Improving oral health care for the frail elderly: a review of widespread problems and best practices

Oral frailty: A concept analysis

AIM

To clarify the concept of oral frailty to provide a clear and standardized conceptual basis for further research in older people.

DESIGN

Rodgers and Knafl's evolutionary concept analysis approach.

METHODS

The narrative analysis detailedly extracted and synthesized the attributes of oral frailty, as well as its antecedents, consequences and related terms under the guidance of Rodgers' evolutionary method.

DATA SOURCES

Multiple databases including Pubmed, CINAHL and Cochrane were searched using selected search terms 'oral frail*', 'oral health' and 'aged' respectively. Articles written between 2013 and 2023 were included, and grey literature was excluded.

RESULTS

A total of 32 articles were included for further analysis and synthesis. The attributes of oral frailty were hypofunction, predisposing in nature, non-specific and multidimensional. Antecedents of prefrailty were classified into four categories, namely, sociodemographic characteristics, comorbidity, physical function and psychosocial factors. Consequences of oral frailty include three themes: increased risk of adverse outcomes, poor nutritional status and possibility of social withdrawal. Related terms that had shared attributes with oral frailty were oral health, functional dentition, oral hypofunction and deterioration of oral function.

CONCLUSIONS

Oral frailty is an age-related phenomenon reflected in decreased oral function. The findings of this concept analysis are conducive to understanding and clarifying the oral frailty, which can help clinicians or other healthcare providers to consider how to distinguish oral frailty in older adults and further promote the development of this field.

IMPACT

Oral frailty is increasingly recognized as an age-related phenomenon reflected in decreased oral function. As it is newly proposed, no consensus has been reached regarding the theoretical and operational concept of it. Through clarifying the concept, this paper will guide future healthcare research on oral frailty regarding the influencing factors, mechanisms and interventions, thus raising the awareness with regard to oral health among older adults. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: In the context of older adults, oral frailty is a concept that requires further research to guide future theoretical development, and the influencing factors, mechanisms and interventions need to be further studied. Raise awareness with regard to oral health among older people and more attention will be paid to the early identification and intervention of oral frailty, so as to further improve the quality of life of older adults.

To assess the knowledge, attitudes, and confidence of caregivers and administrators towards the oral health of nursing home residents in San Antonio, Texas

OBJECTIVE

The primary objective of this research was to use qualitative methods to assess the knowledge, attitudes, and confidence of caregivers in their ability to provide oral hygiene assistance to residents. The secondary objective was to assess the knowledge and attitude of administrators on the provision of oral hygiene assistance for residents, and their confidence in caregivers' ability to provide oral hygiene assistance to nursing home residents in San Antonio, Texas.

METHODS

A semi-structured interview guide was used to conduct face-to-face interviews with seven caregivers and twelve administrative staff from ten nursing homes in San Antonio, Texas. Employees in nursing homes who are caring for residents are referred to as caregivers and those whom they care for are referred to as nursing home residents. One survey instrument was developed for the caregiver's knowledge, attitude, and confidence toward providing oral health care, and another to assess the administrator's knowledge, attitude, and confidence in caregivers providing oral care for nursing home residents. The interviews were recorded, transcribed, and coded for thematic content.

RESULTS

The findings revealed that caregivers and administrators had adequate knowledge of the connection between oral and systemic health. The administrators were confident that caregivers were adequately trained to provide oral hygiene care for residents. Caregivers had a positive attitude toward the importance of good oral health. They regularly assessed the residents' oral health, but due to time constraints, staffing shortages, and other competing tasks providing oral health care to the residents was challenging. Most caregivers were confident in their skills in providing oral care for the residents since 85.6% agreed. On the contrary, almost half of the administrators were confident that caregivers have the necessary skills to provide oral care for residents, while 41.7% were unsure.

CONCLUSIONS

The study gave a broader insight into the provision of oral care in nursing home residents from the perspectives of caregivers and administrative staff. Administrators must provide caregivers with adequate training and time so they can provide adequate oral health care for the residents.

Health status, care dependency and oral care utilization among older adults: a register-based study

BACKGROUND AND OBJECTIVES

The aim of the study was to examine oral care utilisation among older Danes and to describe the extent to which oral care use is associated with the co-existence of challenges relating to general health and care dependency.

MATERIALS AND METHODS

The study used registry data covering the entire population of older adults (≥65 years) in seven municipalities in Denmark (N = 178 787 individuals). Oral care services utilisation was computed from administrative data on oral care contacts up to and including 2019, including both private oral care and a municipal oral care programme (MOCP). Various registry data sources were used to compute risk factors to describe oral care utilisation across indicators of general health and care dependency.

RESULTS

Indicators for poorer health were associated with larger proportions of individuals enrolled in the MOCPs and larger proportions of non-users of any type of oral care. Higher degrees of care dependency were associated with larger proportions of individuals enrolled in MOCPs and individuals with no use of any oral care services, with the exception of nursing home residents, who comprised a lower proportion of non-users than individuals receiving at-home care. Municipal oral care mainly enrolled older adults who were nursing home residents (60% of nursing home residents were enrolled).

CONCLUSION

Our findings support existing evidence on the link between oral care utilisation and general health and frailty. While the municipal care programmes assisted in covering oral care for those with the highest level of care dependency, future preventive strategies for ensuring care continuity for older adults that are increasing in frailty may want to focus on the earlier stages of frailty and of general health deterioration.

Oral self-care among dependent older New Zealanders

OBJECTIVES

The objective of the study was to describe the occurrence and associations of oral self-care by dependent older New Zealanders.

BACKGROUND

Dependent older adults who require some level of assisted daily care have been shown to have poorer oral health than their independent counterparts, yet national estimates are lacking.

MATERIALS AND METHODS

A secondary analysis was conducted of data from New Zealand's 2012 Older People's Oral Health Survey, a national survey that interviewed and examined a representative sample of 2,218 dependent older adults living in aged residential care or receiving home-based care. Survey data were weighted for statistical analyses, and modelling was carried out using a modified Poisson approach.

RESULTS

Overall, 59.5% (95% CI: 55.1, 63.7) of participants brushed their teeth twice a day, with this rate higher among women, Asians and those without cognitive or physical impairment. Cleaning interdentally at least once a week was less common than brushing, at 25.9% (95% CI: 21.5, 30.9), and that proportion was significantly lower among those with higher dependency or who were cognitively or physically impaired. Almost 9 in 10 (87.8%; 95% CI 83.1, 91.4) used fluoride toothpaste, and adults of high socio-economic status had lower rates of fluoride toothpaste use. Only 15.0% (95% CI 12.4, 18.0) used mouthwash, with this being most prevalent in Pasifika. More than half of those who wore dentures also wore them at night.

CONCLUSION

Oral self-care was sub-optimal among dependent older New Zealanders. Improving the situation should be a high priority.

The Dutch version of the Oral Health Assessment Tool: Translation and inter-rater reliability among community nurses

OBJECTIVES

Translating the Oral Health Assessment Tool (OHAT) into Dutch and assessing the inter-rater reliability among community nurses.

METHODS

The original version of the OHAT was translated following the five stages of the 'Guidelines for the Process of Cross-Cultural Adaptation'. After a forward and backward translation, consensus on the pre-final version was obtained in an expert panel discussion. This version was pre-tested on its comprehensibility among 31 nurses and hereafter finalized. Then, inter-rater reliability of the OHAT-NL was determined by two trained nurses during oral assessments of 37 care-dependent community-dwelling older people. Intraclass correlation coefficient (ICC) and the Cohen's kappa statistic for individual items were estimated.

RESULTS

Feedback from nurses in the pre-test did lead to minor changes of the OHAT-NL. Inter-rater reliability was good (ICC 0.79; 95% CI 0.63-0.89) on the total score. Agreement on item level ranged from fair to very good, the kappa ranged from 0.36-0.89.

CONCLUSIONS

OHAT is now available in Dutch having good inter-rater reliability among trained community nurses. Future research can further validate the OHAT-NL and develop intervention according to total OHAT-NL scores.

Relationship between risk of oral frailty and awareness of oral frailty among community-dwelling adults: a cross-sectional study

We aimed to investigate the relationship between the risk of oral frailty and awareness of oral frailty among Japanese adults in an adult dental health field study conducted in Kanagawa Prefecture. Questionnaire data from a total of 5051 individuals (1907 males, 3144 females; mean age; 59.9 years) were used. The risk of oral frailty was assessed using the Oral Frailty Index-8. Of the participants, 1418 (28.1%) had a high risk of oral frailty and 1495 (29.6%) had knowledge of oral frailty. Logistic regression analysis indicated that the risk of oral frailty was significantly associated with awareness of oral frailty. We further found that awareness of oral frailty was significantly related to gender (female), age (20-39 compared to 70-79, ≥ 80), residential areas (Yokohama compared to Kawasaki, Sagamihara), exercise habits (yes), eating a balanced diet (yes), consciousness of oral health (yes), risk of oral frailty (low) and outpatient category (hospital visit). For groups with low levels of awareness obtained from the results of this study, it is necessary to consider the means of accessibility and increase awareness further.

Best Practices in Oral Care

Topic

Assessing functional cognition is a critical need for intensive care unit survivors transitioning to another level of care.

Clinical Relevance

Up to 62% of patients discharged from an intensive care unit have significant cognitive impairment that is not associated with severity of illness, number of comorbidities, or length of hospital stay. For more than 20 years, researchers have published an array of potentially effective interventions, including case management, patient and informal caregiver education, and home health care services.

Purpose

To describe the impact of and potential interventions for cognitive decline at intensive care unit discharge and discharge readiness on 30-day readmission rates.

Content Covered

Assessing the patient’s functional cognition assessment and advocating for appropriate resources are needed to improve patient and clinical outcomes.

The Prevention, Diagnosis, and Treatment of Rapid Oral Health Deterioration (ROHD) among Older Adults

The world’s population is aging. Older adults are at risk for multiple chronic medical problems as they age. The management of these diseases requires these people to take a variety of medications, which may have undesired side effects. These medical issues can impact oral healthcare and result in a precipitous decline in oral health. A standardized teaching model has been developed to help novice dental practitioners learn how to access and treat oral health problems in older adults. This model is called rapid oral health deterioration (ROHD) risk assessment. The model has four steps for assessment and four categories of risk. This paper describes the components of the ROHD risk assessment, and how it can be used to prevent, diagnose and treat ROHD among older adults.

The Efficacy of Gum Arabic in Managing Diseases: A Systematic Review of Evidence-Based Clinical Trials

Gum arabic (GA) is a natural product commonly used as a household remedy for treating various diseases in the Sub-Saharan Africa region. Despite its claimed benefits, there has been a lack of research on the findings of current clinical trials (CTs) that investigated its efficacy in the treatment of various medical diseases. The aim of this systematic review was to study CTs which focused on GA and its possible use in the management of various medical diseases. A search of the extant literature was performed in the PubMed, Scopus, and Cochrane databases to retrieve CTs focusing on evidence-based clinical indications. The databases were searched using the keywords ("Gum Arabic" OR "Acacia senegal" OR "Acacia seyal" OR "Gum Acacia" OR "Acacia Arabica") AND ("Clinical Trial" OR "Randomized Controlled Trial" OR "Randomized Clinical Trial"). While performing the systematic review, data were obtained on the following parameters: title, authors, date of publication, study design, study aim, sample size, type of intervention used, targeted medical diseases, and main findings. Twenty-nine papers were included in this systematic review. The results showed that ingestion of GA altered lipid profiles, renal profiles, plaque, gingival scores, biochemical parameters, blood pressure, inflammatory markers, and adiposity. GA exhibited anti-inflammatory, prebiotic, and antibacterial properties. GA has been successfully used to treat sickle cell anemia, rheumatoid arthritis, metabolic disorders, periodontitis, gastrointestinal conditions, and kidney diseases. Herein, we discuss GA with respect to the underlying mechanisms involved in each medical disease, thereby justifying GA's future role as a therapeutic agent.

Sarcopenic Dysphagia, Malnutrition, and Oral Frailty in Elderly: A Comprehensive Review

Frailty is a highly prevalent condition in the elderly that has been increasingly considered as a crucial public health issue, due to the strict correlation with a higher risk of fragility fractures, hospitalization, and mortality. Among the age-related diseases, sarcopenia and dysphagia are two common pathological conditions in frail older people and could coexist leading to dehydration and malnutrition in these subjects. “Sarcopenic dysphagia” is a complex condition characterized by deglutition impairment due to the loss of mass and strength of swallowing muscles and might be also related to poor oral health status. Moreover, the aging process is strictly related to poor oral health status due to direct impairment of the immune system and wound healing and physical and cognitive impairment might indirectly influence older people’s ability to carry out adequate oral hygiene. Therefore, poor oral health might affect nutrient intake, leading to malnutrition and, consequently, to frailty. In this scenario, sarcopenia, dysphagia, and oral health are closely linked sharing common pathophysiological pathways, disabling sequelae, and frailty. Thus, the aim of the present comprehensive review is to describe the correlation among sarcopenic dysphagia, malnutrition, and oral frailty, characterizing their phenotypically overlapping features, to propose a comprehensive and effective management of elderly frail subjects.

Behaviors of care providers and resistiveness to oral care of persons living with dementia

Since care providers' behavior could be related to resistiveness to care (RTC) among persons living with dementia, developing care providers' behavioral strategies to reduce or prevent RTC is required. This study examined whether care providers' person-centered or task-centered behaviors were related to RTC. A secondary data analysis was conducted using 70 videos of 23 persons living with dementia who received routine oral care in long-term care settings. Data were analyzed using linear mixed models. Among task-centered behaviors, "physically controlling" significantly increased RTC. For person-centered behaviors, "cooperatively negotiating" increased RTC, while "assessing comfort" decreased RTC. Care providers need to consider the comfort or needs of persons living with dementia rather than physically controlling them in oral care situations. These findings may offer insight into the context of RTC occurrences to provide more comfortable oral care for persons living with dementia.

Dental plaque control strategies for the elderly population: A scoping review

OBJECTIVE

To review the scientific literature and identify dental plaque control strategies focussed on elderly people that improve plaque indices.

DESIGN

Scoping review (Joanna Briggs protocol).

DATA SOURCES

Individual search strategies developed for six databases. The selection of the manuscripts in two phases: title and abstract review, and complete review.

ELIGIBILITY CRITERIA

Studies on interventions for plaque control in elderly people (60y+). Epidemiological studies and those focussed on caregivers, health professionals and periodontal maintenance therapies were excluded.

RESULTS

The initial search yielded 2803 studies, 26 were included. The results were classified into: exclusively chemical (10), educational (9), exclusively mechanical (6), and combined mechanical and chemical (1). The studies reported different types of interventions: sugarless chewing gum, chlorhexidine (CHX) in different preparations and concentrations, mouthwash based on essential oils, stannous/sodium fluoride dentifrice and lactoferrin/lactoperoxidase tablets. Additionally, conventional and alternative toothbrushes and professional brushing were tested. Educational interventions included oral hygiene guidance, verbal information, and demonstrations of dental and denture cleaning procedures, and lifestyle changes. Many studies have reported strategies that improve dental plaque indices but without statistical significance when compared to control groups. Promising results were found with the use of CHX, sugarless chewing gum, professional brushing and educational strategies with demonstration, but the results were not long-lasting.

CONCLUSION

The literature reports that mechanical, chemical and educational strategies have some efficacy in dental plaque control in the elderly population. The results should be viewed with caution, considering the type of intervention (isolated or combined) and the maintenance of the results obtained.

Event-Based but Not Time-Based Prospective Memory Is Related to Oral Health in Late Adulthood

BACKGROUND

Most evidence now indicates that cognitive function is related to poorer oral health in late adulthood, but that this relationship is not invariant across specific cognitive domains. Prospective memory (PM) is a core memory skill that refers to memory for future intentions and is known to be related to the formation of habits such as tooth flossing. However, the relationship between PM and oral health has been subject to only limited empirical study.

OBJECTIVE

The two studies reported in this paper were designed to test whether PM is related to oral health in older adults of varying vulnerability status.

METHODS

Study 1 sampled community-dwelling older adults (N = 172) living independently in the community; Study 2 sampled older adults living in a retirement village (N = 32). Participants in both studies were asked to complete a behavioural measure of PM, with their oral health indexed via self-report (Study 1) or an objective oral health exam (Study 2).

RESULTS

In both studies, relationships emerged between event-based PM and oral health, with Study 2 showing that these relationships were specific to oral health measures of plaque and calculus.

CONCLUSIONS

Older adults are particularly vulnerable to dental pathology, with important implications for their broader health and well-being. By showing that there is a relationship between oral health and a particular type of PM, this work will have potential implications for the development of more effective interventions focused on enhancing oral health outcomes in this group, such as those focused on strengthening habit formation.

How accurate is the assessment of certified nursing assistants on resident's oral self-care function in three North Carolina assisted-living facilities?

AIMS

To examine the association between the assessments of certified nursing assistants (CNAs) on resident's oral self-care function and resident's oral hygiene outcomes in three North Carolina assisted-living (AL) facilities.

METHODS AND RESULTS

Sixty-five dentate AL residents were included in this secondary analysis. CNAs were asked to rate the AL residents' overall oral self-care function using a 6-point Likert scale. Their assessments were then compared with the objective, performance-based Dental Activities Test and the oral hygiene and gingival health measures. The analysis showed that nearly 90% of the participants presented with at least one untreated decayed or broken tooth. On average, nearly two-thirds of the surfaces were covered by soft deposits (Debris Index = 1.83, SD = 0.60). Generalized mild to moderate inflammation (Gingival Index = 1.51, SD = 0.53) commonly presented on residents' gingiva. CNAs were able to accurately identify the residents with substantial impairment in oral self-care function, yet they tended to overestimate the oral self-care function of residents with mild to moderate impairment. CNAs assessments were also not significantly correlated with residents' oral hygiene measures.

CONCLUSION

CNAs failed to identify and provide assistance to AL residents with impaired oral self-care function, contributing to poor oral oral hygiene in these vulnerable individuals.

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.

Consensus of Chinese experts on protection of skin and mucous membrane barrier for health-care workers fighting against coronavirus disease 2019

Health professions preventing and controlling Coronavirus Disease 2019 are prone to skin and mucous membrane injury, which may cause acute and chronic dermatitis, secondary infection and aggravation of underlying skin diseases. This is a consensus of Chinese experts on protective measures and advice on hand‐cleaning‐ and medical‐glove‐related hand protection, mask‐ and goggles‐related face protection, UV‐related protection, eye protection, nasal and oral mucosa protection, outer ear, and hair protection. It is necessary to strictly follow standards of wearing protective equipment and specification of sterilizing and cleaning. Insufficient and excessive protection will have adverse effects on the skin and mucous membrane barrier. At the same time, using moisturizing products is highly recommended to achieve better protection.

A context analysis on how oral care is delivered in hospitalised patients: A mixed-methods study

AIMS AND OBJECTIVES

To analyse oral care delivery in one hospital through exploring experiences from both nurses' and patients' perspectives and examining patients' oral health.

BACKGROUND

Oral health problems are associated with undernutrition and other general health outcomes. Although oral care belongs to the essentials of nursing, it is often neglected. Improving oral health may require behaviour change of both nurses and patients. Defining tailored strategies need a clear view on the context.

DESIGN

A context analysis in one hospital using a convergent parallel mixed-methods design was reported following the EQUATOR guidelines using two checklists: COnsolidated criteria for REporting Qualitative research (qualitative research) and STROBE (observational research).

METHODS

Semi-structured interviews were conducted with 19 nurses and 11 patients. The topic list was based on the Integrated Change Model. Prospective oral examination was performed among 91 surgical patients using the Oral Health Assessment Tool (OHAT).

RESULTS

Nurses acknowledged that they did not prioritise oral care in daily practice. Furthermore, they lacked knowledge and skills to identify and provide care for oral problems. Nurses mentioned helpful resources to perform oral care, like standardised language and instruments. However, they had no access to or were unaware of them. Patients admitted that they did not prioritise oral care due to their sickness during hospitalisation, were unaware of the importance of oral care, but felt responsible for their oral care. The most prominent oral problems identified with the OHAT were unclean mouths (n = 75, 82%), unhealthy gum and tissues (n = 55, 60%) and dry mouth (n = 42, 46%).

CONCLUSIONS

This context analysis identified inadequate oral care due to lack of positive attitude and knowledge in both nurses and patients, skills for nurses, and resources.

RELEVANCE TO CLINICAL PRACTICE

The behavioural factors indicate strategies for development of a multicomponent intervention to improve oral care in this hospital, nutritional status and general health outcomes.

Older People Living in Nursing Homes: An Oral Health Screening Survey in Florence, Italy

The oral health state plays an important role in the concept of 'elderly frailty', since institutionalized older people are prone to suffering from bad oral conditions. The aim of this study is to assess the state of oral health in the older residents of nursing homes and to measure its potential association with the cognitive state, the degree of functional autonomy, and the malnutrition risk. Methods: We enrolled 176 subjects from 292 residents in five nursing homes in Florence. For each subject, we performed the Malnutrition Universal Screening Tool, the Pfeiffer test, the Minimum Data Set-Long Form, a dental examination, and the Geriatric Oral Health Assessment Index questionnaire. The results show that the oral condition was poor in 43.8% of cases, medium in 38.1%, and good in 18.2%. A worse oral health state was significantly associated (p < 0.05) with a worse cognitive state and with a higher dependency in daily living activities. The malnutrition score among the older people was unrelated to the oral health condition (p = 0.128). It can be concluded that the oral health condition in older institutionalized subjects is an open challenge for the public healthcare system, since the maintenance of adequate good oral health is an essential element of good physical as well as cognitive and psychological health.

Severity of Candida-associated denture stomatitis is improved in institutionalized elders who consume Lactobacillus rhamnosus SP1

BACKGROUND

This study aimed to determine the effect of the consumption of a probiotic on the clinical characteristics of Candida-associated denture stomatitis (DS) and to determine the impact of a protocol of self-care measures in oral/prosthetic hygiene in institutionalized elders that wear removable prostheses (RP). The current treatment for DS is the systemic use of antifungals, as well as the replacement of these devices together with oral/prosthetic hygiene instructions.

METHODS

This study was a randomized, controlled and triple-blind trial. Thirty-six elders presenting DS of different severity and who carried RP consumed milk with/without the probiotic L. rhamnosus SP1. The prevalence and severity of DS and prevalence of Candida were determined and all participants/caregivers were trained in oral/prosthetic hygiene.

RESULTS

In both groups a decrease in the prevalence of DS was observed (P < 0.05) but only the group that consumed probiotic throughout the trial had a significant reduction in the severity of DS and reduced Candida counts (P < 0.05). Educational instruction in oral/prosthetic hygiene was relevant for the participants, regarding the prevalence of this lesion.

CONCLUSIONS

The frequent consumption of Lactobacillus rhamnosus SP1 and the establishment of a protocol of oral/prosthetic hygiene drastically reduced the severity of DS in institutionalized elders who wore RP.

Oral health and oral care in short-term care: prevalence, related factors and coherence between older peoples' and professionals' assessments

Background

Oral health is important for well‐being and overall health. Older peoples′ oral health is well described in the residential care context, but remains understudied in short‐term care.

Objective

The aim of this study was to describe oral health, daily oral care and related factors among older people in short‐term care and to compare self‐perceived oral health with professional assessment.

Materials and methods

This cross‐sectional study included 391 older people in 36 short‐term units in 19 Swedish municipalities. Oral health was assessed professionally by clinical oral assessment and the Revised Oral Assessment Guide (ROAG). The older peoples’ perceptions of their own oral health were measured with a global question on self‐perceived oral health. Self‐care ability was assessed with Katz Index of Activities of Daily Living (Katz‐ADL).

Results

Mean age was 82.9 years, 19% of participants were totally edentulous, and 43% had ≥20 teeth. Almost 60% had coating or food debris on their teeth, but only 19% received help with daily oral care. Those who were dependent on help with self‐care had around a sixfold higher risk of having oral problems. There was a low level of agreement between the clinical assessment based on ROAG and self‐perceived oral health.

Conclusion

Professionals’ assessments of oral health differed considerably from the older peoples′ own assessments. A higher risk of oral problems and more occurrence of coating or food debris or broken teeth were seen among those dependent on help with self‐care (ADL). This study indicates that in order to improve older peoples′ oral health and oral care we need to provide person‐centred oral care and to develop a close collaboration between nursing and dental staff.

Oral health trajectories in community-dwelling older adults in the last 3 years of life

BACKGROUND

Systemic health and physical, cognitive, and social function gradually decline at the end of life. How oral health change at the end of life in community-dwelling older adults remains unknown, increasing the difficulty in treatment planning for these individuals.

METHODS

A total of 250 community-dwelling decedents of a longitudinal study were included in the analysis. Decedents' clinical and interview data collected at baseline, 18, 36, 60, and 84 months were linked to their death dates and plotted on an inverted time scale to study their oral health changes in the 3 years prior to death. Mixed effect models with random intercepts and slopes of months from death and sociodemographic variables were used to model the subjective and objective oral health trajectories in the last 3 years of life. The association of the change in the outcomes with a linear trend of months from death were assessed using the F-test.

RESULTS

Number of missing teeth was significantly associated with a linear trend of months from death. With every month in proximity to death, the expected number of missing teeth increased by 0.03 (SE = 0.004; p < 0.001), resulting in an average of 1.08 missing teeth in 3 years. Among subjective outcomes, the odds of good versus poor or "neither" self-rated systemic health (p = 0.009) and mouth appearance (p = 0.008) significantly decreased as death approached.

CONCLUSION

Although other oral health measures remained relatively stable, tooth loss and dissatisfaction with mouth appearance steadily increased in community-dwelling older adults as death approached. These changes were gradual and parallel the end-of-life general health decline.

Iowa nursing facility oral hygiene (INFOH) intervention: A clinical and microbiological pilot randomized trial

PURPOSE/AIM

The aim of this pilot study was to evaluate feasibility and gather initial data for a definitive study to test the clinical and microbiological effectiveness of a nursing facility (NF) customized oral hygiene protocol, intended to be delivered by dental hygienists and NF personnel.

MATERIALS AND METHODS

A convenience sample of 8 Eastern Iowa NFs was recruited, and each NF was assigned to one of three intervention groups: (1) control (current oral hygiene practice), (2) educational program only, and (3) educational program plus 1% chlorhexidine varnish monthly application. Demographic information, systemic health data, patient centered data, oral health data, and microbiology samples were collected at baseline and after 6 months.

RESULTS

Recruitment response rates were 21% for NFs and 23% for residents. A total of 81 residents were examined at baseline and of those, 49 were examined at 6 months (39.5% attrition). There were no statistically or clinically significant differences among the intervention groups at 6 months for any of the recorded clinical or microbiological outcomes.

CONCLUSIONS

Recruitment and retention posed a significant challenge to this trial, even with a relatively short observation period. Results from this pilot study did not encourage further investigation of this customized oral hygiene protocol.

The pathway from cognitive impairment to caries in older adults: A conceptual model

BACKGROUND

Caries significantly increases in people with cognitive impairment (PWCI). However, the interrelationships among cognitive impairment, dentally related function (DRF), oral hygiene, and caries remain unclear, increasing difficulties to care appropriately for PWCI. In this study, the researchers tested a conceptual model in which impaired DRF acts as a mediator between cognitive impairment and poor oral hygiene, which then leads to caries.

METHODS

The researchers recruited 68 older adult dentate participants with normal to severely impaired cognition from 3 assisted-living communities in North Carolina. Within 1 week of a calibrated oral examination performed by a geriatric dentist, a trained examiner blinded to the oral examination results conducted cognitive and functional assessments. The researchers conducted statistical analyses to examine the mediating effect of DRF on the relationship between cognitive impairment and oral hygiene or caries.

RESULTS

Cognitive impairment (β = 0.05; standard error [SE], 0.02; P = .017) and DRF (β = -0.07; SE, 0.02; P = .005) were significantly associated with oral hygiene. However, the association between cognitive impairment and oral hygiene was greatly reduced and became nonsignificant after controlling for DRF (β = 0.01; SE, 0.03; P = .430), suggesting that the effect of cognitive impairment on oral hygiene was mediated by DRF. DRF accounted for 80% of the total effect of cognitive impairment on oral hygiene. The ratio of the indirect effect to the total effect was .8. Associations between either cognitive impairment or DRF and caries were not significant, but oral hygiene was significantly associated with caries (β = 0.87; SE, 0.28; P < .001).

CONCLUSIONS

DRF mediated the association between cognitive impairment and oral hygiene. It accounted for 80% of the total impact of cognitive impairment on oral hygiene, which was associated with increased caries in PWCI.

PRACTICAL IMPLICATIONS

As a result of cognitive impairment, impaired DRF plays a critical role in the pathway from cognitive impairment to oral health decline. Therefore, DRF assessment should be a standard component of geriatric dental assessment. A functionally-tailored oral hygiene intervention is essential to improve oral health for persons with cognitive impairment.

Aging-related changes in quantity and quality of saliva: Where do we stand in our understanding?

Saliva is crucial to oral processing of food and consequently is also related to the sensory and textural experience. It is often assumed that the secretion and properties of saliva change with age, which can result in dry mouth conditions, taste aberrations. Such changes may result in reduced nutrient intake and malnutrition besides adversely affecting the quality of life. Based on some recent research findings, this article reviews our current understandings on age-dependent changes on quantity (bulk salivary flow rate) as well as quality of saliva (e.g., composition, viscosity, lubrication) in healthy elderly individuals. The review begins with a short introduction to histological changes of salivary glands upon aging. This is followed by covering different aspects of salivary changes with key articles highlighting decreased flow rate, increased ionic concentration, decreased calcium and mucin content in saliva of elderly subjects consequently affecting the oral coating and flavor perception. We also highlight issues in data associated with respect to variance in saliva collection protocols as well as factors influencing such results other than age, such as health conditions and polypharmacy. Clear gaps in literature have been highlighted with respect to lack of quantitative data in viscoelasticity, rheology, and lubrication properties of saliva in healthy elderly population and the potential impact of changes in these material properties on sensory and textural perception of food and consequently food intake. Such insights will not only have clinical implications for maintaining optimal oral health in elderly population but also serve to optimize food for elderly population. PRACTICAL APPLICATIONS: The population has undergone a fundamental change in its age structure globally, with a rapid increase in elderly population. Innovation of tailored foods is still in its early stage to satisfy the needs of growing aging population. One of the biggest challenges in such food product development is lack of adequate understanding and characterization of endogenous factors, that is, age-related changes in saliva, which may influence oral processing of food and subsequently nutrient intake. Aging affects the salivary glands and alters quantity (flow rate) and quality (e.g., ion and protein composition, rheology, tribology) of saliva. Thus, older adults may suffer from dry mouth, taste aberration, and poor oral hygiene, greatly affecting their quality of life. This review provides insights into how age versus other health conditions influence salivary properties. Understanding of age-dependent changes in salivary rheology and tribology will be of paramount importance to optimize food for elderly population.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

An Expert Opinion from the European College of Gerodontology and the European Geriatric Medicine Society: European Policy Recommendations on Oral Health in Older Adults

This is an expert opinion paper on oral health policy recommendations for older adults in Europe, with particular focus on frail and care-dependent persons, that the European College of Gerodontology (ECG) and the European Geriatric Medicine Society (EUGMS) Task and Finish Group on Gerodontology has developed. Oral health in older adults is often poor. Common oral diseases such as caries, periodontal disease, denture-related conditions, hyposalivation, and oral pre- and cancerous conditions may lead to tooth loss, pain, local and systemic infection, impaired oral function, and poor quality of life. Although the majority of oral diseases can be prevented or treated, oral problems in older adults remain prevalent and largely underdiagnosed, because frail persons often do not receive routine dental care, due to a number of barriers and misconceptions. These hindrances include person-related issues, lack of professional support, and lack of effective oral health policies. Three major areas for action are identified: education for healthcare providers, health policy action plans, and citizen empowerment and involvement. A list of defined competencies in geriatric oral health for non-dental healthcare providers is suggested, as well as an oral health promotion and disease prevention protocol for residents in institutional settings. Oral health assessment should be incorporated into general health assessments, oral health care should be integrated into public healthcare coverage, and access to dental care should be ensured.

Evaluating student learning outcomes in oral health knowledge and skills

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN

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

RESULTS

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

CONCLUSION

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

RELEVANCE TO CLINICAL PRACTICE

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

Examination of intensive care unit patients' oral health

BACKGROUND

Oral health problems are common complications that most intensive care unit patients experience. There are many factors that affect oral health negatively and nurses have important responsibilities in this regard.

AIM

The aim of this study was assessment of the intensive care unit patients' oral health and risk factors.

METHODS

This study was planned as a descriptive study and conducted between December 2015 and June 2016, with 202 patients in 20 intensive care units of 6 hospitals in Turkey. Data were collected via Data Collection Form and Bedside Oral Exam guide. Oral health assessment of patients was made using a source of light and a tongue depressor.

RESULTS

We observed a significant difference in score of the Bedside Oral Exam guide by age, consciousness, type of respiration and feeding, the frequency of oral health, the total number of drugs, and technique of oral care (P < 0.05). None of the intensive care units were using the oral assessment guide.

CONCLUSION

The result of this study shows that there are various risk factors that adversely affect the oral health of intensive care unit patients. Nurses should undertake assessments on the basis of oral care protocols for patients at risk and carry out evidence-based individualized oral care applications.

Use of care and the oral health status of people aged 60 years and older in France: results from the National Health and Disability Survey

Objective

We aimed to analyze, from the data in a national survey, the use of oral care and the oral health status of patients living at home or in an institution.

Background

Patients aged 60 years and older have important oral health needs, but their oral management may differ according to their immediate environment. The fact of living at home or in an institution can influence the use of care and alter the patients’ perception of their oral health status.

Methods

The data analyzed were taken from a survey on disability and health carried out in 2008–2009, which is representative of the population living in France. It consists of two sections, one centered on disability and health among home-dwellers and the other on patients living in an institution. In each of these two populations, we carried out descriptive analysis of three themes: use of care, forgoing of care, and oral health.

Results

Although visits to physicians and specialists were frequent, visits to dentists were lower in both populations. While a minority of patients forwent care, it was dental care that was mainly forgone by both home-dwellers and institutionalized patients. The cost factor remained the principal reason, but other factors such as fear or accessibility problems were cited. Use of a dental appliance was considerably more frequent among institutionalized patients than among home-dwellers, with just over half the institutionalized population wearing a dental appliance. Perceived state of oral health remained difficult to interpret.

Conclusion

To improve access to oral care for the elderly, the patients, their entourage and health providers need increased awareness and information on the importance of good oral health. Better information must be associated with regular clinical examination.

Association Between Malnutrition and Oral Health in Dutch Nursing Home Residents: Results of the LPZ Study

INTRODUCTION

According to the World Health Organization (WHO) and FDI World Dental Federation (FDI), malnutrition and bad oral health are of great concern to global health, especially among the older population. This study aimed to assess the associations between oral health problems ([artificial] teeth problems, chewing problems, and xerostomia) and malnutrition in residents of somatic and psychogeriatric wards in Dutch nursing homes.

METHODS

Data of the cross-sectional National Prevalence Measurement of Quality of Care study (Landelijke Prevalentiemeting Zorgproblemen study) in the Netherlands were used to evaluate nutritional status and oral health of 3220 residents, aged 65 or older and living in somatic or psychogeriatric wards in Dutch nursing homes. Cox regression was performed to calculate prevalence ratios (PR) of malnutrition among these residents.

RESULTS

Of the total study population, 11.7% were malnourished, 28.6% suffered from xerostomia, 25.6% suffered from chewing problems, and 10.1% experienced problems eating due to (artificial) teeth problems. Within somatic wards, 9.0% were malnourished, whereas 13.2% of residents in psychogeriatric wards were malnourished. Increased risk for malnutrition was found among psychogeriatric residents who had problems with eating due to (artificial) teeth problems (PR 1.6, 95% CI 1.1-2.3).

CONCLUSION

Poor oral health, mostly problems with eating due to (artificial) teeth problems, was associated with an almost twofold risk for malnutrition in older residents in Dutch nursing homes and even more so in psychogeriatric residents than in somatic residents.

Exploring dental student participation in interdisciplinary care team conferences in long-term care

OBJECTIVE

The purpose of this study was to explore how the participation of dental hygiene students in interdisciplinary care conferences conducted in long-term care (LTC) facilities influenced the staff's awareness of oral health, the student's provision of care as well as the student's ability to work on an interdisciplinary team.

BACKGROUND

Oral health in LTC continues to be poor despite many educational and clinical interventions. The care of a frail elder requires an interdisciplinary team approach, yet dental professionals are often absent from these teams. As an educational intervention, dental hygiene students, in addition to providing clinical care to residents and education to staff in a LTC facility, have been participating in interdisciplinary care conferences for 4 years.

METHODS

Nine LTC facility staff and eight students participated in two focus groups and five personal interviews to discuss their experiences of the care conferences. Narratives were transcribed verbatim and thematic analysis was conducted.

RESULTS

Four major themes emerged that described the essence of the experience of involving dental professionals within interdisciplinary care conference: (i) addressing oral health, (ii) reciprocal learning, (iii) dealing with complexity and (iv) impact of collaborative care.

CONCLUSION

Overall, students found the educational intervention to be worthwhile that allowed for the development of interdisciplinary skills and a greater understanding of dental geriatrics. The dental support in care conferences was welcomed by the staff as it facilitated a new way of exchanging knowledge and experiences so that a more holistic approach to care could be undertaken by all.

Culturally and linguistically diverse (CALD) carers' perceptions of oral care in residential aged care settings in Perth, Western Australia

OBJECTIVE

The aims of the study were twofold: to explore African migrant carers' perceptions of oral health who worked in residential aged care and to investigate their perspectives of oral care for aged care residents.

BACKGROUND

Culturally and linguistically diverse (CALD) carers are strongly represented in Australian residential aged care facilities.

METHODS

Exploratory qualitative research targeted carers from African backgrounds working in residential aged care facilities in Perth, Western Australia. Fifteen African carers were recruited through community networks and participated in semistructured interviews. Data were analysed for key themes related to the study's aims noting similarities and differences between participants.

RESULTS

All participants considered oral health important to individual well-being and quality of life. Most had limited knowledge of prevention and early detection of oral disease resulting from regular dental check-ups with the majority visiting dental professionals only for dental pain. Yet participants considered oral health care for residents needed improvement. Suggestions included dental professionals on staff and training and professional development for all staff not just in oral health care but also in working respectfully and sensitively with residents and staff from CALD backgrounds.

CONCLUSION

Our findings suggest that, to ensure residents receive high quality oral health care, ongoing professional development is required, not only for CALD carers in oral health but also for non-CALD staff in care that is respectful of cultural differences.

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

Background/Introduction

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

Objective

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

Methods

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

Results

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

Conclusion

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

Association between dentures and the rate of falls in dementia

Background

Poor oral health, chronic diseases, functional decline, and low cognitive ability can increase the risk of falls in the elderly.

Objectives

The current study aimed to show the effects of oral health, diabetes mellitus (DM), hypertension (HT), heart disease, functional status, and sociodemographic factors on the risk of falls in elderly with dementia.

Materials and methods

The sample comprised 1,210 Malaysian elderly who were demented and noninstitutionalized. This study was a national cross-sectional survey entitled “Determinants of Health Status among Older Malaysians”. The effects of age, ethnicity, sex differences, marital status, educational level, oral health, DM, HT, heart disease, and functional status on the risk of falls were evaluated. The multiple logistic regression model was used to estimate the effects of contributing variables on the risk of falls in samples.

Results

The prevalence of falls was approximately 17% in subjects. It was found that age (odds ratio [OR] 1.02), non-Malay ethnicity (OR 1.66), heart disease (OR 1.92), and functional decline (OR 1.58) significantly increased the risk of falls in respondents (P<0.05). Furthermore, having teeth (OR 0.59) and dentures (OR 0.66) significantly decreased the rate of falls (P<0.05).

Conclusion

It was concluded that age, non-Malay ethnicity, functional decline, heart disease, and oral health significantly affected falls in dementia.

The effect of programs to improve oral hygiene outcomes for older residents in long-term care: a systematic review

Nurses have a critical role in promoting oral health in dependent older adults residing in long-term care or having extended hospital stays. Strategies aimed at improving the quality of oral hygiene care nurses provide may contribute to better oral hygiene outcomes. The purpose of this systematic review was to examine the effect of intervention programs designed to enhance the ability of nurses or those to whom they delegate care to improve oral hygiene outcomes in frail older adults. Studies reported an educational program, either alone or augmented in some way. The study interventions consisted of: (a) single in-service education sessions; (b) single in-service education sessions supplemented by a "train-the-trainer" approach; and (c) education sessions supplemented with ongoing active involvement of a dental hygienist. None of the approaches emerged as being desirable over the others, as methodologically strong studies with good intervention integrity were lacking, and a variety of oral health outcomes were used to measure effectiveness of the interventions, making comparisons across studies difficult.

The impact of frailty on oral care behavior of older people: a qualitative study

BACKGROUND

Frailty has been demonstrated to negatively influence dental service-use and oral self-care behavior of older people. The aim of this study was to explore how the type and level of frailty affect the dental service-use and oral self-care behavior of frail older people.

METHODS

We conducted a qualitative study through 51 open interviews with elders of varying frailty in the East-Netherlands, and used a thematic analysis to code transcripts, discussions and reviews of the attributes and meaning of the themes to the point of consensus among the researchers.

RESULTS

Three major themes and five sub-themes emerged from our analyses. The major themes indicate that frail elders: A) favor long-established oral hygiene routines to sustain a sense of self-worth; B) discontinue oral hygiene routines when burdened by severe health complaints, in particular chronic pain, low morale and low energy; and C) experience psychological and social barriers to oral health care when institutionalized. The subthemes associated with the discontinuation of oral care suggest that the elders accept more oral pain or discomfort because they: B1) lack belief in the results of dental visits and tooth cleaning; B2) trivialize oral health and oral care in the general context of their impaired health and old age; and B3) consciously use their sparse energy for priorities other than oral healthcare. Institutionalized elderly often discontinue oral care because of C1) disorientation and C2) inconveniencing social supports.

CONCLUSION

The level and type of frailty influences people's perspectives on oral health and related behaviors. Frail elders associate oral hygiene with self-worth, but readily abandon visits to a dentist unless they feel that a dentist can relieve specific problems. When interpreted according to the Motivational Theory of Life Span Development, discontinuation of oral care by frail elderly could be viewed as a manifestation of adaptive development. Simple measures aimed at recognizing indicators for poor oral care behavior, and providing appropriate information and support, are discussed.

Effect of a person-centered mouth care intervention on care processes and outcomes in three nursing homes

OBJECTIVES

To develop and test a person-centered, evidence-based mouth care program in nursing homes.

DESIGN

Pre-post assessment, with an 8-week intervention period and a pilot 6-month extension at one site.

SETTING

Three North Carolina nursing homes.

PARTICIPANTS

Ninety-seven residents and six certified nursing assistants (CNAs).

INTERVENTION

CNAs already working in the facilities were trained as dedicated mouth care aides. A psychologist and dental hygienist provided didactic and hands-on training in evidence-based mouth care products and techniques and in person-centered behavioral care.

MEASUREMENTS

Primary outcome measures for natural teeth were the Plaque Index for Long-Term Care (PI-LTC) and Gingival Index for Long-Term Care(GI-LTC) and for dentures the Denture Plaque Index (DPI); a dentist unmasked to study design obtained measures. Secondary outcomes included quantity and quality of care provided.

RESULTS

Outcome scores significantly improved (P < .001 for PI-LTC and GI-LTC; P = .04 for DPI). Coding of videotaped care episodes indicated that care was more thorough (P < .001-P = .03) but took more time (P < .001) after training. Consistency of care appeared to be more important for natural teeth than dentures.

CONCLUSION

As little as 8 weeks of mouth care can significantly improve oral hygiene outcomes. Given the consequences of poor oral hygiene, greater attention to mouth care education and provision are merited. The dedicated worker model is controversial, and future work should assess whether other models of care are equally beneficial.

Oral care of hospitalised older patients in the acute medical setting

Oral health care is an essential aspect of nursing care. There are many variances in the quality and frequency of the oral care that is delivered to patients by nursing staff, such as oral care being given a low priority when compared to other nursing care elements, oral care being neglected, and oral care delivery being dependent on the nurse's knowledge of oral hygiene. Additionally, there are some particular patient groups known to be at risk of oral health problems or who have existing oral diseases and conditions. As people age their susceptibility increases to chronic and life-threatening diseases, and they can be at increased risk of acute infections increases compromised by ageing immune systems. The aim of this literature review was to ignite the discussion related to the oral care practices of nurses for older acute medical hospitalised patients. The review revealed that nursing staff know that good nursing includes oral health care, but this knowledge does not always mean that oral health care is administered. Oral health care seems to be separated from other nursing activities and is not discussed when nursing care plans are written, only when oral problems are obvious.