Poor oral health in frail, dependent older adults can lead to pain and suffering, difficulty speaking, problems with chewing and swallowing, and poor self-esteem (Coleman, 2002). Poor oral hygiene contributes to the build-up of plaque, a sticky biofilm that hosts microorganisms on teeth and dentures. As the plaque matures, it allows the growth of opportunistic respiratory pathogens that can contribute to aspiration pneumonia (El-Solh et al., 2004). Plaque build-up can lead to periodontal disease, which in turn can contribute to other potentially deadly systemic diseases such as ischemic stroke, carotid atherosclerosis, and poor glycemic control in diabetes (Jablonski, Swecker, Munro, Grap, & Ligon, 2009).
Older patients with cognitive and functional disabilities who have extended lengths of stay in hospitals or long-term care facilities must rely on nurses and nursing assistants to meet their oral hygiene needs. It has been suggested that oral health assessment, dentistry, and oral hygiene constitute the three central pillars of an effective oral health program for older adults in long-term and extended care settings (Thorne, Kazanjian, & MacEntee, 2001). Oral hygiene can be the responsibility of both dental professionals and nurses, but it is nurses who meet the daily oral hygiene needs of their patients. The role of nurses in promoting oral hygiene, and therefore better oral health outcomes for their patients, is critical (Coleman, 2002), and they are often in a position to role model and support care interventions provided by nursing assistants.
Poor oral hygiene is prevalent in older adults residing in long-term care facilities (Chami et al., 2012; Philip, Rogers, Kruger, & Tennant, 2012). Despite self-reported valuing of oral hygiene care, it is given low priority in nursing practice and is poorly delivered (Coleman & Watson, 2006; MacEntee, 2005). Helping a patient with toothbrushing was considered by 60% of staff in one study to be troublesome compared with hair washing, feeding, and providing incontinence care—activities that were found to be troublesome by less than 15% of staff (Wårdh, Jonsson, & Wikström, 2012). In the midst of other competing priorities, oral hygiene care is one of the first tasks to be set aside (Chalmers, Levy, Buckwalter, Ettinger, & Kambhu, 1996; Dharamsi, Jivani, Dean, & Wyatt, 2009; Kalisch, Tschannen, Lee, & Friese, 2011).
In addition to workload issues, other reasons cited for overlooking oral hygiene needs of patients include lack of material resources, well-intentioned attempts to preserve patients’ autonomy rather than assuming their care, and fear of being hurt by patients with dementia who exhibit self-protective behaviors (Jablonski, Munro, Grap, & Elswick, 2005; Kalisch et al., 2011; Pearson & Chalmers, 2004; Sonde, Emami, Kiljune, & Nordenram, 2011; Thorne et al., 2001). Attitudes of nursing assistants, licensed practical nurses, and RNs toward providing mouth care, as well as their lack of knowledge, can also influence the care they provide to their patients (Dharamsi et al., 2009; Jablonski, Munro, Grap, Schubert, & Spigelmyer, 2009; Wårdh et al., 2012).
Because oral hygiene is one of the three pillars of an effective oral health program and nurses typically provide such measures—or direct others to do so—efforts to improve patients’ oral hygiene might well be directed toward nurses and nursing assistants who provide oral care. To this end, clinical practice guidelines and evidence-based protocols have emerged (e.g., Chalmers & Johnson, 2004; Fiske, Griffiths, Jamieson, & Manger, 2000; O’Connor, 2012; Pearson & Chalmers, 2004; Registered Nurses’ Association of Ontario, 2008), but few studies have reported on the implementation of the recommendations in those guidelines. Educational interventions may enhance the knowledge and beliefs of nursing staff, but less is known about the ability of programs, educational or otherwise, to translate into improved oral hygiene outcomes for older adults in long-stay settings. Such programs could involve enhancing knowledge and skill of nurses, creating a specialized nursing role, or introducing a protocol that would be delivered by nurses. The aim of this systematic review is to examine the effect of intervention programs designed to enhance the ability of nurses and nursing assistants to improve oral hygiene outcomes in frail older adults residing in long-term care or having an extended hospital stay.
Literature Search and Eligibility Criteria
Published articles were sought using the databases MEDLINE, Embase, AgeLine, and CINAHL, from the date of each database’s origin and updated to the end of July 2013. Search terms and keywords included combinations of: dental, dental health education, education, elderly, interventions, nurs*, nurses’ aides, nursing assistants, oral hygiene, oral health, and quality. Full search strategies are available from the authors.
Primary quantitative research studies were eligible if: (a) they evaluated an intervention aimed at nurses or nursing assistants (under a variety of job titles) who provide oral hygiene care to primarily older adults with functional or cognitive disabilities in an institutional care setting; (b) the outcome was directly related to patients’ oral health status (e.g., a change in one or more oral health measures, or a change in risk for oral hygiene related sequelae); and (c) they were published in English. Finally, eligible studies were assessed for their inclusion of a comparison group. Studies were not included if (a) they measured outcomes such as caregiver knowledge, attitudes and beliefs, perceptions of barriers, an observed behavioral change in caregivers’ ability to provide oral hygiene, or patient reports of well-being without measuring oral health outcomes of those patients; (b) they reported on interventions that were primarily delivered by other than nurses or their assistants (i.e., by dental professionals); (c) they evaluated interventions such as mouth rinses without reporting a role for nurses or care aides; or (d) the setting was palliative care, critical care, or a mixed population consisting primarily of patients younger than 65.
Identification of Relevant Studies
The search yielded 1,771 titles that were screened along with their abstracts to determine eligibility (Figure). This resulted in 93 potentially relevant studies; when duplicates were removed, 38 remained. Full-text articles were read to determine whether the studies met eligibility criteria. To supplement the electronic search, volumes of the journals Gerodontology and Special Care in Dentistry and the Cochrane Central Register of Controlled Trials were hand searched. Articles in the reference lists of all relevant studies and those articles citing the relevant studies were also screened. Finally, a search using Google Scholar was conducted as an added measure to confirm the list of relevant articles retrieved. The search strategy was guided by a skilled research librarian, and two research librarians attempted unsuccessfully to uncover additional articles. Two independent reviewers confirmed that a total of 29 studies met the initial criteria. The last criterion to be applied was that the design should incorporate a comparison group. The lack of a comparison group makes it impossible to know what would have happened in the absence of the intervention, and according to the Cochrane Handbook for Systematic Reviews of Interventions (Higgins & Green, 2011) such studies should be treated with caution. Twelve studies that used a comparison group were ultimately assessed for quality.
Identification of eligible studies.
Quality Assessment and Data Extraction
The methodological quality of the 12 studies and their susceptibility to bias were assessed using the Quality Assessment Tool for Quantitative Studies (National Collaborating Centre for Methods and Tools, 2010; Thomas, Ciliska, Dobbins, & Micucci, 2004). This tool is useful for assessing studies of public health and health promotion interventions; was judged by Deeks et al. (2003) to be one of the top tools; and is recommended by the Cochrane Handbook for Systematic Reviews of Interventions (Higgins & Green, 2011). This valid and reliable tool ultimately assigns a global methodological rating of strong, moderate, or weak. It consists of 21 items separated into eight sections: (a) selection bias, (b) study design, (c) confounders, (d) blinding, (e) data collection methods, (f) withdrawals and dropouts, (g) intervention integrity, and (h) analysis. The first six sections are scored and contribute to the global rating; the last two sections—intervention integrity and analysis—although assessed, do not contribute to the overall global rating.
A dictionary assists reviewers to maintain standardized results and includes a standard approach to identifying the study design. For example, in a strongly rated study, the selected individuals would be very likely representative of the target population; there is greater than 80% participation; the design would be a randomized or controlled clinical trial; the study would have controlled for at least 80% of relevant confounders if there were differences between groups prior to the intervention; the outcome assessor would not be aware of the intervention status of participants and the study participants would not be aware of the research question; data collection tools are reliable and valid; and the follow-up rate is 80% or greater (National Collaborating Centre for Methods and Tools, 2010).
Two reviewers independently performed the quality assessment and differences in scoring were resolved by discussion. The section and global ratings for the 12 studies are shown in Table 1. For a study to receive a global rating of strong, four of the six scored subsections must be rated as strong, with no weak ratings among the six subsections. Ultimately, one study was given a global rating of strong (Frenkel, Harvey, & Newcombe, 2001), seven were rated as moderate (Budtz-Jørgensen, Mojon, Rentsch, & Deslauriers, 2000; De Visschere, Schols, van der Putten, de Baat, & Vanobbergen, 2012; MacEntee et al., 2007; Mojon, Rentsch, Budtz-Jørgensen, & Baehni, 1998; Nicol, Sweeney, McHugh, & Bagg, 2005; Simons, Baker, Jones, Kidd, & Beighton, 2000; van der Putten et al., 2013), and four as weak (Bassim, Gibson, Ward, Paphides, & DeNucci, 2008; Le, Dempster, Limeback, & Locker, 2012; Peltola, Vehkalahti, & Simoila, 2007; Pyle, Massie, & Nelson, 1998).
Quality Assessment Ratings Using Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies
Although data extraction from only strong studies is preferred, data in this review were also extracted from articles rated as moderate, given the relative absence of methodologically strong articles. Data from the articles, including general information, research question/purpose of the study, setting, patient participants, intervention details, length of follow up, oral health measurement methods, and outcomes, were extracted independently by two reviewers using a comprehensive tool designed specifically for this review. A summary of the extracted information from studies rated as methodologically strong and moderate is shown in Table 2.
Characteristics of Included Studies
Although considered, the Quality Assessment Tool for Quantitative Studies (Thomas et al., 2004) does not rate the integrity of the intervention (i.e., the extent to which the intervention has been delivered as planned). Often, this is not reported in enough detail to be extracted from studies. It is an important consideration here, however, because the aim was to determine whether an intervention that involved nurses as participants might change the way they deliver oral hygiene care and ultimately lead to better outcomes for patients. The Workgroup for Intervention Development and Evaluation Research (WIDER, 2009) has made recommendations about the reporting of behavior change interventions that were considered in the assessment of intervention integrity in this review. They are: (a) a detailed description of interventions including characteristics of those delivering the intervention, characteristics of recipients, the setting, the mode of delivery, the intensity, adherence/fidelity to delivery protocols, and detailed description of the intervention content provided for each study group; (b) clarification of the assumed change process including the intervention development, the change techniques used in the intervention, and the causal processes targeted by the change techniques; (c) access to intervention manuals or protocols; and (d) detailed description of active control conditions. Key components and characteristics of the interventions were extracted and are summarized in Table 3.
Characteristics of Interventions Based on WIDER (2009) Recommendations
Studies took place in long-term care settings in the United Kingdom (n = 3), Canada (n = 1), Switzerland (n = 2), Belgium (n = 1), and the Netherlands (n = 1). None of the studies took place in hospital settings. Patients with dementia did not participate in a number of studies as a result of study exclusion criteria, or because they could not provide consent (Budtz-Jørgensen et al., 2000; Frenkel et al., 2001; MacEntee et al., 2007; Mojon et al., 1998; Nicol et al., 2005). Heterogeneity in the study samples, interventions, and outcomes assessed prevented pooling of results. The studies will be described in terms of the oral health outcomes measured, the interventions, and the effectiveness of those interventions.
Outcomes Measured in the Studies
The outcomes studied in all of the articles (Table 2) included a variety of oral hygiene measures, with many studies having more than one outcome measured. Dental and denture hygiene were assessed by considering (a) dental debris (MacEntee et al., 2007), (b) denture debris (Nicol et al., 2005; Simons et al., 2000), (c) denture plaque (De Visschere et al., 2012; Frenkel et al., 2001; Simons et al., 2000; van der Putten et al., 2013), (d) dental plaque (Frenkel et al., 2001; De Visschere et al., 2012; Mojon et al., 1998; Simons et al., 2000; van der Putten et al., 2013), and (e) calculus score (Frenkel et al., 2001). Although a number of studies used the same measurement (e.g., plaque index, debris index), some measurement protocols were modified and there were inconsistencies in how the measurements were performed across studies.
Condition of teeth was measured by examining for root caries (Budtz-Jørgensen et al., 2000; Frenkel et al., 2001; Mojon et al., 1998; Simons et al., 2000), tooth mobility (Frenkel et al., 2001), or fillings (Simons et al., 2000). Oral flora was measured in four studies: One looked at Mutans streptococci (Mojon et al., 1998), another at Candida albicans (Budtz-Jørgensen et al., 2000), and two studies (Budtz-Jørgensen et al., 2000; Nicol et al., 2005) measured Lactobacillus spp. in the oral cavity and on dentures. Condition of oral mucosa was an outcome in the study by Nicol et al. (2005). Gingival health was an outcome in three studies and measured by the Gingival Bleeding Index in one study (MacEntee et al., 2007), a gingivitis score in another study (Frenkel et al., 2001), and the Gingival Index in a third (Simons et al., 2000). Glossitis (Budtz-Jørgensen et al., 2000) and tongue plaque (De Visschere et al., 2012) were outcomes in two studies. Denture stomatitis (Budtz-Jørgensen et al., 2000, Frenkel et al., 2001, Nicol et al., 2005) and angular cheilitis, an inflamed lesion at the corner of the mouth often associated with stomatitis, were other study outcomes (Budtz-Jørgensen et al., 2000; Nicol et al., 2005).
Study Interventions and Effectiveness
All studies reported an educational program, either alone or augmented in some way. The study interventions can be clustered into three categories: (a) single in-service education sessions; (b) single in-service education sessions supplemented by a “train-the-trainer” (or pyramid) approach; and (c) educational sessions supplemented with ongoing active involvement of a dental hygienist. Studies within each cluster will be described in terms of their research designs, sample and setting, the intervention components, and the effect of those interventions on outcomes.
Single In-Service Education Session. Three controlled clinical trials reported a single educational session aimed at nurses or care aides as the main intervention (Frenkel et al., 2001; Nicol et al., 2005; Simons et al., 2000). All studies took place in long-term care, and the intervention sites ranged in number from three (Nicol et al., 2005) to 11 (Frenkel et al., 2001), with the number of patient participants ranging from 39 (Nicol et al., 2005) to 155 (Frenkel et al., 2001).
With respect to details provided about the interventions in the three studies, the disciplines of those delivering the intervention were reported in all studies (Frenkel et al., 2001; Nicol et al., 2005; Simons et al., 2000). They consisted of a dental health promoter in one study (Frenkel et al., 2001), and a dental hygienist and dentist in the other studies. The educational program in all studies was intended for those who provided oral care to the patients in the study settings, most often nursing assistants. The lengths of the programs varied from 60 to 90 minutes and were offered as single sessions. Two of the studies used 90-minute standardized curricula (Nicol et al., 2005; Simons et al., 2000).
In two studies, participants received samples of oral hygiene supplies and information about how to obtain them (Frenkel et al., 2001; Simons et al., 2000). Two of the sessions involved a demonstration (Nicol et al., 2005; Simons et al., 2000), and two provided an opportunity for hands-on practice (Frenkel et al., 2001; Simons et al., 2000). In two studies, the use of individualized oral care plans was encouraged (Simons et al., 2000; Nicol et al., 2005).
All three studies reported statistically significant changes in outcomes, although not in all outcomes studied. The strongly rated study (Frenkel et al., 2001) achieved statistically significant improvements in denture plaque, denture-induced stomatitis, dental plaque, and gingivitis that were sustained at 6 months. Nicol et al. (2005) found statistically significant improvements in mucosal disease, angular cheilitis, denture hygiene, and denture stomatitis that were sustained at 9 months, but not fully maintained at 18 months. At 12 months, Simons et al. (2000) found an increased number of filled cavities in the intervention group, but no improvement in dental and denture hygiene, root caries, and gingival health.
Train-the-Trainer Approach. MacEntee et al. (2007) trialed a “train-the-trainer” approach to oral hygiene education in a randomized controlled trial (RCT) in 14 long-term care homes. The control group of care aides (n = 23) received 1 hour of standardized training involving a knowledge component, demonstration, and written materials from a dental hygienist with no further follow up. In the intervention group of care aides (n = 20), the researchers sought to test the effectiveness of the dental hygienist training an experienced nurse (e.g., a nurse educator) to provide the 1-hour education program and provide ongoing encouragement to staff to improve residents’ oral health. Although the educators had telephone access to the hygienist, they did not consistently deliver on the intervention, and only 15% of care aides attended the voluntary education sessions. This low “coverage efficiency” resulted in no clinically meaningful improvements in oral debris and gingival inflammation being achieved at 3 months in the 51 residents in the intervention group.
De Visschere et al. (2012) and van der Putten et al. (2013) achieved significant improvements in denture plaque scores in a controlled clinical trial conducted in 12 nursing homes in Belgium and later using the same design in 12 nursing homes in the Netherlands. The patient sample sizes were 146 and 177, respectively, in the intervention groups. Usual care in the control groups was not described. A dental hygienist provided 5 hours of training to a nurse who in turn provided a 90-minute training to staff members, most of whom were care assistants. The nurse also provided support at the bedside to ensure the recommendations were implemented, and the hygienist visited the units every few weeks to monitor and provide support to staff. At the 6-month follow up, there was significant improvement in mean denture plaque (p < 0.01). However, there was a non-significant difference in both tongue plaque (p = 0.74) and dental plaque (p = 0.22). Residents’ level of dependence influenced the results as residents who brushed their dentures mostly by themselves had higher denture plaque levels. Residents with natural teeth had on average 4 to 6 teeth, and this may have limited the ability to observe significant differences between groups.
Active Involvement of a Dental Hygienist to Supplement Nursing Care. A third intervention studied in two controlled clinical trials was an educational program for staff supplemented by the ongoing intervention and support of a dental hygienist (Budtz-Jørgensen et al., 2000; Mojon et al., 1998). The two studies were conducted on 12 wards of a long-term care facility in Switzerland by the same team with a shared intervention, although different outcomes were measured for distinct groups of patients. The sample size of the experimental group of patients in one study was 122 with 115 in the comparison group (Mojon et al., 1998). The other study focused on 116 dentate residents with equal numbers in the control and comparison groups (Budtz-Jørgensen et al., 2000). The study intervention involved an oral health program consisting of prophylaxis (cleaning and scaling) by a dental hygienist with a recall program every 6 months, treatment plans, toothbrushes and paste, and education of nurse aides through lecture and demonstration with emphasis on dentures being left out overnight.
The outcomes of the two distinct trials were mixed: a statistically significant decrease in severity of palate inflammation (denture stomatitis); decreased prevalence of glossitis; reduction in mucosal yeast scores; reduction in denture yeast scores (Budtz-Jørgensen et al., 2000); no significant difference in plaque indices; no significant changes in lactobacillus counts; reduced Mutans streptococci colonization; and reduced root caries (root decay) prevalence in the intervention group (Mojon et al., 1998). The introduction of two simultaneous interventions (i.e., education of staff and interventions by a dental hygienist) make it impossible to determine the impact of each.
Even the strong and moderate studies in this review fell short of meeting the WIDER (2009) recommendations for reporting behavior change interventions. All articles reported to whom and by whom the interventions were delivered. However, attendance rates were not given in all studies, and when reported ranged from 15% to 75%. It was not clear in any of the studies whether the caregivers attending the sessions were the same as those providing the care and therefore contributing to outcomes. Adherence to protocols was not reported, and treatment of the control groups was vague, if reported at all. Only three studies referenced the educational intervention as a packaged program that could theoretically be obtained and replicated (MacEntee et al., 2007; Nicol et al., 2005; Simons et al., 2000). Behavior change in the recipients of the educational sessions was not reported in any of the studies, but can be inferred from changes in oral hygiene outcomes.
Findings from this review suggest that educational approaches may have an effect, although perhaps limited, on measures of oral health of dependent older adults in long-term care. The literature was lacking in methodologically strong studies with good intervention integrity. A variety of oral health outcomes were used to measure effectiveness of the interventions across studies, and this precluded conducting a meta-analysis.
In many cases, the educational interventions were followed by a supplemental intervention (e.g., the use of individualized protocols or care plans, staff training on specially implemented protocols, use of oral care champions who ensured that practices took place, presence of supplies and tools, and involvement of a dental hygienist). It is not possible to determine from the review what combination of those approaches might constitute the most effective program.
Despite some elements of these programs intuitively offering promise, a number of factors prevented their evaluation. In studies where dental professionals became involved, the extent of their involvement was not always apparent. The actual contributions of oral care champions in studies using such a role were not outlined in detail. The length of time to follow up in the studies varied widely from 3 to 18 months. Intervention integrity was not always addressed or was poor. An acceptable attendance rate of participating caregivers is unknown, but actual rates varied across studies from 15% to 75%. The extent of adherence to protocols and compliance with care plans, where they were used, was not made clear in any of the studies. None of the studies reported whether those receiving the educational intervention were actually the ones providing the care to patients whose outcomes were measured. Adherence by staff to oral care interventions taught in the sessions was not reported.
This lack of intervention integrity is a significant barrier to determining the contribution of nursing staff to patient outcomes. For example, in a systematic review of the literature, Weening-Verbree, Huisman-de Waal, van Dusseldorp, van Achterberg, and Schoonhoven (2012) attempted to identify those elements of educational strategies (e.g., knowledge, self-efficacy, facilitation of behavior) that were effective in improving oral health, but this assumes that nurses or nursing assistants who were the target of the educational interventions had attended the sessions and then actually carried out the interventions, and this is not necessarily the case. A review by de Lugt-Lustig et al. (2013) of the effect of oral health care education on knowledge, attitudes, and skills of nursing staff focused on nurses’ oral health care knowledge and attitudes, care home residents’ oral hygiene, and nurses’ oral hygiene skills and does not report on the implications of poor intervention integrity among these studies. This review makes a unique contribution to our understanding of how outcomes of educational programs may be tied not only to the program interventions but to attendance rates and whether those in attendance implemented the program as planned, and underlines the importance of considering both in the quality assessment process.
Implications for Nursing Practice
Oral hygiene care and prevention of systemic disease should be elevated to the same status as preventing pressure ulcers—no longer considered merely “basic personal care.” Recent advances in knowledge related to oral hygiene and its relation to oral health and the connection to systemic disease require nurses to gain knowledge, change attitudes, and learn new behaviors. Practice guidelines offer a comprehensive list of oral health educational recommendations using expert opinion as evidence. This review has shown that no clear evidence yet exists to suggest that any combination of educational components is superior to others.
Protocols and clinical practice guidelines related to oral hygiene care that can have potential beneficial oral health outcomes require creative implementation and sustainability of programs. Ploeg, Davies, Edwards, Gifford, and Miller (2007) found that individual factors (i.e., learning about the guideline through small group interaction and having positive attitudes and beliefs), organizational factors (i.e., leadership support, champions, and collaborative teamwork), and environmental factors (i.e., professional association support and interorganizational collaboration) were key to successful implementation of clinical practice guidelines.
There is a need to develop and test oral hygiene care interventions that are not only more effective, but more acceptable for staff who need to promote oral health in frail older adults in long-term settings. Nurses should partner with dental professionals (dentists and dental hygienists) and other professionals such as speech-language pathologists to find the most effective and efficient ways to deliver oral care and to reinforce them with those providing care.
Implications for Future Research
There is a need for high-quality studies of interventions to improve the oral health of older adults in both hospitals and long-term care. Well-designed RCTs in the area of oral hygiene care delivered by nurses to dependent older adults are needed but should not be limited to long-term and critical care. For practice guideline recommendations to be embraced by nurses and those to whom nurses delegate care, interventions must be perceived as effective and practical. Nurses must actively collaborate with dental professionals and others in this research agenda. It was surprising that of the 30 authors associated with the selected studies in this review, only one was a nurse, and not one of the articles’ lead authors was a nurse.
Given the barriers to oral hygiene expressed by caregivers, it will be important to discover the least intensive intervention that can lead to clinically significant outcomes. There are only three studies to date where oral care provided by caregivers has actually been observed (Chami et al., 2012; Coleman & Watson, 2006; Gammack & Pulisetty, 2009). Further research could reveal the connection between explicit oral hygiene care interventions offered and specific, meaningful oral hygiene outcomes achieved.
The development and evaluation of quality indicators should follow a psychometrically sound process and undergo extensive empirical study (Nakrem, Vinsnes, Harkless, Paulsen, & Seim, 2009). Future research into developing and evaluating oral hygiene as a nurse sensitive quality indicator would promote it to the same level of importance as some of the indicators that are currently used for monitoring clinical quality (e.g., falls rates and pressure ulcer development).
The search for relevant articles was limited to published articles or those available online ahead of publication. Only articles published in English were included, and this could have led to publication bias. Authors were not contacted for missing information if it could not be found in a previous publication or available electronically in some other form.
All studies took place in long-term care settings and none took place on medical-surgical units of acute care hospitals where older adults might also have extended lengths of stay. Some studies could not include patients with dementia because of consent issues. However, consideration of this group of patients is important, as their behaviors present challenges in the provision of oral care. More than half of the intervention studies retrieved were excluded because they did not use a comparison group. However, some of those studies described promising interventions that led to positive outcomes.
Most studies did not describe the interventions in sufficient detail, nor did they describe the control conditions adequately. Often intervention consistency was not reported, and in many cases the proportion of staff in attendance at educational sessions was either unknown or low. Voluntary attendance at educational sessions is a reality, as is low attendance, but when determining the impact of an educational program, it is important to be able to distinguish between a failure of implementation and an ineffective intervention.
Whether nursing behaviors related to oral hygiene care changed as a result of the interventions is not known. Studies used such a variety of oral hygiene measures that it was difficult to compare across studies, and as a result, a metaanalysis could not be performed.
Although a link has been made between oral hygiene and systemic disease, poor oral hygiene occurs frequently among older adults in institutions who are dependent on others for care. A literature search for studies of interventions to improve oral hygiene delivered by nurses or nursing assistants yielded eight moderate to strongly rated studies reporting in-service educational sessions, either alone or augmented in some way (i.e., single in-service education sessions, single in-service education sessions supplemented by a “train-the-trainer” [or pyramid] approach, and educational sessions supplemented with ongoing active involvement of a dental hygienist).
None of the approaches emerged as being more effective than the others but this was due in great part to poor intervention integrity in many of the studies. A well-designed and executed educational program cannot have its effect measured if the caregivers for whom it is intended do not attend the session or do not subsequently care for the patients whose oral hygiene status is being measured.
Further study of ways to enhance nurses’ ability to deliver oral hygiene care to improve the oral health of patients is crucial. The newly exposed significance of oral hygiene and the role nurses can play in optimizing the oral health of older adults promises to be an important area for practice and research.
- Bassim, C.W., Gibson, G., Ward, T., Paphides, B.M. & DeNucci, D.J. (2008). Modification of the risk of mortality from pneumonia with oral hygiene care. Journal of the American Geriatrics Society, 56, 1601–1607 doi:10.1111/j.1532-5415.2008.01825.x [CrossRef]
- Budtz-Jørgensen, E., Mojon, P., Rentsch, A. & Deslauriers, N. (2000). Effects of an oral health program on the occurrence of oral candidosis in a long-term care facility. Community Dentistry and Oral Epidemiology, 28, 141–149. doi:10.1034/j.1600-0528.2000.028002141.x [CrossRef]
- Chalmers, J. & Johnson, V. (2004). Evidence-based protocol: Oral hygiene care for functionally dependent and cognitively impaired older adults. Journal of Gerontological Nursing, 30(11), 5–12.
- Chalmers, J.M., Levy, S.M., Buckwalter, K.C., Ettinger, R.L. & Kambhu, P.P. (1996). Factors influencing nurses’ aides’ provision of oral care for nursing facility residents. Special Care in Dentistry, 16, 71–79. doi:10.1111/j.1754-4505.1996.tb00837.x [CrossRef]
- Chami, K., Debout, C., Gavazzi, G., Hajjar, J., Bourigault, C., Lejeune, B. & Rothan-Tondeur, M. (2012). Reluctance of caregivers to perform oral care in long-stay elderly patients: The three interlocking gears grounded theory of impediments. Journal of the American Medical Directors Association, 13, e1–e4 doi:10.1016/j.jamda.2011.06.007 [CrossRef]
- Coleman, P. (2002). Improving oral health care for the frail elderly: A review of widespread problems and best practices. Geriatric Nursing, 23, 189–199. doi:10.1067/mgn.2002.126964 [CrossRef]
- Coleman, P. & Watson, M. (2006). Oral care provided by certified nursing assistants in nursing homes. Journal of the American Geriatrics Society, 54, 138–143. doi:10.1111/j.1532-5415.2005.00565.x [CrossRef]
- Deeks, J., Dinnes, J., D’Amico, R., Sowden, A., Sakarovitch, C., Song, F. & Altman, D. (2003). Evaluating non-randomised intervention studies. Health Technology Assessment, 7(27), iii–x, 1–173.
- de Lugt-Lustig, K., Vanobbergen, J., van der Putten, G., De Visschere, L., Schols, J. & de Baat, C. (2013). Effect of oral healthcare education on knowledge, attitude and skills of care home nurses: A systematic literature review. Community Dentistry and Oral Epidemiology. Advance online publication. doi:10.1111/cdoe.12063 [CrossRef]
- De Visschere, L., Schols, J., van der Putten, G.J., de Baat, C. & Vanobbergen, J. (2012). Effect evaluation of a supervised versus non-supervised implementation of an oral health care guideline in nursing homes: A cluster randomised controlled clinical trial. Gerodontology, 29, e96–e106 doi:10.1111/j.1741-2358.2010.00418.x [CrossRef]
- Dharamsi, S., Jivani, K., Dean, C. & Wyatt, C. (2009). Oral care for frail elders: Knowledge, attitude, and practices of long-term care staff. Journal of Dental Education, 73, 581–588.
- El-Solh, A.A., Pietrantoni, C., Bhat, A., Okada, M., Zambon, J., Aquilina, A. & Berbary, E. (2004). Colonization of dental plaques: A reservoir of respiratory pathogens for hospital acquired pneumonia in institutionalized elders. Chest, 126, 1575–1582.
- Fiske, J., Griffiths, J., Jamieson, R. & Manger, D. (2000). Guidelines for oral health care for long-stay patients and residents. Gerodontology, 17, 55–64. doi:10.1111/j.1741-2358.2000.00055.x [CrossRef]
- Frenkel, H., Harvey, I. & Newcombe, R. (2001). Improving oral health in institutionalised elderly people by educating caregivers: A randomised controlled trial. Community Dentistry & Oral Epidemiology, 29, 289–297. doi:10.1034/j.1600-0528.2001.290408.x [CrossRef]
- Gammack, J.K. & Pulisetty, S. (2009). Nursing education and improvement in oral care delivery in long-term care. Journal of the American Medical Directors Association, 10, 658–61 doi:10.1016/j.jamda.2009.09.001 [CrossRef]
- Higgins, J. & Green, S. (2011). Cochrane handbook for systematic reviews of interventions Version 5.1.0. Retrieved from http://www.cochrane-handbook.org
- Jablonski, R.A., Munro, C.L., Grap, M.J. & Elswick, R.K. (2005). The role of biobehavioral, environmental, and social forces on oral health disparities in frail and functionally dependent nursing home elders. Biological Research for Nursing, 7, 75–82. doi:10.1177/1099800405275726 [CrossRef]
- Jablonski, R.A., Munro, C.L., Grap, M.J., Schubert, C.M. & Spigelmyer, P. (2009). Mouth care in nursing homes: Knowledge, beliefs, and practices of nursing assistants. Geriatric Nursing, 30, 99–107 doi:10.1016/j.gerinurse.2008.06.010 [CrossRef]
- Jablonski, R.A., Swecker, T., Munro, C., Grap, M.J. & Ligon, M. (2009). Measuring the oral health of nursing home elders. Clinical Nursing Research, 18, 200–217 doi:10.1177/1054773809335306 [CrossRef]
- Kalisch, B.J., Tschannen, D., Lee, H. & Friese, C.R. (2011). Hospital variation in missed nursing care. American Journal of Medical Quality, 26, 291–299 doi:10.1177/1062860610395929 [CrossRef]
- Le, P., Dempster, L., Limeback, H. & Locker, D. (2012). Improving residents’ oral health through staff education in nursing homes. Special Care in Dentistry, 32, 242–250 doi:10.1111/j.1754-4505.2012.00279.x [CrossRef]
- MacEntee, M.I. (2005). Caring for elderly long-term care patients: Oral health-related concerns and issues. Dental Clinics of North America, 49, 429–443. doi:10.1016/j.cden.2004.10.008 [CrossRef]
- MacEntee, M.I., Wyatt, C.C., Beattie, B.L., Paterson, B., Levy-Milne, R., McCandless, L. & Kazanjian, A. (2007). Provision of mouth-care in long-term care facilities: An educational trial. Community Dentistry and Oral Epidemiology, 35, 25–34. doi:10.1111/j.1600-0528.2007.00318.x [CrossRef]
- Mojon, P., Rentsch, A., Budtz-Jørgensen, E. & Baehni, P.C. (1998). Effects of an oral health program on selected clinical parameters and salivary bacteria in a long-term care facility. European Journal of Oral Sciences, 106, 827–834. doi:10.1046/j.0909-8836.1998.eos106401.x [CrossRef]
- Nakrem, S., Vinsnes, A.G., Harkless, G.E., Paulsen, B. & Seim, A. (2009). Nursing sensitive quality indicators for nursing home care: International review of literature, policy and practice. International Journal of Nursing Studies, 46, 848–857 doi:10.1016/j.ijnurstu.2008.11.005 [CrossRef]
- National Collaborating Centre for Methods and Tools. (2010). Quality assessment tool for quantitative studies. Retrieved from http://www.nccmt.ca/registry/view/eng/14.html
- Nicol, R., Sweeney, P., McHugh, S. & Bagg, J. (2005). Effectiveness of health care worker training on the oral health of elderly residents of nursing homes. Community Dentistry & Oral Epidemiology, 33, 115–124. doi:10.1111/j.1600-0528.2004.00212.x [CrossRef]
- O’Connor, L.J. (2012). Oral health care. In Boltz, M., Capezuti, E., Fulmer, T. & Zwicker, D. (Eds.), Evidence-based geriatric nursing protocols for best practice (4th ed., pp. 409–418). New York: Springer.
- Pearson, A. & Chalmers, J. (2004). Oral hygiene care for adults with dementia in residential aged care facilities. JBI Reports, 2(3), 65–113 doi:10.1111/j.1479-6988.2004.00009.x [CrossRef]
- Peltola, P., Vehkalahti, M. & Simoila, R. (2007). Effects of 11-month interventions on oral cleanliness among the long-term hospitalised elderly. Gerodontology, 24, 14–21. doi:10.1111/j.1741-2358.2007.00147.x [CrossRef]
- Philip, P., Rogers, C., Kruger, E. & Tennant, M. (2012). Oral hygiene care status of elderly with dementia and in residential aged care facilities. Gerodontology, 29, e306–e311 doi:10.1111/j.1741-2358.2011.00472.x [CrossRef]
- Ploeg, J., Davies, B., Edwards, N., Gifford, W. & Miller, P.E. (2007). Factors influencing best-practice guideline implementation: Lessons learned from administrators, nursing staff, and project leaders. Worldviews on Evidence-Based Nursing, 4, 210–219. doi:10.1111/j.1741-6787.2007.00106.x [CrossRef]
- Pyle, M.A., Massie, M. & Nelson, S. (1998). A pilot study on improving oral care in long-term care settings. Part II: Procedures and outcomes. Journal of Gerontological Nursing, 24(10), 35–38.
- Registered Nurses’ Association of Ontario. (2008). Oral health: Nursing assessment and interventions. Retrieved from http://rnao.ca/bpg/guidelines/oral-health-nursing-assessment-and-intervention
- Simons, D., Baker, P., Jones, B., Kidd, E.A. & Beighton, D. (2000). An evaluation of an oral health training programme for carers of the elderly in residential homes. British Dental Journal, 188, 206–210.
- Sonde, L., Emami, A., Kiljune, H. & Nordenram, G. (2011). Care providers’ perceptions of the importance of oral care and its performance within everyday caregiving for nursing home residents with dementia. Scandinavian Journal of Caring Sciences, 25, 92–99 doi:10.1111/j.1471-6712.2010.00795.x [CrossRef]
- Thomas, B.H., Ciliska, D., Dobbins, M. & Micucci, S. (2004). A process for systematically reviewing the literature: Providing the research evidence for public health nursing interventions. Worldviews on Evidence-Based Nursing, 1, 176–184. doi:10.1111/j.1524-475X.2004.04006.x [CrossRef]
- Thorne, S.E., Kazanjian, A. & MacEntee, M.I. (2001). Oral health in long term care: The implications of organizational culture. Journal of Aging Studies, 15, 271–283. doi:10.1016/S0890-4065(01)00023-8 [CrossRef]
- van der Putten, G.J., Mulder, J., de Baat, C., De Visschere, L.M., Vanobbergen, J.N. & Schols, J.M. (2013). Effectiveness of supervised implementation of an oral health care guideline in care homes: A single-blinded cluster randomized controlled trial. Clinical Oral Investigations, 17, 1143–1153 doi:10.1007/s00784-012-0793-2 [CrossRef]
- Wårdh, I., Jonsson, M. & Wikström, M. (2012). Attitudes to and knowledge about oral health care among nursing home personnel—An area in need of improvement. Gerodontology, 29, e787–e792 doi:10.1111/j.1741-2358.2011.00562.x [CrossRef]
- Weening-Verbree, L., Huisman-de Waal, G., van Dusseldorp, L., van Achterberg, T. & Schoonhoven, L. (2013). Oral health care in older people in long term care facilities: A systematic review of implementation strategies. International Journal of Nursing Studies, 50, 569–582 doi:10.1016/j.ijnurstu.2012.12.004 [CrossRef]
- Workgroup for Intervention Development and Evaluation Research. (2009). WIDER recommendations to improve reporting of the content of behaviour change interventions. Retrieved from http://interventiondesign.co.uk/wp-content/uploads/2009/02/widerrecommendations.pdf
Quality Assessment Ratings Using Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies
|Study (Publication Year)||Selection Bias||Study Design||Confounders||Blinding||Data Collection Methods||Withdrawals/Dropouts||Global Rating|
|Bassim, Gibson, Ward, Paphides, & DeNucci (2008)||Weak||Moderate||Strong||Moderate||Weak||Strong||Weak|
|Budtz-Jørgensen, Mojon, Rentsch, & Deslauriers (2000)||Moderate||Strong||Moderate||Moderate||Weak||Moderate||Moderate|
|De Visschere, Schols, van der Putten, de Baat, & Vanobbergen (2012)||Moderate||Strong||Strong||Moderate||Moderate||Moderate||Moderate|
|Frenkel, Harvey, & Newcombe (2001)||Strong||Strong||Strong||Moderate||Moderate||Strong||Strong|
|Le, Dempster, Limeback, & Locker (2012)||Weak||Strong||Weak||Weak||Strong||Strong||Weak|
|MacEntee et al. (2007)||Moderate||Strong||Weak||Strong||Strong||Strong||Moderate|
|Mojon, Rentsch, Budtz-Jørgensen, & Baehni (1998)||Weak||Strong||Strong||Moderate||Strong||Moderate||Moderate|
|Nicol, Sweeney, McHugh, & Bagg (2005)||Weak||Strong||Moderate||Moderate||Moderate||Moderate||Moderate|
|Peltola, Vehkalahti, & Simoila (2007)||Weak||Strong||Weak||Moderate||Weak||Weak||Weak|
|Pyle, Massie, & Nelson (1998)||Weak||Strong||Weak||Weak||Strong||Strong||Weak|
|Simons, Baker, Jones, Kidd, & Beighton (2000)||Moderate||Strong||Moderate||Moderate||Moderate||Strong||Moderate|
|van der Putten et al. (2013)||Moderate||Strong||Strong||Moderate||Moderate||Moderate||Moderate|
Characteristics of Included Studies
|Budtz-Jørgensen, Mojon, Rentsch, & Deslauriers (2000); Switzerland||Controlled clinical trial||Geriatric LTC facility: five wards (n = 122) in experimental group; seven wards (n = 115) in comparison group||Oral health program consisting of regular prophylactic treatment by dental hygienist with recall program, treatment plan, toothbrushes and toothpaste, education of nurse aides (lecture/demonstration) with emphasis on dentures being left out overnight||Clinical examination by dentist and yeast cultures from the oral mucosa and fitting denture surface at baseline and 18 months||Improvements in denture stomatitis, glossitis, mucosal yeast scores, denture yeast scores
Plaque Index (PI) negatively correlated with Barthel Index (BI) (degree of dependence for care)||Comparison group did not receive baseline prophylaxis and scaling by hygienist, nor did they visit hygienist every 6 months.
Intervention integrity: No details about interventions provided by health care staff after their course.|
|De Visschere, Schols, van der Putten, de Baat, & Vanobbergen (2012); Belgium||Controlled clinical trial||12 nursing homes: stratified sample of n = 146 in intervention group (six homes) and n = 151 in comparison group (six homes)||Supervised implementation of practice guideline including a daily oral health care protocol and implementation of a specially educated team that would train, encourage, and assist staff in daily delivery of oral hygiene
Nurses and care aides attended educational sessions, both theoretical and practical. Free oral health materials and products provided to residents.||Oral hygiene of natural teeth (PI) and dentures (denture plaque disclosing solution) and tongue coating index measured over 6 months||Statistically significant improvements in denture plaque, but no differences in tongue plaque and dental plaque between groups||Compliance in intervention group settings varied. Usual interventions received by comparison group not described.
Intervention integrity: Not clear whether study patients received the interventions consistently.|
|Frenkel, Harvey, & Newcombe (2001); United Kingdom||Controlled clinical trial||22 nursing homes: n = 155 (intervention group = 11 sites) and n = 182 (comparison group = 11 sites)||1-hour optional oral health care education by dental health promoter for staff. Included role of plaque; teeth and denture cleaning demonstrations; practice on mannequin; and other teaching aids. Toothbrushes were distributed.||Patients examined by dentist (blind to allocation) for four oral health outcomes at baseline, 1 month, and 6 months. Also examined for outcomes that would be dependent on professional cleaning: calculus, root caries, and tooth mobility.||Improvements in oral health measures: denture plaque (most improved), denture induced stomatitis, dental plaque, gingivitis
No significant differences in calculus, root caries, and tooth mobility||Excluded 21% of patients who had severe cognitive impairment.|
|MacEntee et al. (2007); Canada||Randomized controlled trial||14 LTC facilities (ranging in size from 31 to 217 beds) selected from a list of 130 homes. Homes were randomized to control (n = 7) or intervention group (n = 7)
n = 51 residents in intervention group; n = 62 in comparison group; n = 20 care aides in intervention group; n = 23 in comparison group interviewed at 3 months||Intervention group: Full-time in-house nurse educator was trained and supported by dental hygienist to deliver a packaged 1-hour seminar on how to examine and clean mouth. Hygienist was available to give advice over 3 months (i.e., pyramid-based education design).
Control group: Dental hygienist delivered seminar and provided no ongoing advice.||Patients examined by dental hygienist (blind to allocation and blind to baseline scores) at baseline and 3 months.||No significant differences between groups in changes in Geriatric Simplified Debris Index (GDI-S), Malnutrition Indicator Score (MIS), or Gingival Bleeding Index score from baseline. Oral health and nutritional status not improved through intervention.||Slightly smaller than necessary sample size for power; low coverage efficiency of education
Intervention integrity: Only 15% of aides in intervention group and 22% in control group attended the session; nurse educators not committed (dropped out or did not follow up for advice with hygienist).|
|Mojon, Rentsch, Budtz-Jørgensen, & Baehni (1998); Switzerland||Controlled clinical trial||Geriatric LTC facility: 116 dentate residents (intervention group, n = 58 on five wards; comparison group, n = 58 on seven wards)||See Budtz-Jørgensen et al. (2000)
Intervention integrity: 76% of caregivers, mostly nurse aides, attended the course.||Microbiological sampling 1 hour after meal to estimate Lactobacillus counts in saliva; clinical examination to measure PI. Measured level of dependence using BI to see if more dependent residents (low BI) had higher PI.||No significant difference in plaque indices; no significant changes in Lactobacillus counts; reduced Mutans streptococci colonization and root caries prevalence in intervention group. Negative correlation between PI and BI score in control group only.||Comparison group did not receive baseline prophylaxis and scaling by hygienist, nor did they visit hygienist every 6 months.|
|Nicol, Sweeney, McHugh, & Bagg (2005); United Kingdom (Scotland)||Controlled clinical trial||Long-stay institutions. Three intervention sites; two comparisons: n = 78 residents (median age = 84); n = 39 in intervention group; n = 39 in comparison group||“Making Sense of the Mouth” program, a 90-minute session consisting of lecture and discussion of seven protocols, admission sheet and care plan, practical demonstrations on tooth brushing and denture care, and discussion of problems.
Intervention integrity: Standard curriculum offered; attendance rate of staff not clear; oral hygiene frequency monitored and reported.||Baseline dental assessment and reassessment at 3 and 9 months. Control group given education after 9 months and assessment of all again at 18 months.||Statistically significant improvements at 3 months in mucosal disease, angular cheilitis, denture hygiene, and denture stomatitis. Overnight denture-wearing habits not maintained at 18 months. Control group significantly improved at 18 months after education offered after 9 months.||No gingival plaque scores compared due to few dentate residents. Improved outcomes not fully maintained at 18 months. Involvement of care staff in hygiene activities for patients increased significantly after training.|
|Simons, Baker, Jones, Kidd, & Beighton (2000); United Kingdom||Controlled clinical trial||87 residents living in seven homes where staff received training; 126 residents from 11 homes where they did not.||Standardized 90-minute session including oral hygiene demonstration, tooth brushing and denture cleaning techniques, practical involvement, oral health assessment, and care plans
39 caregivers (3 RNs and 36 aides) from seven homes attended accredited program||Oral examinations at baseline and 12 months for PI, gingival index, root caries index, and denture debris levels||At 12 months, there were no significant differences except for an increase in number of fillings. Only 14 of 213 residents had oral hygiene care plans at 12 months.||Attrition rate of caregivers was high (21% remained).
Not clear whether study patients received interventions consistently.|
|van der Putten et al. (2013); Netherlands||Controlled clinical trial||12 nursing homes: Stratified sample of n = 177 in intervention group (six homes); n = 166 in comparison group (six homes); mean age = 85||See De Visschere et al. (2012)||See De Visschere et al. (2012)||Statistically significant improvements in denture plaque, but no significant differences in dental plaque between groups.||Usual interventions received by comparison group not described|
Characteristics of Interventions Based on WIDER (2009) Recommendations
|Characteristic||Budtz-Jørgensen et al. (2000)||De Visschere et al. (2012)||Frenkel et al. (2001)||MacEntee et al. (2007)||Mojon et al. (1998)||Nicol et al. (2005)||Simons et al. (2000)||van der Putten et al. (2013)|
|Characteristics of those delivering interventions|
| Provider of intervention reported||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes|
|Characteristics of recipients|
| To whom intervention delivered is reported||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes|
|Detailed description of intervention content|
| Content of program described||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes|
| Standardized program that was referenced and replicable||No||No||No||Yes||No||Yes||Yes||No|
| Knowledge component||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes|
| Demonstration component||Yes||Yes||Yes||Yes||Yes||Yes||Yes||Yes|
| Discussion component||Yes||NR||NR||NR||Yes||Yes||Yes||NR|
| Case study component||NR||NR||NR||NR||NR||Yes||NR||NR|
| Hands-on practice component||NR||Yes||Yes||NR||NR||NR||Yes||NR|
| Bedside practice component||NR||NR||NR||NR||NR||NR||NR||NR|
| Oral hygiene supplies provided||Yes||Yes||Yes||NR||Yes||NR||Yes||Yes|
| Champion role described||No||Yes||No||Yes||No||No||No||Yes|
| Dental staff role in hygiene described||Yes||No||No||No||Yes||No||No||No|
| Dental staff available to consult||Yes||Yes||No||Yes||Yes||No||No||Yes|
|Access to intervention manuals/protocols|
| Written materials provided||NR||Yes||NR||Yes||NR||Yes||Yes||Yes|
| Procedure cards/care plans||NR||Yes||NR||NR||NR||Yes||Yes||Yes|
| Length of session||0.75 hour||1.5 hours||1 hour||1 hour||0.75 hour||1.5 hours||1.5 hours||1.5 hours|
| Attendance rate||75%||NR||66%||15%||NR||NR||n = 39||NR|
| Group size||8 to 10||NR||NR||NR||NR||6||4 to 8||NR|
| Length of time until follow up||18 months||6 months||6 months||3 months||18 months||18 months||12 months||6 months|
|Adherence/fidelity to delivery protocols|
| Adherence noted||No||No||No||No||No||No||No||No|
| Staff receiving intervention same as those delivering care||Not known||Not known||Not known||Not known||Not known||Not known||Not known||Not known|
|Detailed description of active control conditions|
| Education of comparison group||No||No||No||No||No||No||No||No|