Daily oral hygiene practices, particularly in older adults, are essential in the prevention of oral diseases. Improvements in preventive oral care services have allowed many older adults to enter old age with more of their natural dentition (Kotzer et al., 2012). This ability to keep one's natural teeth is of particular importance for those entering long-term care (LTC) facilities, as oral health in LTC is often viewed as unimportant and frequently described as inadequate (McNally et al., 2012).
Many older adults in LTC have dementia and often exhibit behaviors that make oral care difficult to perform (Jablonski et al., 2018; Jablonski et al., 2011). Due to poor mouth care, nursing home residents are more likely to experience oral complications such as dental caries, tooth pain, dry mouth, and periodontal disease (Kohli et al., 2017). Approximately 70% of adults older than 65 have periodontal disease (Centers for Disease Control and Prevention, 2015). Research shows there is a correlation between poor oral hygiene and systemic diseases, such as diabetes, heart disease, and nursing home aspiration pneumonia (Dahm et al., 2015). Oral care reduces the incidence of systemic illnesses and other oral complications (Urata et al., 2018).
Nursing home residents are often at a disadvantage for poor oral health due to polypharmacy, limited availability of dental health care, and debility, which causes oral hygiene self-care measures to be challenging (VanArsdall & Aalboe, 2016). Because of functional decline and neurological impairments, many residents cannot provide oral care themselves and rely on nursing home staff (Porter et al., 2015). Although all nursing staff are responsible for oral care, this task usually is the responsibility of certified nursing assistants (CNAs) (Sloane et al., 2013). CNAs provide up to 80% of care for nursing home residents (Hoben et al., 2017). CNAs face many barriers and difficulties especially when providing oral care (Hoben et al., 2017). Common barriers recognized in research include lack of time, fear of providing care to residents with care-resistant behaviors, staff members' limited oral care knowledge and training (Hoben et al., 2017; Janssens et al., 2016), and lack of oral care policies and procedures (Hilton et al., 2016; Reigle & Holm, 2015). Most nursing curricula offer little training and education in oral care practices (Hollaar et al., 2015). A gap exists between oral health in nursing home residents and staff members' knowledge and skills in oral hygiene practices to effectively meet the oral care needs in this population.
In a LTC facility in Mississippi, oral care was identified as an area for improvement due to observations of poor oral hygiene on visual inspection, the absence of oral health training programs for staff, and lack of oral care policies and protocols at this institution. A quality improvement (QI) project focused on educating nursing staff of oral care practices in older adults was explored. The aim of this QI project was to determine if an evidence-based oral care protocol in addition to a staff oral care training program on a LTC unit would increase staff knowledge of oral care in older adults and improve oral health outcomes in LTC residents within a 14-day period. Other outcomes were to monitor compliance with documenting daily oral care two times per day for 14 consecutive days.
The Iowa Model of Evidence-Based Practice (Iowa Model Collaborative, 2017) was used to guide the QI project. An opportunity was identified to improve oral health in nursing home residents. A diverse team was brought together including CNAs, RNs, a nurse practitioner, nurse scientists, and a dentist. An oral health protocol was developed and implemented.
A logic model was developed by the principal investigator (PI; A.R.) and used to inform the evaluation of the project (Figure 1). The logic model visually summarizes detailed actions related to implementing the project. Resources, activities, outputs, outcomes, and impacts were developed to evaluate the QI project.
Logic model of oral care protocol implementation.
The current QI project provided nursing home staff with an educational intervention and an evidence-based oral care protocol to improve staff knowledge, skills, and attitudes of oral care practices and improve oral health outcomes in older adults. A pre-/post-intervention design was used to evaluate staff knowledge, skills, and attitudes in oral care practices of older adults, and oral health status of residents was measured using the Oral Health Assessment Tool (OHAT) (Chalmers et al., 2005). Compliance of daily documentation of oral care was also monitored twice daily for 14 days as recommended by a consulting dentist. This project was approved by the University of Alabama Huntsville Institutional Review Board.
Setting and Participants
This project was conducted over a 14-day period in a 100-bed LTC facility in central Mississippi serving skilled and LTC residents during October 2018. The facility incorporates a multidisciplinary team approach to meet the long-term and short-term needs of residents. Nursing staff including RNs, licensed practical nurses (LPNs), and CNAs were recruited to participate in the oral care educational program. A convenience sample of 10 older adults was selected to participate in the project. Residents had to be 65 or older and a LTC resident of the facility. Residents were excluded if they were a skilled resident, were younger than 65, or had a diagnosis of dysphagia. The majority of residents on the LTC unit have dementia, and they can partially assist with mouth care. Nursing staff provided consent before the educational training, and legal guardians provided consent for residents.
Oral Health Educational Session
An educational program was developed to address the importance of oral health in nursing home residents. Four 30-minute oral health educational in-services were provided on 1 day so nursing staff from all shifts could attend. Administration paid for the time for staff to attend, which demonstrated the importance and value of this project. The educational intervention was delivered via an 18-minute PowerPoint® presentation and centered on the significance of oral health in the older adult with a focus on basic mouth care, denture care, oral care techniques, and standards of care. Caring for residents with disruptive behaviors was also discussed along with techniques to manage resistant care (Jablonski-Jaudon et al., 2016). Proper brushing techniques were demonstrated by the PI using model dentures. A review of the evidence-based oral health protocol along with instructions on how to document daily oral care using a checklist developed by the PI was discussed. Oral health educational handouts were provided to participants at the end of the educational intervention.
Evidence-Based Oral Care Protocol
No current evidence-based practice oral care protocol was in place at the facility. An evidence-based Oral Care Protocol was developed from a review of the literature and incorporated standards of practice to direct safe and effective oral care in older adults (Table 1). Four different oral hygiene protocols were developed: oral hygiene–denture care—full or partial dentures; oral hygiene–basic mouth care—resident with natural teeth; oral hygiene—edentulous resident without dentures; and oral hygiene—techniques to manage resistant behaviors. The Oral Care Protocol was designed to be time efficient and easy to use by diverse staff in a LTC facility. This tool incorporated evidence-based practice guidelines for denture care as defined by Felton et al. (2011), basic mouth care for older adults with natural teeth, and oral care for edentulous older adults. Permission to use techniques for managing older adults with resistant behaviors using threat reduction strategies was granted by Jablonski-Jaudon et al. (2016) and was included in the evidence-based protocol.
Oral Care Protocol
Following completion of the educational intervention, the evidence-based Oral Care Protocol and the daily oral care checklist were initiated. A RN at the facility was selected by the PI to act as an oral health champion. The RN acted in a capacity to provide support to direct care staff and ensured oral care procedures were being followed. The implementation period took place over 14 days. Dental care packages consisting of fluorinated toothpaste, a soft bristle toothbrush, and alcohol-free mouthwash were distributed to each participant.
An eight-item oral health knowledge, skills, and attitudes questionnaire using true/false statements and a 4-point Likert scale was developed from a review of the literature. The knowledge section comprised four true/false questions and focused on key topics of sleeping in dentures, oral hygiene in individuals with dementia, denture placement, and brushing frequency. The Likert scale questions assessed confidence (skill) in performing basic oral care and attitudes related to the responsibility of providing oral care. A demographic questionnaire was administered before the start of the educational intervention and contained questions such as age, gender, title, education level, and years of experience. Participant confidentiality was ensured by issuing ID numbers to all nursing staff and residents.
After consent was obtained from the resident's responsible party, a noninvasive dental assessment was conducted by the PI using the OHAT to measure residents' oral health status at baseline, end of Week 1, and end of Week 2. The OHAT is an established evidence-based oral screening instrument developed to evaluate oral health in LTC residents (Chalmers et al., 2005). The OHAT is a modified version of the Brief Oral Health Status Examination (BOHSE) and can be used by health care professionals in the LTC setting (Chalmers et al., 2005). The OHAT comprises eight categories, which include lips, tongue, gums and tissue, saliva, natural teeth, oral cleanliness, dentures, and dental pain (Chalmers et al., 2005). Each category is given a score of 0 to 2 with a maximum score of 16. The lower the score, the healthier the mouth; higher scores indicate poor oral health.
A daily oral care checklist was a communication guide used to document twice daily assessments of oral care. Staff were instructed to place a checkmark in the yes or no column to indicate whether mouth care was performed for each individual item. If mouth care was not performed, nursing staff were asked to document an explanation. Nursing staff were also required to list any abnormalities observed while performing mouth care and report the oral concerns to the supervising nurse and oral health champion.
SPSS version 24 was used for data analysis. Descriptive statistics and non-parametric tests, such as the Wilcoxon signed rank and chi-squared tests, were used to analyze the data. A Kruskal-Wallis test was used to analyze differences in OHAT scores.
Nursing home staff (67%) participated in a one-time 30-minute evidence-based oral health educational session and used the daily oral care checklist on 10 LTC nursing home residents over 14 days. Staff members were all female (100%) and were CNAs (62.1%), LPNs (31%) and RNs (6.9%). Fifty-two percent of staff members had >15 years of LTC experience (Table 2). The average age of the 10 residents was 79, and 80% were female.
Demographics of Nursing Home Staff (N = 29)
A Wilcoxon signed ranks test indicated total post-test scores were statistically higher than total pre-test scores (Z = −2.308, p = 0.021). Knowledge scores on the questionnaire improved from a total mean score of 88.8 on the pre-test to 97.7 on the post-test (Table 3). There was no statistically significant change in skills or attitudes. The majority of nurses agreed or strongly agreed about being confident in performing basic oral care and performing oral care to residents with resistant behavior. CNAs recognized that oral care is their responsibility. Most nurses disagreed with the statement “Residents who are independent should be responsible for their own mouth care.” A reliability analysis of the knowledge section of the oral care questionnaire indicated Cronbach's alpha = 0.258.
Pre- and Post-Test Results of the Oral Care Questionnaire
OHAT scores from nursing home residents were compared at baseline, end of Week 1, and end of Week 2. OHAT scores ranged from 1 to 7 (SD = 0.966 to 1.350). A Kruskal-Wallis test was conducted to examine the differences on OHAT score among baseline, Week 1, and Week 2 score data (Figure 2). A statistical difference (F = 14.2, p = 0.001) was observed among the three groups. All OHAT scores were combined into one Total OHAT mean score. This Total OHAT mean became a computed variable. Statistical significance was identified between all time points. OHAT baseline compared to OHAT Week 1 (p = 0.012); OHAT Week 1 compared to OHAT Week 2 (p = 0.020); OHAT Week 1 compared to Total OHAT (p = 0.005); and OHAT Week 2 compared to Total OHAT (p = 0.005). A chi-squared automatic interaction decision tree analysis of the Total OHAT score indicated dentures (F = 11.402, p = 0.0006) have a possible interaction effect related to dentures present, removed, and cleaned. Sixty percent of residents had dentures.
Box plot of Oral Health Assessment Tool (OHAT) scores at baseline, end of Week 1, and end of Week 2.
Staff members used the daily oral care checklist 100% of the time on both morning and evening shifts. The checklist was completely filled out 100%, and no missing data were present.
The findings of the current QI project identified an oral health educational intervention and evidence-based oral care protocol implementation increased staff knowledge of oral care practices and improved oral health outcomes in older adults, and CNAs accounted for the majority of health care providers and were primarily responsible for providing oral care. The majority of staff had education beyond high school, suggesting this was an educated workforce. Findings demonstrated staff knowledge, skills, and attitudes regarding oral care practices improved with participation in the educational intervention. This finding is similar to other studies demonstrating improvement in knowledge after an educational intervention. McConnell et al. (2018) also saw improvement in staff knowledge after a mandatory educational intervention. Responses on the oral care questionnaire indicated nursing staff recognized the importance of oral care, responded to training, and agreed it was their responsibility to assist residents with oral care.
During the OHAT baseline assessment, residents had common oral conditions, such as dry and chapped lips, dry gums, dry mouth, plaque, and tarter. In 14 days, residents showed statistically significant improvement in oral health status. The removal and cleaning of dentures may play a key role in oral health improvement. The improvement in OHAT scores indicates that staff education and mandatory daily documentation of mouth care along with an evidence-based oral care protocol contributed to a change in oral care behavior as measured by a reduction in resident OHAT scores. Similar results have been found in other studies and suggest an educational intervention and oral protocols improve oral health outcomes (de Lugt-Lustig et al., 2014; Jablonski et al., 2011; Luong et al., 2018; Murray & Scholten, 2018). Oral outcomes in older adults can be improved by providing staff oral care education, using a daily oral care checklist, and implementing oral care protocols.
Implications for Clinical Practice
Education and providing staff with guidelines to follow were useful findings from this QI project and can be used to influence safe and effective oral hygiene practices, advance policy, and improve patient outcomes. The project reflected the importance of oral health in LTC residents and directly contributed to the prevention of poor dental outcomes by providing an oral care protocol. After the educational program, staff voiced they found the session informative and they gained new knowledge of oral care that can be used in daily practice. The findings in this project can be used to guide practice and shape policy by emphasizing the importance of staff training and continuing education in oral health. Plans for sustainability include making the newly developed protocol a part of the facility's policies and procedures along with routine oral screenings using the OHAT every 3 months for ongoing monitoring of oral health status of residents. Furthermore, findings from this project will be used to guide associated facilities in oral health program development.
Limitations of the current project include the oral care questionnaire having poor reliability. It was challenging to identify a questionnaire with established reliability that would meet the assessment needs of this diverse nursing staff related to oral care knowledge, skills, and attitudes. Another limitation is the small sample of 10 residents, which does not allow for generalization of the data or stratification of variables to identify which factors had a greater influence in improving oral health. Dentures present and removal and cleaning of dentures are variables to explore with a larger sample to evaluate the influence the factors may have on oral health hygiene. Another limitation is the homogeneity of the sample. Only one unit in a nursing home was identified to recruit participants. A heterogeneous sample of individuals who were cognitive and of sound mind to consent may have different oral hygiene behaviors than those individuals who needed consent by legal guardians. Another limitation was the exclusion of residents with dysphagia. Although dysphagia is a significant health issue in LTC, training for staff focused on assistance with providing oral care to those residents who had an effective swallow and gag reflex to prevent any potential complications of aspiration.
Oral care in LTC is often inadequate and predisposes residents to noncommunicable diseases, such as diabetes, heart disease, and pneumonia (Porter et al., 2015). It is important f or nurses to be properly trained and skilled in providing sufficient oral care to nursing home residents with dementia. It is essential for health care providers to drive the integration of current evidence into practice by improving oral care in older adults through interprofessional collaboration, using evidence-based data, and developing QI initiatives that will enhance staff knowledge of oral care and improve patient oral health outcomes.
- Centers for Disease Control and Prevention. (2015). What is periodontal disease?https://www.cdc.gov/oralhealth/periodontal_disease
- Chalmers, J. M., King, P. L., Spencer, A. J., Wright, F. A. & Carter, K. D. (2005). The oral health assessment tool—Validity and reliability. Australian Dental Journal, 50(3), 191–199 doi:10.1111/j.1834-7819.2005.tb00360.x [CrossRef] PMID:16238218
- Dahm, T. S., Bruhn, A. & LeMaster, M. (2015). Oral care in the long-term care of older patients: How can the dental hygienist meet the need?Journal of Dental Hygiene, 89(4), 229–237 PMID:26304947
- de Lugt-Lustig, K. H., Vanobbergen, J. N., van der Putten, G. J., De Visschere, L. M., Schols, J. M. & de Baat, C. (2014). Effect of oral healthcare education on knowledge, attitude and skills of care home nurses: A systematic literature review. Community Dentistry and Oral Epidemiology, 42(1), 88–96 doi:10.1111/cdoe.12063 [CrossRef] PMID:23895301
- Felton, D., Cooper, L., Duqum, I., Minsley, G., Guckes, A., Haug, S., Meredith, P., Solie, C., Avery, D. & Deal Chandler, N. (2011). Evidence-based guidelines for the care and maintenance of complete dentures: A publication of the American College of Prosthodontists. Journal of Prosthodontics, 20(Suppl. 1), S1–S12 doi:10.1111/j.1532-849X.2010.00674.x [CrossRef] PMID:21324026
- Hilton, S., Sheppard, J. J. & Hemsley, B. (2016). Feasibility of implementing oral health guidelines in residential care settings: Views of nursing staff and residential care workers. Applied Nursing Research, 30, 194–203 doi:10.1016/j.apnr.2015.10.005 [CrossRef] PMID:27091278
- Hoben, M., Clarke, A., Huynh, K. T., Kobagi, N., Kent, A., Hu, H., Pereira, R. A. C., Xiong, T., Yu, K., Xiang, H. & Yoon, M. N. (2017). Barriers and facilitators in providing oral care to nursing home residents, from the perspective of care aides: A systematic review and meta-analysis. International Journal of Nursing Studies, 73, 34–51 doi:10.1016/j.ijnurstu.2017.05.003 [CrossRef] PMID:28531550
- Hollaar, V., Maarel-Wierink, C., van der Putten, G., Rood, B., Elvers, H., de Batt, C. & de Swart, B. (2015). Nursing staff's knowledge about and skills in providing oral hygiene care for patients with neurological disorders. Journal of Oral Hygiene & Health, 03(06). doi:10.4172/2332-0702.1000190 [CrossRef]
- Iowa Model Collaborative. (2017). Iowa model of evidence-based practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175–182 doi:10.1111/wvn.12223 [CrossRef]
- Jablonski, R. A., Kolanowski, A. M., Azuero, A., Winstead, V., Jones-Townsend, C. & Geisinger, M. L. (2018). Randomised clinical trial: Efficacy of strategies to provide oral hygiene activities to nursing home residents with dementia who resist mouth care. Gerodontology, 35(4), 365–375 doi:10.1111/ger.12357 [CrossRef] PMID:30004139
- Jablonski, R. A., Therrien, B., Mahoney, E. K., Kolanowski, A., Gabello, M. & Brock, A. (2011). An intervention to reduce care-resistant behavior in persons with dementia during oral hygiene: A pilot study. Special Care in Dentistry, 31(3), 77–87 doi:10.1111/j.1754-4505.2011.00190.x [CrossRef] PMID:21592161
- Jablonski-Jaudon, R. A., Kolanowski, A. M., Winstead, V., Jones-Townsend, C. & Azuero, A. (2016). Maturation of the MOUThintervention: From reducing threat to relationship-centered care. Journal of Gerontological Nursing, 42(3), 15–23 doi:10.3928/00989134-20160212-05 [CrossRef] PMID:26934969
- Janssens, B., De Visschere, L., van der Putten, G. J., de Lugt-Lustig, K., Schols, J. M. G. A., Vanobbergen, J. & de Lugt-Lustig, K. (2016). Effect of an oral healthcare protocol in nursing homes on care staffs' knowledge and attitude towards oral health care: A cluster-randomised controlled trial. Gerodontology, 33(2), 275–286 doi:10.1111/ger.12164 [CrossRef] PMID:25424132
- Kohli, R., Nelson, S., Ulrich, S., Finch, T., Hall, K. & Schwarz, E. (2017). Dental care practices and oral health training for professional caregivers in long-term care facilities: An interdisciplinary approach to address oral health disparities. Geriatric Nursing, 38(4), 296–301 doi:10.1016/j.gerinurse.2016.11.008 [CrossRef] PMID:28063685
- Kotzer, R. D., Lawrence, H. P., Clovis, J. B. & Matthews, D. C. (2012). Oral health-related quality of life in an aging Canadian population. Health and Quality of Life Outcomes, 10(1), 50 doi:10.1186/1477-7525-10-50 [CrossRef] PMID:22587387
- Luong, E., deClifford, J., Coutsouvelis, J., Lam, S. H., Drysdale, P., Danckert, R. & Campbell, E. (2018). Implementation of standardised oral care treatment and referral guidelines for older sub-acute patients: A multidisciplinary approach. Journal of Pharmacy Practice and Research, 48(1), 10–17 doi:10.1002/jppr.1311 [CrossRef]
- McConnell, E. S., Lee, K. H., Galkowski, L., Downey, C., Spainhour, M. V. & Horwitz, R. (2018). Improving oral hygiene for veterans with dementia in residential long-term care. Journal of Nursing Care Quality, 33(3), 229–237 doi:10.1097/NCQ.0000000000000303 [CrossRef] PMID:29120955
- McNally, M. E., Martin-Misener, R., Wyatt, C. C., McNeil, K. P., Crowell, S. J., Matthews, D. C. & Clovis, J. B. (2012). Action planning for daily mouth care in long-term care: The brushing up on mouth care project. Nursing Research and Practice, 2012, 368356 doi:10.1155/2012/368356 [CrossRef] PMID:22550572
- Murray, J. & Scholten, I. (2018). An oral hygiene protocol improves oral health for patients in inpatient stroke rehabilitation. Gerodontology, 35(1), 18–24 doi:10.1111/ger.12309 [CrossRef] PMID:29152787
- Porter, J., Ntouva, A., Read, A., Murdoch, M., Ola, D. & Tsakos, G. (2015). The impact of oral health on the quality of life of nursing home residents. Health and Quality of Life Outcomes, 13(1), 102 doi:10.1186/s12955-015-0300-y [CrossRef] PMID:26169066
- Reigle, J. A. & Holm, K. (2015). Knowledge of oral health of nursing staff caring for disadvantaged older people. Journal of Nursing Education and Practice, 6(1). doi:10.5430/jnep.v6n1p31 [CrossRef]
- Sloane, P. D., Zimmerman, S., Chen, X., Barrick, A. L., Poole, P., Reed, D., Mitchell, M. & Cohen, L. W. (2013). Effect of a person-centered mouth care intervention on care processes and outcomes in three nursing homes. Journal of the American Geriatrics Society, 61(7), 1158–1163 doi:10.1111/jgs.12317 [CrossRef] PMID:23772769
- Urata, J. Y., Couch, E. T., Walsh, M. M. & Rowe, D. J. (2018). Nursing administrators' views on oral health in long-term care facilities: An exploratory study. Journal of Dental Hygiene, 92(2), 22–30 PMID:29739844
- VanArsdall, P. S. & Aalboe, J. (2016). Improving the oral health of long term care facility residents. http://decisionsindentistry.com/article/improving-oral-health-long-term-care-facility-residents
Oral Care Protocol
|1. All residents entering the long-term care facility will receive an oral care assessment using the Minimum Data Set 3.0 section L. Assessment will be conducted as follows:
Any change in oral status
|2. Nursing staff will provide oral care to residents at a minimum of twice daily: in the morning and at night before bed. Oral care should be documented using the daily oral care checklist.
See procedures specific to oral care guidelines
|3. Nursing staff will conduct routine oral screenings using the Oral Health Assessment Tool every 3 months for ongoing monitoring of oral health status of residents.|
|1. Orientation: New staff, RN staff, and certified nursing assistants will receive oral hygiene care education and information during their orientation.|
|2. Continuing education: Staff education sessions regarding oral care hygiene will be provided annually and additionally, as required.|
|No lemon glycerin swabs—these products have a drying effect
No mouthwash containing alcohol—these products have a drying effect
Never use toothpaste or mouth rinse in residents who have swallowing problems|
Demographics of Nursing Home Staff (N = 29)
| Female||29 (100)|
| 18 to 24||2 (6.9)|
| 25 to 36||13 (44.8)|
| 37 to 45||4 (13.8)|
| ≥46||10 (34.5)|
| LPN||9 (31)|
| CNA||18 (62.1)|
|Years worked in LTC|
| 0 to 4||11 (37.9)|
| 5 to 10||2 (6.9)|
| 11 to 15||1 (3.4)|
| >15||15 (51.7)|
|Highest level of education|
| High school graduate, diploma or equivalent (GED)||8 (27.6)|
| Some college, no degree||12 (41.4)|
| Associate's degree||7 (24.1)|
| Bachelor's degree||2 (6.9)|
Pre- and Post-Test Results of the Oral Care Questionnaire
|Item||Correct Answer||p Value|
|1. Residents should sleep in dentures overnight so that they may become accustomed to wearing them.||False||1.000|
|2. When providing oral care for a resident with dementia, introduce yourself using a high-pitched voice.||False||0.317|
|3. Dentures should be placed in a dry container after cleaning if not replaced in the oral cavity.||False||0.014*|
|4. Teeth should be brushed twice a day.||True||0.317|
|Item||Mean Response||p Value|
|5. I feel confident in performing basic oral care to residents.||Strongly agree||0.096|
|6. I feel confident when performing oral care to residents with resistant behaviors.||Agree||0.360|
|7. Oral care is not my responsibility.||Strongly disagree||1.000|
|8. Residents who are independent should be responsible for their own mouth care.||Disagree||0.052|