately high rehospitalization rates for pneumonia and long-term care residents. Nursing homes were pair matched and randomly assigned to intervention or control groups.

Intervention

Mouth Care Without a Battle is a standardized program that teaches that mouth care is health care, provides instruction on individualized techniques and products for mouth care, and trains caregivers to provide care to residents who are resistant and in special situations. The control condition was standard mouth care.

Main Outcomes and Measures

Pneumonia incidence (primary) and hospitalization and mortality (secondary), obtained from medical records.

Results

Overall, the study enrolled 2152 residents (mean [SD] age, 79.4 [12.4] years; 1281 [66.2%] women; 1180 [62.2%] white residents). Participants included 1219 residents (56.6%) in 7 intervention NHs and 933 residents (43.4%) in 7 control NHs. During the 2-year study period, the incidence rate of pneumonia per 1000 resident-days was 0.67 and 0.72 in the intervention and control NHs, respectively. Neither the primary (unadjusted) nor secondary (covariate-adjusted) analyses found a significant reduction in pneumonia due to Mouth Care Without a Battle during 2 years (unadjusted incidence rate ratio, 0.90; upper bound of 1-sided 95% CI, 1.24; P = .27; adjusted incidence rate ratio, 0.92; upper bound of 1-sided 95% CI, 1.27; P = .30). In the second year, the rate of pneumonia was nonsignificantly higher in intervention NHs. Adjusted post hoc analyses limited to the first year found a significant reduction in pneumonia incidence in intervention NHs (IRR, 0.69; upper bound of 1-sided 95% CI, 0.94; P = .03).

Conclusions and Relevance

This matched-pairs cluster randomized trial of a mouth care program compared with standard care was not effective in reducing pneumonia incidence at 2 years, although reduction was found during the first year. The lack of significant results in the second year may be associated with sustainability. Improving mouth care in US NHs may require the presence and support of dedicated oral care aides.

Trial Registration

ClinicalTrials.gov Identifier: NCT03817450.

Longitudinal analysis of cost and dental utilization patterns for older adults in outpatient and long-term care settings in Minnesota

BACKGROUND

Dental utilization patterns and costs of providing comprehensive oral healthcare for older adults in different settings have not been examined.

METHODS

Retrospective longitudinal cohort data from Apple Tree Dental (ATD) were analyzed (N = 1,159 total; 503 outpatients, 656 long-term care residents) to describe oral health status at presentation, service utilization patterns, and care costs. Generalized estimating equation (GEE) repeated measures analysis identified significant contributors to service cost over the three-year study period.

RESULTS

Cohort mean age was 74 years (range = 55-104); the outpatient (OP) group was younger compared to the long-term care (LTC) group. Half (56%) had Medicaid, 22% had other insurance, and 22% self-paid. Most (72%) had functional dentitions (20+ teeth), 15% had impaired dentitions (9-19 teeth), 6% had severe tooth loss (1-8 teeth), and 7% were edentulous (OP = 2%, LTC = 11%). More in the OP group had functional dentition (83% vs. 63% LTC). The number of appointments declined from 5.0 in Year 1 (OP = 5.7, LTC = 4.4) to 3.3 in Year 3 (OP = 3.6, LTC = 3.0). The average cost to provide dental services was $1,375/year for three years (OP = $1,427, LTC = $1,336), and costs declined each year, from an average of $1,959 (OP = $2,068, LTC = $1,876) in Year 1 to $1,016 (OP = $989, LTC = $1,037) by Year 3. Those with functional dentition at presentation were significantly less costly than those with 1-19 teeth, while edentulous patients demonstrated the lowest cost and utilization. Year in treatment, insurance type, dentition type, and problem-focused first exam were significantly associated with year-over-year cost change in both OP and LTC patients.

CONCLUSION

Costs for providing comprehensive dental care in OP and LTC settings were similar, modest, and declined over time. Dentate patients with functional dentition and edentulous patients were less costly to treat. LTC patients had lower utilization than OP patients. Care patterns shifted over time to increased preventive care and decreased restorative care visits.

Measuring Self-Efficacy and Attitudes for Providing Mouth Care in Nursing Homes

OBJECTIVES

Mouth care is increasingly recognized as an important component of care in nursing homes (NHs), yet is known to be deficient. To promote quality improvement and inform research efforts, it is necessary to have valid measures of staff self-efficacy and attitudes to provide mouth care.

DESIGN

A self-administered questionnaire completed by NH staff, information about the NH obtained from the administrator, and oral hygiene assessments of NH residents.

SETTING AND PARTICIPANTS

A total of 434 staff in 14 NHs in North Carolina who were participating in a cluster randomized pragmatic trial of Mouth Care Without a Battle (MCWB).

METHODS

Staff in MCWB homes completed the questionnaire at baseline; staff in control homes completed it at 2-year follow-up. The 35-item questionnaire used new items and those from previous measures, many of which were modified for the NH setting. Factorial, construct, and criterion validity were assessed.

RESULTS

Exploratory factor analysis identified a 3-factor 11-item self-efficacy scale (promoting oral hygiene, providing mouth care, obtaining cooperation) named "Self-Efficacy for Providing Mouth Care" (SE-PMC), and a 2-factor 11-item attitudes scale (care of residents' teeth, care of own teeth), named Attitudes for Providing Mouth Care (A-PMC). Scores varied significantly across NHs and differentiated them based on profit status, age, and, for the A-PMC, NH size. Scores also differentiated among staff based on age and, for the SE-PMC, years of experience. In NHs where staff scored more highly, residents featured better oral hygiene (P < .001).

CONCLUSIONS AND IMPLICATIONS

The SE-PMC and A-PMC are valid, parsimonious, and useful measures for quality improvement and research to improve mouth care in NHs that can be used jointly or individually. Preliminary evidence suggests that these scales may be associated with resident-level plaque and gingival hygiene, making them useful tools to assess promotion of mouth care.

Disparities in Access to Oral Health Care

In the United States, people are more likely to have poor oral health if they are low-income, uninsured, and/or members of racial/ethnic minority, immigrant, or rural populations who have suboptimal access to quality oral health care. As a result, poor oral health serves as the national symbol of social inequality. There is increasing recognition among those in public health that oral diseases such as dental caries and periodontal disease and general health conditions such as obesity and diabetes are closely linked by sharing common risk factors, including excess sugar consumption and tobacco use, as well as underlying infection and inflammatory pathways. Hence, efforts to integrate oral health and primary health care, incorporate interventions at multiple levels to improve access to and quality of services, and create health care teams that provide patient-centered care in both safety net clinics and community settings may narrow the gaps in access to oral health care across the life course.