Dental Pain in Care Homes: Is It a Phenomenon? A Systematic Review of the Literature

Background: Evidence suggests that 80% of residents living in nursing homes have moderate to severe pain, could dental causes be an under reported contributory factor. The evidence suggests that this is an under-researched area. Our project aims were to explore and consolidate the current literature and conduct some stakeholder groups with care home managers and dentists. Our stakeholder group will be reported elsewhere. Methods: We used the SPIDER framework to set out key search terms. Which included “dementia” OR “cognitively-impaired” OR “carehome residents” AND “dental pain” OR “oralfacial pain” OR “mouth pain” AND “pain assessment” OR “pain identification”. A literature search was carried out on 8 and 9 March 2022 in the electronic databases: Cochrane, PubMed, Medline, Dental & Oral Sciences Source, CINAHL, Global Health, SocINDEX, Ovid (Medline) and Scopus. Restrictions were placed on dates and language (2012–2022 and English only). Results: The search yielded 775 papers up to the year 2020. After screening and exclusion, we were left with five papers: four quantitative and one qualitative. Conclusions: This review demonstrates that there has been very little research into oral health and/or dental pain in adults with dementia. Furthermore, the recommendations have yet to be taken forward. Identifying pain in older adults with dementia remains challenging. There is a need to develop an algorithm in conjunction with care home staff and dental practitioners in order to identify and address the pain associated with dental disease in adults with dementia.

Aging and Oral Care: An Observational Study of Characteristics and Prevalence of Oral Diseases in an Italian Cohort

Background: Poor oral health is a common condition in patients suffering from dementia. Several aspects of this systemic pathology contribute to causing oral problems: cognitive impairment, behavior disorders, communication and, motor skills deterioration, low levels of cooperation and medical-nursing staff incompetency in the dental field. Objectives: The objectives of this study were to evaluate the prevalence and the characteristics of oral pathology in a demented elderly population, as well as to check the association between the different degree of dementia and the oral health condition of each patient. Materials and Methods: In this observational study (with cross-sectional design) two groups of elderly patients suffering from dementia, living in two different residential care institutions were recruited. The diagnosis of dementia of each included patient was performed using the Clinical Dementia Rating Scale. In order to evaluate the oral health condition of the included subjects, each patient underwent a physical examination of the oral cavity, during which different clinical parameters were analyzed (number of remaining teeth, oral mucosa, periodontal tissues, bone crests). To each parameter, a score was assigned. Spearman’s Rho test was used. Results: Regarding the prevalence of oral pathology in elderly suffering from dementia, it emerged that 20.58% of the included patients had mucosal lesions and/or new mucosal formations (in most cases undiagnosed and therefore untreated). The prevalence of periodontal disease was equal to 82.35% and a marked clinically detectable reabsorption of bone crests was found in almost all patients (88.23%). 24.13% of patients, who underwent the oral examination, had totally edentulous maxillae and/or with retained roots, without prosthetic rehabilitations. The correlation index r showed the presence of a linear correlation (inverse relationship) between the degree of dementia and the state of health of the oral cavity of each patient. Conclusions: Several factors contribute to poor oral health in the elderly suffering from dementia: cognitive functions deterioration, behavioral disorders and inadequate medical-staff nursing training on oral hygiene. This study also demonstrated that the lower the dementia degree is, the lower tends to be the oral health status. In order to guarantee a complete assistance to these patients, residential care institutions should include in their healthcare program specific dental protocols.

Effectiveness of professional oral health care intervention on the oral health of residents with dementia in residential aged care facilities: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to critically appraise and synthesize evidence on the effectiveness of professional oral health care intervention on the oral health of aged care residents with dementia.More specifically the objectives are to identify the efficacy of professional oral health care interventions on general oral health, the presence of plaque and the number of decayed or missing teeth.

BACKGROUND

Dementia poses a significant challenge for health and social policy in Australia. The quality of life of individuals, their families and friends is impacted by dementia. Older people with dementia often have other health comorbidities resulting in the need for a higher level of care. From 2009 to 2010, 53% of permanent residents in Residential Aged Care Facilities (RACFs) had dementia on admission. Older Australians are retaining more of their natural teeth, therefore residents entering RACFs will have more of their natural teeth and require complex dental work than they did in previous generations. Data from the Australian Institute of Health and Welfare showed that more than half the residents in RACFs are now partially dentate with an average of 12 teeth each. Furthermore, coronal and root caries are significant problems, especially in older Australians who are cognitively impaired.Residents in aged care facilities frequently have poor oral health and hygiene with moderate to high levels of oral disease and overall dental neglect. This is reinforced by aged care staff who acknowledge that the demands of feeding, toileting and behavioral issues amongst residents often take precedence over oral health care regimens. Current literature shows that there is a general reluctance on the part of aged care staff to prioritize oral care due to limited knowledge as well as existing psychological barriers to working on another person's mouth. Although staff routinely deal with residents' urinary and faecal incontinence, deep psychological barriers exist when working on someone's mouth due to their own personal values of oral health or their views that residents should be looking after their own teeth or dentures. Furthermore, residents with behavioral issues associated with dementia frequently have their oral hygiene neglected as they may be resistant and violent towards receiving oral care from aged care staff. Studies have shown that residents with dementia will often refuse to open their mouth or partake in oral hygiene care by aged care staff. The aged care staff in return often do not pursue an oral care regimen for these "difficult" residents, perpetuating the cycle of oral neglect and resultant disease.Dental hygienists are qualified oral health professionals who are specifically trained to develop individualized oral health care plans and preventative programs to reduce oral health disease in the community. Residents with dementia in aged care facilities have the right to live their lives comfortably and free of oral discomfort or pain. A Victorian study conducted by Hopcraft et al. investigated the ability of a dental hygienist to undertake a dental examination/screening for residents in aged care facilities, to develop a preventative and periodontal treatment plan and to refer patients appropriately to a dentist. Results from this study demonstrated that there was an excellent agreement between the dentist and dental hygienist regarding the decision to refer residents to a dentist for treatment, demonstrating high sensitivity (99.6%) and high specificity (82.9%). Residents from 31 Victorian RACFs (n=510) were examined by a single experienced dental epidemiologist and one of four dental hygienists using a simple mouth mirror and probe. Hopcraft et al. concluded that hygienists should be utilized more widely in providing holistic oral health care to residents in aged care facilities.Recently, Lewis et al. discussed the need to develop models of care to improve access to dental care for frail and functionally dependent elderly people in aged care facilities, with the model of care involving dental hygienists/oral health therapists having merit.The concept of professional oral care involves an oral health professional such as a dental hygienist or oral health therapist supervising or assisting residents with their oral care. Oral care involves the mechanical removal of plaque and food debris using a toothbrush, interproximal brush and floss.In 2014, Morino et al. explored the efficacy of short term professional oral care from dental hygienists once a week after breakfast for one month. In this study, the dental hygienists did not perform dental scaling but brushed subjects' teeth using a toothbrush and interdental brush. Dental plaque scores decreased significantly (Fisher's two-tailed tests, p<0.05) in the professional oral health intervention group. Interestingly, the positive effects of this short term intervention were sustained for the following three months (Wilcoxon test, p<0.05).A pilot study in Arkansas was conducted by Amerine et al. and utilized the dental hygienist as the "oral health champion" in the residential aged care facility using the Oral Health Assessment Tool (OHAT) and Geriatric Oral Health Assessment Index (GOHAI) scores to measure oral health. The results from this study showed improvements in three measured areas (tongue health, denture status and oral cleanliness) in the dental hygiene champion group. These findings suggest that the presence of a dental hygiene champion in long term care facilities may positively impact the oral health of residents requiring assistance with their oral care. However, the authors noted further research in this concept is required.Van Der Putten GJ et al. explored the effectiveness of a supervised implementation of an oral health care guideline in care homes. In each ward of the care homes, a nurse who acted as the ward oral health care organiser (WOO) was appointed. The dental hygienist and an investigator would attend the RACFs every six weeks to support them. The dental hygienist would train the WOO, and the WOO would train the ward nurses and nurse assistants. Participants were allocated into an intervention or a control group. The intervention group received supervised oral care. Statistically significant differences in mean dental and denture plaque scores at six months in both groups occurred (student t-test, p < 0.0001). This research study implemented an intervention using the train-the-trainer approach and although improvements in dental and denture plaque scores were seen in the six-month period, the long-term effects of this intervention are unknown. Further studies exploring the long-term effects of staff training on oral health education are needed as well as ongoing staff training in aged care facilities.A systematic review on oral health and aspiration pneumonia conducted by Vander Maarel-Wierink et al. has suggested that, in the frail elderly, the best intervention to reduce the incidence of aspiration pneumonia is brushing of teeth after each meal, cleaning dentures once a day, and receiving professional oral health care once a week.The need to advocate for a new model of geriatric dentistry is critical. A holistic multi-disciplinary approach to health care for residents entering aged care homes is imperative to achieve better oral health and comfort for residents, especially with Australia's ageing dentate population. A dental examination and assessment on admission to a RACF should be conducted by a Registered Nurse (RN), followed by an oral health professional such as a dentist, dental hygienist or oral health therapist. Current practice in the majority of Australian government funded nursing homes is that the RN or the Assistant in Nursing (AIN) conduct the oral health assessment as part of the aged care funding instrument (ACFI). Ongoing oral health care supported by an oral health professional is important throughout the individual's residency and eventual palliation whilst in an aged care facility.No systematic reviews conducted on the impact of professional oral care on the oral health of elderly people living in residential aged care facilities could be located, despite extensive searching of Medline, CINAHL, EMBASE, Web of Science, Cochrane Central Register of Trials and Dentistry & Oral Sciences Source (DOSS) databases. A JBI systematic review was conducted in 2004, titled, "Oral hygiene care for adults with dementia in residential aged care facilities"; however, this review examined the prevalence, incidence and increments of oral diseases; the use of assessment tools to evaluate oral health; preventative oral hygiene care strategies; and the provision of dental treatment and so had a different clinical focus. Twenty studies were included for analysis in the review conducted by Weening-Verbree et al, The studies in this review addressed oral health knowledge of aged care staff and mostly were conducted as an educational session delivered by dental hygienists or dentists.Overall, the current evidence available on interventions to improve oral health for residents living in aged care facilities is inadequate and should be explored further.

Oral health and the frailty syndrome

The frailty syndrome is an ever-growing area of study among older adults because of its association with an increased risk of falls, hospitalization, institutionalization, dependency and mortality. Frailty is neither a disease nor a disability but is better understood as a medical syndrome of multisystem dysregulation that results in a diminished ability to overcome everyday stressors. The prevalence of frailty in any given population can vary widely, in part because of the way in which it is defined and measured, but in general it is higher among women and in those with advanced age and declining health. Whilst it is largely understood that older adults will differ biologically, psychologically and socially, and that each of these domains can impact oral health, we are only beginning to investigate how the mouth is affected in frailty. Given that both hard and soft structures contribute to oral health and disease status among older adults with varying degrees of impairment and disability, frailty adds yet another dimension to be considered. This paper will discuss how frailty can influence and be influenced by oral disorders, as well as the potential relationship to oral neglect and the resultant consequences among this vulnerable population.

Oral hygiene and oral health in older people with dementia: a comprehensive review with focus on oral soft tissues

BACKGROUND

The number of older people with dementia and a natural dentition is growing. Recently, a systematic review concerning the oral health of older people with dementia with the focus on diseases of oral hard tissues was published.

OBJECTIVE

To provide a comprehensive literature overview following a systematic approach of the level of oral hygiene and oral health status in older people with dementia with focus on oral soft tissues.

METHODS

A literature search was conducted in the databases PubMed, CINAHL, and the Cochrane Library. The following search terms were used: dementia and oral health or stomatognathic disease. A critical appraisal of the included studies was performed with the Newcastle-Ottawa scale (NOS) and Delphi list.

RESULTS

The searches yielded 549 unique articles, of which 36 were included for critical appraisal and data extraction. The included studies suggest that older people with dementia had high scores for gingival bleeding, periodontitis, plaque, and assistance for oral care. In addition, candidiasis, stomatitis, and reduced salivary flow were frequently present in older people with dementia.

CONCLUSIONS

The studies included in the current systematic review suggest that older people with dementia have high levels of plaque and many oral health problems related to oral soft tissues, such as gingival bleeding, periodontal pockets, stomatitis, mucosal lesions, and reduced salivary flow.

SCIENTIFIC RATIONALE FOR STUDY

With the aging of the population, a higher prevalence of dementia and an increase in oral health problems can be expected. It is of interest to have an overview of the prevalence of oral problems in people with dementia.

PRINCIPAL FINDINGS

Older people with dementia have multiple oral health problems related to oral soft tissues, such as gingival bleeding, periodontal pockets, mucosal lesions, and reduced salivary flow.

PRACTICAL IMPLICATIONS

The oral health and hygiene of older people with dementia is not sufficient and could be improved with oral care education of formal and informal caregivers and regular professional dental care to people with dementia.

Effective strategies to motivate nursing home residents in oral care and to prevent or reduce responsive behaviors to oral care: A systematic review

BACKGROUND

Poor oral health has been a persistent problem in nursing home residents for decades, with severe consequences for residents and the health care system. Two major barriers to providing appropriate oral care are residents' responsive behaviors to oral care and residents' lack of ability or motivation to perform oral care on their own.

OBJECTIVES

To evaluate the effectiveness of strategies that nursing home care providers can apply to either prevent/overcome residents' responsive behaviors to oral care, or enable/motivate residents to perform their own oral care.

MATERIALS AND METHODS

We searched the databases Medline, EMBASE, Evidence Based Reviews-Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science for intervention studies assessing the effectiveness of eligible strategies. Two reviewers independently (a) screened titles, abstracts and retrieved full-texts; (b) searched key journal contents, key author publications, and reference lists of all included studies; and (c) assessed methodological quality of included studies. Discrepancies at any stage were resolved by consensus. We conducted a narrative synthesis of study results.

RESULTS

We included three one-group pre-test, post-test studies, and one cross-sectional study. Methodological quality was low (n = 3) and low moderate (n = 1). Two studies assessed strategies to enable/motivate nursing home residents to perform their own oral care, and to studies assessed strategies to prevent or overcome responsive behaviors to oral care. All studies reported improvements of at least some of the outcomes measured, but interpretation is limited due to methodological problems.

CONCLUSIONS

Potentially promising strategies are available that nursing home care providers can apply to prevent/overcome residents' responsive behaviors to oral care or to enable/motivate residents to perform their own oral care. However, studies assessing these strategies have a high risk for bias. To overcome oral health problems in nursing homes, care providers will need practical strategies whose effectiveness was assessed in robust studies.

Oral health and orofacial pain in older people with dementia: a systematic review with focus on dental hard tissues

Objective

The aim of this review was to provide a systematic overview including a quality assessment of studies about oral health and orofacial pain in older people with dementia, compared to older people without dementia.

Methods

A systematic literature search was performed in PubMed, CINAHL, and the Cochrane Library. The following search terms were used: dementia and oral health or stomatognathic disease. The quality assessment of the included articles was performed using the Newcastle-Ottawa Scale (NOS).

Results

The search yielded 527 articles, of which 37 were included for the quality assessment and quantitative overview. The median NOS score of the included studies was 5, and the mean was 4.9 (SD 2.2). The heterogeneity between the studies was considered too large to perform a meta-analysis. An equivalent prevalence of orofacial pain, number of teeth present, decayed missing filled teeth index, edentulousness percentage, and denture use was found for both groups. However, the presence of caries and retained roots was higher in older people with dementia than in those without.

Conclusions

Older people with dementia have worse oral health, with more retained roots and coronal and root caries, when compared to older people without dementia. Little research focused on orofacial pain in older people with dementia.

Clinical relevance

The current state of oral health in older people with dementia could be improved with oral care education of caretakers and regular professional dental care.

Oral health screening: feasibility and reliability of the oral health assessment tool as used by speech pathologists

BACKGROUND

The aim of this study was to investigate the feasibility and reliability of the Oral Health Assessment Tool (OHAT) as used by speech pathologists, to become part of a comprehensive clinical swallowing examination.

METHODS

A multicentre study in 132 elderly subjects was conducted by speech pathologists. The inter-rater, test-retest and intra-rater reliabilities of the OHAT were assessed in R statistics, version 3.0.1. Intraclass correlation coefficients (ICCs) were used for the total OHAT, and Kappa statistics were used for the individual categories.

RESULTS

Total OHAT scores showed good inter-rater (ICC = 0.96), intra-rater (ICC ≥ 0.95) and test-retest (ICC ≥ 0.78) agreement. The inter-rater Kappa statistics were almost perfect (κ ≥ 0.83) for seven of the eight individual categories of the OHAT and perfect for 'dental pain' (κ = 1.00). The test-retest Kappa statistics indicated excellent agreement for 'natural teeth' and 'dentures' (κ ≥ 0.86). The intra-rater per cent agreement was excellent for all categories except 'gums and tissues'.

CONCLUSIONS

This is the first study to examine the feasibility and reliability of the OHAT as used by speech pathologists. As the results showed both good feasibility and reliability, the OHAT has the potential to add to the clinical swallowing examination. However, future research investigating actual referral strategies and adaptation of care strategies following assessment with OHAT is needed.

Confronting dental uncertainty in old age

OBJECTIVE

To provide an overview of the literature about uncertainty in health care and how it relates to the oral health care of older people.

BACKGROUND

The medical literature describes uncertainty in health care from the initial informed-consent to its impact on a patient's ability to cope with undesirable outcomes.

METHODS

A narrative review of the medical, dental and psychological literature was conducted to identify pertinent information on the theory and implications of uncertainty in healthcare. The findings are infused into a case-report illustrating the recurrence of uncertainty experienced by an older woman who had multiple treatments over several years to restore her dentition damaged severely by dental caries.

RESULTS

Uncertainty originates from inadequate understanding, incomplete information and undifferentiated alternatives leading to unnecessary diagnostic tests and healthcare costs. A conceptual taxonomy clarifies the characteristics of uncertainty in the context of scientific, practical or personal sources and offers management possibilities through effective communications to identify choices and probabilities that help patients to adapt and cope with adverse events.

CONCLUSIONS

Uncertainty pervades healthcare. It can lead patients to self-blame, anger and withdrawal from care unless it is communicated effectively so that they can adapt and cope with the disappointment of adversity and continue with alternative approaches to care.

Hospitalisation impacts on oral hygiene: an audit of oral hygiene in a metropolitan health service

BACKGROUND

Poor oral health has been associated with systemic diseases, morbidity and mortality. Many patients in hospital environments are physically compromised and rely upon awareness and assistance from health professionals for the maintenance or improvement of their oral health. This study aimed to identify whether common individual and environment factors associated with hospitalisation impacted on oral hygiene.

METHODS

Data were collected during point prevalence audits of patients in the acute and rehabilitation environments on three separate occasions. Data included demographic information, plaque score, presence of dental hygiene products, independence level and whether nurse assistance was documented in the health record.

RESULTS

Data were collected for 199 patients. A higher plaque score was associated with not having a toothbrush (p = 0.002), being male (p = 0.007), being acutely unwell (p = 0.025) and requiring nursing assistance for oral hygiene (p = 0.002). There was fair agreement between the documentation of requiring assistance for oral care and the patient independently able to perform oral hygiene (ICC = 0.22).

CONCLUSION

Oral hygiene was impacted by factors arising from hospitalisation, for those without a toothbrush and male patients of acute wards. Establishment of practices that increase awareness and promote good oral health should be prioritised.

Barriers to managing behavioural and psychological symptoms of dementia: staff perceptions

BACKGROUND

Residential aged care facilities are increasingly using pharmacological methods of managing BPSD such as antipsychotics, despite little evidence of effectiveness and high rates of adverse effects. Nonpharmacological approaches to management of behavioural and psychological symptoms of dementia (BPSD) have not been widely implemented in residential aged care, despite reported effectiveness of these strategies. Residential aged care staff opinions on the effectiveness of non-pharmacological approaches to dementia care and any limitations to their use are not well documented.

METHODOLOGY

This is the qualitative arm of a broader research project. A 43-point questionnaire was distributed to 6 rural aged care facilities to explore nurses' perceptions of the limitations of five commonly employed non pharmacological and pharmacological interventions in managing BPSD.

FINDINGS

Staff reported that some non-pharmacological methods of managing BPSD were not the role of nursing staff. This suggests that other interventions such as increased staffing levels would not be effective in facilitating non pharmacological approaches to managing BPSD.

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.

Needs of people with dementia in long-term care: a systematic review

With the aging of the population and the projected increase of dementia in the coming years, it is crucial that we understand the needs of people with dementia (PWD) in order to provide appropriate care. The aim of this study is to determine, using the best evidence possible, the care needs of PWD living in long-term care (LTC). A total of 68 studies, published between January 2000 and September 2010, were identified from six databases. From the selected studies, 19 needs of PWD were identified. The existing evidence suggests that psychosocial needs such as the need to engage in daily individualized activities and care must not be ignored in LTC. This review aims to provide a clearer picture of the needs of this growing patient population.

Miíase bucal e doença de Alzheimer: relato de caso clínico

Miíase é uma afecção causada pela presença de larvas de moscas em órgãos e/ou tecidos do homem ou de outros animais vertebrados, sendo mais frequentemente observada em países tropicais. A ocorrência de miíase na cavidade bucal é rara. Dentre os fatores predisponentes, destacam-se a senilidade, o comprometimento neurológico e a halitose. Assim, pacientes com doenças neuro-degenerativas, como a doença de Alzheimer (DA), são mais propensos a adquirirem essa alteração. Este trabalho relata um caso de miíase bucal, acometendo um paciente de 67 anos de idade, com DA em fase avançada, totalmente dependente para as atividades de vida diária (AVD), residente em uma instituição de longa permanência (ILP). O paciente apresentava falta de selamento labial e resistência aos cuidados de higiene bucal. O diagnóstico foi estabelecido clinicamente com base na observação de sangramento na região anterior do palato, descolamento da mucosa bucal e presença de larvas. Foi prescrito o uso de ivermectina e o paciente foi hospitalizado para debridamento do tecido necrótico e remoção das larvas. Após a alta, os cuidadores foram orientados quanto ao uso de máscara pelo paciente, que não se mostrou efetiva, pois o paciente passou a mordê-la, levando a seu deslocamento e reinfestação por larvas. Após o tratamento da reinfestação, adotou-se o uso de cortinado como rotina. Pacientes com DA constituem um grupo de risco para miíase bucal, sendo necessário orientar cuidadores e familiares em relação aos cuidados odontológicos para a prevenção desta patologia. O principal tratamento para a alteração baseia-se na remoção mecânica das larvas e instituição do uso oral da ivermectina.

Implementation of oral health recommendations into two residential aged care facilities in a regional Australian city

Background  Residents of aged care facilities usually have a large number of oral health problems. Residents who suffer from dementia are at particular risk. A systematic review of the best available evidence with regard to maintaining the oral health of older people with dementia in residential aged care facilities provided a number of recommendations. Objectives  The aim of the implementation project was to introduce evidence-based oral hygiene practices for patients with dementia in two publicly funded residential aged care facilities and monitor for changes in nursing awareness, knowledge, documentation and practice to improve patient outcomes and ensure appropriate accreditation standards were met. An additional aim was to identify barriers and strategies to overcome barriers to implementation of evidence-based recommendations. Methods  Two facilities, a 40-bed facility and a 71-bed facility in the health service district of the regional Australian city of Toowoomba, provided the setting. A quality improvement approach was taken, using a number of strategies from the National Health and Medical Research Council guidelines for implementation studies. The implementation involved a number of stages, including project development, interactive oral health education, oral audits of residents, changes to oral hygiene practice via care plans and critical reflection. Results  The multidisciplinary approach to improving oral healthcare appeared to improve knowledge and awareness and move oral health practices in facilities closer to best practice. Specialised training in oral health was provided to a Clinical Nurse Consultant. Regular oral audits were introduced and facility staff were trained in the use of the oral audit tool. Care plans at one facility were of better quality and more comprehensive than before the intervention. Comments made during critical reflection suggested improvements in the oral health of residents, increased use of oral swabs and saliva substitutes, improved care of dentures and mention of the use of mouth props in resident care plans. There was also some evidence that changes brought about by the implementation are sustainable. Conclusion  The majority of recommendations provided in the systematic review of oral healthcare for dementia patients were applicable to the applied context. The importance of day-to-day leaders was highlighted by the apparently varied outcomes across target facilities. The quality improvement approach would appear to have considerable advantages when applied to improving practice in residential aged care.

Factors affecting caregivers' perceptions of residents' oral health in long-term care facilities in Taiwan

The purpose of this study was to investigate the differences between resident oral care policies provided by 2 types of long-term care (LTC) institutions. The study also investigated factors affecting LTC institutional caregivers' perceptions of the residents' oral health. Overall, 103 completed questionnaires were returned. Of these, 44 were from senior citizen welfare institutions, and 59 were from nursing homes. The variables affecting these perceptions included institution type and whether the residents attended hospital dental clinics or consulted a hospital doctor regarding oral health problems. The research results showed that institution type and whether an oral care-related professional was available in an institution were correlated with an increase in institutional caregivers' perceptions of oral care.

Oral health in institutionalised elderly people in Oslo, Norway and its relationship with dependence and cognitive impairment

OBJECTIVE

Investigating oral health's relationship with dependency and cognitive state.

BACKGROUND

Oral hygiene is poor in the institutionalised elderly. There are problems regarding the oral care of residents having poor mobility or cognitive impairment.

MATERIAL AND METHODS

Cross-sectional study involving 135 participants (mean age 85.7, SD 8.8 years) in two categories: nurses doing tooth cleaning and residents doing tooth cleaning. Those cleaned by nurses were categorised as co-operative or unco-operative. The oral hygiene status, presence of caries, retained roots and denture-related stomatitis were recorded.

RESULTS

Of the participants, 70% had only natural teeth. The prevalence of caries was 28%. A significant correlation showed that having more teeth gave a poorer Simplified Oral Hygiene Index (OHI-S) (p = 0.018). The number of retained roots increased with the severity of cognitive impairment (p < 0.05). Significant differences were found between nurses or residents doing the tooth cleaning on the OHI-S (p = 0.05) and percentage of dental plaque (p = 0.003). Unco-operative residents had poorer oral hygiene (p = 0.028), more caries (p = 0.008) and were more often moderate-severe cognitive impaired (p = 0.016).

CONCLUSIONS

A high percentage of participants had unacceptable oral hygiene. Residents whose teeth were cleaned by the nurses had poorer oral hygiene. Unco-operative residents had the worst oral hygiene and more caries.

Public health issues in geriatric dentistry in the United States

The aging United States population living in the new millennium has dental needs that are very different and more complex than those experienced by previous older adult cohorts during the twentieth century. The type of dental care to be provided for older Americans goes way beyond emergency care, extractions and denture care. Dental caries is still clearly a public health problem for subgroups of older Americans, such as those of lower socioeconomic status, with dementia, who are homebound and who are institutionalized. These are also the subgroups experiencing greater barriers to accessing dental care. Stakeholders, including dental professionals and the dental benefits industry, need to work together to develop innovative dental financing programs that will increase older Americans access to dental care.

Evidence-Based Rationale Supports a National Periodontal Disease Screening Program

INTRODUCTION

The evidence-based decision-making process that led to the inclusion of periodontal diseases (PD) in the newly revised Austrian National Periodic Health Examination (PHE) is described. Although intraoral inspection by physicians had already been a routine part of the PHE, obvious signs of PD, which are highly prevalent in Austria, have been largely ignored.

OBJECTIVE

The objectives of this periodontal screening (PS) program are to direct persons with a series of identifiable risk factors to seek proper care.

METHOD

The PS program development methodology was based on 2 factors: a systematic review of evidence-based publications that establish correlations between individual risk factors or multifactorial risk models with an increased susceptibility to progression of PD, and a selection of brief and cost-effective screening interventions that could be administered by nondental clinicians such as general physicians.

RESULTS

The final screening model is a 3-step intervention:

CONCLUSION

The final PS model within the Austrian PHE is based on a wealth of data justifying an evidence-based intervention. The Austrian population is likely to benefit in many ways from the intervention through increased awareness of PD and through a collaboration of medical and dental clinicians in their prevention.

[Oral hygiene for the institutionalized elderly]

INTRODUCTION

The poor oral health of the institutionalized elderly is often underestimated, despite the seriousness of the complications it causes.

OBJECTIVES

This descriptive cross-sectional study aims to evaluate the oral health needs of a representative sample of residents of institutions for the elderly in the Limousin and Poitou-Charentes regions.

METHOD

This study assessed clinical indicators of need for dental prevention or treatment for 756 residents in 152 establishments (563 women and 193 men, mean age 83+/-9 years), noting the level of oral hygiene and access to treatment at each center. Directors and staff were also asked for suggestions to improve the situation.

RESULTS

At least one indicator of need for prevention or treatment was found for 86% of residents, and 91% of this group was not currently receiving treatment. Staff suggestions confirmed the high level of need reported.

DISCUSSION

Caregivers in institutions for the elderly must receive training in the provision of oral hygiene measures, oral examinations should be performed routinely on admission to each establishment, and treatment networks should be developed to meet the oral health needs of the institutionalized elderly.

Improving the oral health of older adults with dementia/cognitive impairment living in a residential aged care facility

Background  Studies conducted in Residential Aged Care Facilities (RACFs) indicate that high levels of oral diseases and conditions are prevalent in older adults who have dementia. Poor oral health impacts on eating ability, weight, speech, hydration, severity of behavioural problems, appearance and social interactions. This study looked at a group of older adults with dementia in a RACF site in the northern suburbs of Adelaide, South Australia. It is known that in nursing home residents with dementia dental pain and problems are under-detected and under-treated. Strategy  An audit was conducted to assess the level of compliance of the RACFs oral hygiene care practices with established best practice. The audit questions were based on current best practice as identified from a rigorous international systematic review of the subject. A clinical audit software program (The Joanna Briggs Institute, Practical Application of Clinical Evidence System (JBI PACES)) was used to manage the audit. An audit, feedback, re-audit cycle was followed. Stakeholders of the project were identified from which a Project team was formed. The Project team analysed the results of the first audit, conducted a situational analysis and formulated and implemented a strategic plan to target specific criteria for a change management process. Short-term and longer-term strategies were identified. Those criteria targeted as achievable in the short term were then re-audited after 6 weeks to determine the effectiveness of the change management process. Findings  The criterion Daily cleaning and night-time removal of dentures are documented was re-audited and although there was a slight increase in compliance across the site this increase was not statistically significant. The criterion Resident's dentures are individually marked was re-audited and showed a large increase in compliance across the site, this increase was statistically significant.

The oral health assessment tool--validity and reliability

BACKGROUND

The Oral Health Assessment Tool (OHAT) was a component of the Best Practice Oral Health Model for Australian Residential Care study. The OHAT provided institutional carers with a simple, eight category screening tool to assess residents' oral health, including those with dementia. This analysis presents OHAT reliability and validity results.

METHODS

A convenience sample of 21 residential care facilities (RCFs) in urban and rural Victoria, NSW and South Australia used the OHAT at baseline, three-months and six-months to assess intra- and inter-carer reliability and concurrent validity.

RESULTS

Four hundred and fifty five residents completed all study phases. Intra-carer reliability for OHAT categories: percent agreement ranged from 74.4 per cent for oral cleanliness, to 93.9 per cent for dental pain; Kappa statistics were in moderate range (0.51-0.60) for lips, saliva, oral cleanliness, and for all other categories in range of 0.61-0.80 (substantial agreement) (p < 0.05). Inter-carer reliability for OHAT categories: percent agreement ranged from 72.6 per cent for oral cleanliness to 92.6 per cent for dental pain; Kappa statistics were in moderate range (0.48-0.60) for lips, tongue, gums, saliva, oral cleanliness, and for all other categories in range of 0.61-0.80 (substantial agreement) (p < 0.05). Intraclass correlation coefficients for OHAT total scores were 0.78 for intra-carer and 0.74 for inter-carer reliability. Validity analyses of the OHAT categories and examination findings showed complete agreement for the lips category, with the natural teeth, dentures, and tongue categories having high significant correlations and percent agreements. The gums category had significant moderate correlation and percent agreement. Non-significant and low correlations and percent agreements were evident for the saliva, oral cleanliness and dental pain categories.

CONCLUSION

The Oral Health Assessment Tool was evaluated as being a reliable and valid screening assessment tool for use in residential care facilities, including those with cognitively impaired residents.

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

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