Attitudes to and knowledge about oral health care among nursing home personnel--an area in need of improvement

doi: 10.1111/j.1741‐2358.2011.00562.x
Attitudes to and knowledge about oral health care among nursing home personnel – an area in need of improvement Background: In 1999, a dental reform became law in Sweden that regulated both dental care to dependent individuals and training in oral health care for nursing home personnel. Substantial resources have been channelled into these efforts, but the outcome of these efforts has not been evaluated. The aim of this study was to explore attitudes to and knowledge about oral health care among nursing home personnel more than 5 years after the law was adopted, that being 2005. Methods: A total of 454 individuals employed at nursing homes answered a questionnaire of 16 multiple‐choice items concerning attitudes to and knowledge about oral health care. Results: Eighty‐nine per cent considered oral health care to be an important part of good nursing. The answers indicated problems, however, when it came to its implementation and knowledge, and 35% stated that they had had no formal education in oral health care. Conclusions: Despite generally positive oral health care attitudes, it is important that oral health care education is available to and made of interest for all nursing home personnel, especially in light of the increase in number of natural teeth and frequency of crowns and bridges among dependent elderly.     

Behind the screens: care staff observations on delivery of oral health care in nursing homes

Objective: To identify qualitatively carer staff attitudes, practices and clinical comments related to oral health care of functionally dependent nursing home clients. Design: Open-ended questions included in a longer quantitative questionnaire. Setting: 22 randomly selected nursing homes in the Bristol area. Subjects: 416 carers employed in these homes. Results: The majority of carers thought that clients had a right to good oral health, accepted the carers' role in helping clients with oral and denture hygiene, but recognised that oral health care provision was deficient. However, some carers believed oral health care to be solely the clients' responsibility despite high disability levels. Main barriers to providing oral health care were low prioritisation of oral health by nursing management, lack of co-operation from cognitively impaired clients, and lack of training. Carers were critical of homes' lack of arrangements for routine professional dental cheeks, lack of commitment to staff training, low standards of oral health care by colleagues, and lack of provision of oral hygiene aids and cleansing materials for clients. Many responses indicated ways in which nursing home oral health care could be improved. Carers reported contrasting experiences of dental treatment, and deplored recent decreased availability of subsidised dental care. Conclusions: Carers' generally positive attitudes towards clients' oral health care should encourage health educators. Insights gained from qualitative data can help to identify the less obvious causes for poor oral care delivery, which can then be addressed in education and training initiatives in nursing home settings.     

Oral health and oral implant status in edentulous patients with implant‐supported dental prostheses who are receiving long‐term nursing care

Aim: The aim of this study was to investigate oral health and oral implant status in a group of edentulous patients receiving long‐term residential or nursing care (LTC), all of whom had implant‐supported fixed or removable dental prostheses. Material and methods: A dental examination was performed on a total of 3310 patients receiving LTC and from this population 35 edentulous patients in whom dental implants had been placed formed the cohort for this study. All examinations were performed by a specialist in hospital dentistry and took place in the patients’ own home environment. Oral health was assessed by means of a protocol which evaluated oral hygiene status, possible oral mucosal inflammation and oral mucosal friction levels. Any problems with the implant‐supported prosthesis, implant mobility or other complications were also assessed. In addition, patients were asked about any oral symptoms and their usual oral hygiene procedures. Results: About half of the subjects (17/35) were registered as having no/mild inflammation with 18 of 35 having moderate/severe inflammation. Twelve of the 35 patients had good/acceptable oral hygiene and 23 of 35 had poor/bad oral hygiene. Twenty‐one of the 35 patients depended on help from the nursing personnel for their daily oral hygiene procedures. Obvious problems with food impaction were noted in 11 patients. A total of 229 implants had been placed in 43 jaws supporting 40 full arch‐fixed prostheses and three implant‐borne overdentures. There was no evidence of mobility or fractures of either the implants or the prostheses. Fifteen implants showed some exposed screw threads. Pus was exuding from one implant site and general peri‐implant gingival hyperplasia was noted in two patients. Twenty‐four patients were completely satisfied with the function and appearance of their implant‐supported prostheses. Two patients were totally dissatisfied. Conclusion: This study indicates that oral implant therapy can be considered as a treatment of choice in elderly patients, even if oral hygiene is sub‐optimal.     

Are the barriers to good oral hygiene in nursing homes within the nurses or the patients?

doi: 10.1111/j.1741‐2358.2011.00554.x
Are the barriers to good oral hygiene in nursing homes within the nurses or the patients? Objective: To explore nursing home patients’ oral hygiene and their nurses’ assessments of barriers to improvement. Background: In nursing homes, nurses are responsible for patients’ oral hygiene. Materials and methods: This study assessed the oral hygiene of 358 patients in 11 Norwegian nursing homes. 494 nurses in the same nursing homes participated in a questionnaire study. Results: More than 40% of patients had unacceptable oral hygiene. ‘More than 10 teeth’ gave OR = 2, 1 (p = 0.013) and ‘resist being helped’ OR = 2.5 (p = 0.018) for unacceptable oral hygiene. Eighty percent of the nurses believed knowledge of oral health was important, and 9.1% often considered taking care of patients’ teeth unpleasant. Half of the nurses reported lack of time to give regular oral care, and 97% experienced resistant behaviour in patients. Resistant behaviour often left oral care undone. Twenty‐one percent of the nurses had considered making legal decisions about use of force or restraints to overcome resistance to teeth cleaning. Conclusion: Oral hygiene in the nursing homes needed to be improved. Resistant behaviour is a major barrier. To overcome this barrier nurses’ education, organisational strategies to provide more time for oral care, and coping with resistant behaviour in patients are important factors.     

A prospective study on oral microbial flora and related variables in dentate dependent elderly residents

doi: 10.1111/j.1741‐2358.2011.00599.x
A prospective study on oral microbial flora and related variables in dentate dependent elderly residents Objective: Oral microorganisms and related variables were followed over a 1‐year period in dentate dependent elderly. Background: For nursing personnel, oral hygiene for the dependent elderly is demanding. It requires good knowledge of how to carry out preventive oral health measures and to judge when help is needed. Previous studies indicate low levels of knowledge, which might be reflected in the oral health of dentate residents. Material and methods: Twenty‐one subjects participated at baseline and 14 one year later. Microbial samples were analysed using cultivation technique. The labial minor gland secretion rate was measured using the Periotron^® method, and oral clinical data were registered. Results: Low labial mucosal flow rates were seen for 95% of the participants. At baseline, visibly thick plaque was seen in 48% and 1 year later in 57%. Both frequency and number of bacteria associated with caries and frequency of microorganisms associated with oral soft tissue infections were high. One year later, a decrease in bacteria associated with good oral health and a tendency to an increase in aciduric microorganisms were seen. Conclusion: Poor oral health, tending to further deteriorate over time, advocates regular professional supplementary support when elderly dentate dependent residents need assistance with their oral care.     

Oral health practices and beliefs among caregivers of the dependent elderly

doi: 10.1111/j.1741‐2358.2011.00553.x Oral health practices and beliefs among caregivers of the dependent elderly Background: Caregivers deal with oral health care of the dependent elderly; however, this has a low priority among them, and their education in daily oral care is deficient. Therefore, studying the oral care practices as well as their oral health beliefs is important as these affect the quality of the oral care they perform. Objective: To compare formal and informal caregivers’ oral care practices and oral health beliefs when taking care of severely dependent elderly. Material and methods: A cross‐sectional study was conducted on a convenience sample of 21 formal caregivers from a long‐term residence and 18 informal caregivers from a local primary health care domiciliary programme. Caregivers were surveyed using a questionnaire designed to elicit oral care practices and oral health beliefs. The nursing Dental Coping Beliefs Scale questionnaire was translated and validated in Chile. Results: Significant differences were observed between formal and informal caregivers’ performance of some oral health care practices. There were no significant differences between formal and informal caregivers’ oral health beliefs. Conclusions: Although there are some differences in formal and informal caregivers’ oral health care practices, we cannot state that one caregiver’s performance is better than the other, in fact, negative oral health beliefs were found in both groups.     

Oral health and dental care facilities in Maltese residential homes

Objectives: To establish oral health care practices, including the use of dental services, in the residential homes of Malta and Gozo by assessing the knowledge of home managers and assistance of care staff regarding residents’ oral health and hygiene; and evaluating the residents’ demand for dental treatment and residential home managers response to this demand. Subjects: A total population sample of licensed residential homes (38) in Malta and Gozo was used comprising all home managers in government (seven), church (20), and privately run (11) residential homes. Method: A 19‐question questionnaire was designed, piloted and sent to the home managers requesting them to report on the dental care provision for their elderly residents. The questionnaire was distributed by post, along with a reply‐paid envelope and an explanatory letter. A response deadline of 1 month was included. Results: An 87% response rate was achieved. Whilst the majority of home managers (64%) were aware of domiciliary dental services, there was no code of care practice for oral health. Routine dental check‐ups were not organised for residents of most homes. Although home staffs were generally given information about residents’ oral health and hygiene, the majority did not assist residents with oral hygiene. Home managers identified the following barriers to the use of dental services by residents: cost, communication problems with dental staff, journey to place of treatment, waiting time at the dental clinic, access to premises/clinic, lack of information on oral health and dental service availability, no one to accompany the person to the clinic, and health problems such as mobility, poor eyesight, hearing impairment and mental health status. Conclusion: Although most home managers appreciate the importance of oral health care for their residents, the residents still face many barriers to maintaining adequate oral health care and accessing dental services.     

Oral health‐related quality of life in patients receiving home‐care nursing: associations with aspects of dental status and xerostomia

doi:10.1111/j.1741‐2358.2009.00344.x
Oral health‐related quality of life in patients receiving home‐care nursing: associations with aspects of dental status and xerostomia Objective: To explore the differences in oral status, dental attendance and dry mouth problems between patients with long‐term disease with high and low scores on Oral Health Impact Profile 14 (OHIP 14) and how patients cope with oral problems such as xerostomia and a reduced ability to brush their teeth. Background: There has been a lack of studies of oral health and oral health‐related quality of life in the frail elderly within the community services. Materials and methods: A cross‐sectional questionnaire study was conducted with 137 patients receiving home‐care nursing. Structured interviews were conducted by student nurses using OHIP‐14, items from the Xerostomia Inventory and questions concerning dental visit habits, brushing of teeth and data from medical records. Results: Eighty‐three per cent of patients had natural teeth and 60% had only natural teeth. ‘Natural teeth only’ indicated a low score on OHIP‐14. Problems with brushing and items concerning xerostomia indicated a high score on OHIP‐14. Contrasts in the assessments concerning brushing of teeth and xerostomia indicated low priority from the patients themselves and the nursing staff. Conclusion: Community health services should focus upon oral health. Both patients and nurses should assess the need for regular brushing of teeth carried out by home‐care nurses. Assessment and treatment of dry mouth problems should have higher priority.     

Oral hygiene care status of elderly with dementia and in residential aged care facilities

doi: 10.1111/j.1741‐2358.2011.00472.x
Oral hygiene care status of elderly with dementia and in residential aged care facilities Objective: To explore the effectiveness of oral hygiene care on plaque and gingival status of residents with dementia. Background: Oral hygiene and oral hygiene care has been reported to be poor among the institutionalised elderly with dementia. The severity of oral diseases has been shown to increase with the severity of physical and cognitive impairment related with dementia. Little research has been carried out on plaque and gingival status of elderly with dementia and the impact of disability related with dementia on oral health in residential aged care facilities (RACF). Materials and methods: A cross‐sectional study of 205 elderly residing in RACF in Perth. Results: Forty‐one percent of the residents in RACF had dementia. Sixty percent of the residents with dementia and 75% of the residents with an Activities of Daily Living Oral Health score of D were assisted with oral care. Mean plaques scores and extent of gingival inflammation were higher for residents in the DD and D subgroups and resident with dementia. Residents assisted with brushing had higher mean plaque score and more moderate gingival inflammation. Conclusion: Oral hygiene care status in residents with dementia was poor despite the fact that oral care assistance was being provided.     

An assessment of the oral health knowledge and recall after a dental talk amongst nurses working with elderly patients: a pilot study

Objective: To assess the oral health knowledge amongst nurses working with elderly people in a local hospital run by a Primary Care Trust before and after a dental training talk. Method: Nursing staff working at Swanage Cottage Hospital completed a questionnaire designed to assess their knowledge of dental decay, periodontal disease, oral hygiene, denture care and palliative care. One month after receiving a dental talk, the questionnaire was redistributed to the participants. A t‐test was used to compare the number of correct answers before and after the talk. Results: Twenty members of the nursing staff completed the initial questionnaire and 14 completed it 1 month after the talk. Prior to the talk, of the 45 questions, the mean number of correct answers per member of staff was 23.95 ± 3.83. One month after the talk this had risen by 25% to 34.9 ± 3.83. This increase was statistically significant (p < 0.0001). Conclusion: A dental talk to a group of nursing staff caring for elderly people in a local hospital produced a significant increase in the level of oral health care knowledge.     

Recall of an oral health education programme by nursing personnel in special housing facilities for the elderly

Objectives: To investigate the recall of oral health knowledge and confidence by nursing personnel in special housing facilities for the elderly, three years after an education programme. Design: A cross sectional design using a questionnaire. Sample: All nursing personnel, a total of 2,901 subjects, in five municipalities in south‐western Sweden; of whom 950 had attended the programme. The response rate was 67% (1930 subjects). Intervention: An oral health education programme consisting of four one‐hour lessons. Results: The oral health education programme still had an effect on the participants' attitudes towards oral health three years later. When comparing the trained group (OHEP+) which attended the programme with those who did not have training (OHEP‐), the perceived ability, opportunity and the knowledge of oral health were significantly better in the former group, p<0.01 Eurther, within the OHEP‐ group who did not attend the programme there was a significant difference in the perceived ability, opportunity and the knowledge of oral health between those with a higher level of health care education, p<0.01. Conclusions: The effect of an oral health education programme on the participants' attitudes towards oral health persists at least for three years. The data indicate that trainees with a low level of health care education benefit most.     

Effect evaluation of a supervised versus non‐supervised implementation of an oral health care guideline in nursing homes: a cluster randomised controlled clinical trial

doi: 10.1111/j.1741‐2358.2010.00418.x
Effect evaluation of a supervised versus non‐supervised implementation of an oral health care guideline in nursing homes: a cluster randomised controlled clinical trial Objective: To compare a supervised versus a non‐supervised implementation of an oral health care guideline in Flanders (Belgium). Background: The key factor in realising good oral health is daily oral hygiene care. In 2007, the Dutch guideline ‘Oral health care in care homes for elderly people’ was developed to improve oral health of institutionalised elderly. Materials and Methods: A random sample of 12 nursing homes was randomly allocated to the intervention or the control group. Representative samples of 30 residents in each home were monitored during a 6‐month study period. The intervention included a supervised implementation of the guideline. Results: At the 6‐month follow‐up, only a small but statistically significant (p = 0.002) beneficial effect (0.32) of the intervention was observed for denture plaque after adjustment for baseline value and the random effect of the institution. In the linear mixed regression models, including a random institution effect, difference in denture plaque level was no longer statistically significant at the 5% level. Conclusion: Only denture hygiene has been improved by the supervised implementation, although with lower benefits than presumed. Factors on institutional level, difficult to assess quantitatively, may play an important role in the final result.     

Evidence of unmet need in the care of severely physically disabled adults.

OBJECTIVE--To identify unmet needs in the care of severely disabled people aged 16-64. DESIGN--Detailed personal interview and physical assessment of physically disabled adults; personal or telephone interview with carers. SETTING--Somerset Health District. SUBJECTS--181 severely disabled adults and their carers. MAIN OUTCOME MEASURES--Independence in activities of daily living; identity of requirements for assessing communication disorders; appropriate provision of services and allowances. RESULTS--53 (29.3%) of the 181 disabled subjects had unmet needs for aids to allow independence in activities of daily living-namely, 43% of subjects (41/95) with progressive disorders and 14% of subjects (12/86) with non-progressive disorders. The prevalence of unmet need was higher among subjects whose sole regular professional contact was with health services personnel (48 (40.3%) of 119 subjects). Only 18 (31.6%) of the 57 subjects with communication disorders had ever been assessed by a speech therapist. CONCLUSIONS--This study shows that the needs of severely physically disabled adults in the community--especially those with progressive disorders--are being monitored inadequately by health professionals.     

Challenges and barriers to quality oral care as perceived by caregivers in long-stay institutions in Brazil

doi: 10.1111/j.1741‐2358.2011.00475.x
Challenges and barriers to quality oral care as perceived by caregivers in long‐stay institutions in Brazil Objective: To describe how caregivers perceive the oral health status in the elderly they care for; the routines for oral hygiene in nursing homes; caregivers perceived barriers for quality oral care; and the caregivers competence and need for training in this area. Background: The phenomena surrounding ageing has been the subject of worldwide interest, particularly concerning issues related to institutionalised elderly, where several studies have shown the precarious oral health status of such individuals. Materials and methods: A qualitative interview study was held in a city in southern Brazil. Study participants were 26 caregivers of elderly people, belonging to seven institutions. Statements were collected through interviews, whose results were interpreted by phenomenological analysis. Results: Caregivers of institutionalised elderly reveal contradictions in knowledge and practices of oral health. Although it could be expected that the perception and attitudes of caregivers of their own oral health could influence the care they offer to the elderly, barriers to the implementation of such activities appear to refer to situations outside of their responsibility, especially in the absence of time and staff. Conclusions: The oral care of older people in geriatric institutions requires multidisciplinary and interinstitutional actions capable of reversing the continuing framework of neglect, requiring interventions for health promotion and disease prevention that can and should be implemented in institutions.     

Edentulism and dental caries in Victorian nursing homes

doi: 10.1111/j.1741‐2358.2011.00510.x Edentulism and dental caries in Victorian nursing homes Objectives: The aim of this project was to investigate edentulism and dental caries in nursing home residents in Victoria, Australia. Background: The Australian population is ageing with a growing number of people living in nursing homes. These residents are at increased risk for dental caries, have more teeth present now than at any time in the past 50 years and often have difficulty maintaining adequate oral hygiene. Materials and methods: Clinical dental examinations were conducted at 31 nursing homes in Melbourne and regional Victoria between May 2005 and June 2006. A total of 510 residents were examined out of 1345 eligible participants. Socio‐demographic and medical history was collected via questionnaire. Results: Just over half of the residents were dentate (53.9%), and dentate residents had a mean of 14.4 teeth present and 2.66 untreated decayed teeth. Residents who required total assistance with oral hygiene had more decayed teeth and fewer filled teeth than residents who did not require assistance. Conclusions: Nursing home residents in Victoria are retaining an increasing number of natural teeth and have more tooth surfaces at risk for dental caries. Untreated dental caries was a significant problem for residents, particularly for those who are dependent on others for their daily oral hygiene care.     

The effect of awareness on the outcome of oral health performed by home care service providers

Objectives: The purpose of this study was to investigate the correlations amongst factors, such as knowledge, attitude, practice and oral health behaviour, in caregiver managers so as to improve the oral health of the dependent elderly. Methods: Data were collected from a sample of 102 caregiver managers from home care service providers using a questionnaire. The respondents were divided into two groups: the group who were aware of effective oral care (A group) and the group who were unaware of effective oral care (U group). The evaluations were frequency distribution tables followed by chi‐squared tests of independence and Fisher’s exact test. Results: Ninety percent of the respondents thought that dependent elderly needed to be provided with oral care and 77% had been trained in oral care. However, only 44% thought that they could provide appropriate oral care and only 52% had experienced its effect on oral health and general health. There was a significant difference in training by dental hygienists between the A group (36%) and the U group (11%). There was also a significant difference in learning of oral care skills. Conclusion: The results suggested a high oral care awareness amongst caregiver managers and an inadequate oral care training system. To improve oral health of the dependent elderly, theoretical teaching alone is not sufficient when providing oral health education and a positive contact with the dental team, especially dental hygienists, is an important factor which supports oral care provided by caregivers.     

Effects of 11-month interventions on oral cleanliness among the long-term hospitalised elderly

Objectives: This trial studied the effects of interventions on the oral cleanliness of the long‐term hospitalised elderly. Background: Oral cleanliness is mostly poor in long‐term facilities. While many agree on the importance of oral hygiene education for nursing personnel, little information and agreement exists on how to organise this education in geriatric institutions. Materials and methods: This is a longitudinal study with interventions. After a baseline clinical examination, the patient wards were divided into three groups (A, B and C) and the type of intervention was randomly assigned. In group A, dental hygienists provided oral hygiene measures for the subjects once every 3 weeks. In group B, the nursing staff first received hands‐on instructions after which they assumed responsibility for the subjects’ daily oral hygiene. Group C served as a control. Denture hygiene and dental hygiene were recorded at baseline and in the end of the 11‐month study period. In total, 130 subjects completed the interventions; their mean age was 82.9 years. Results: The best outcome in both denture and dental hygiene occurred when nursing staff at the wards took care of hygiene (group B). The increase in the proportion of those with good denture hygiene was the most prominent in group B (from 11% to 56%). The proportion of subjects with poor overall dental hygiene decreased from 61% at baseline to 57% in the end, for group B from 80% to 48%. Conclusions: Organised oral health education of the nursing staff should receive more attention.     

In visible bodies: minority women, nurses, time, and the new economy of care

Health care reform in Canadian hospitals has resulted in increased workloads and bureaucratization of patient care contributing to the development of a new economy of care. Interviews with nurses and visible (non-white) minority women who have given birth in institutions undergoing health care reform revealed that nurses felt compelled to avoid interactions with patients deemed too costly in terms of time. Overwhelmingly, these patients were members of culturally marginalized populations whose bodies were read by nurses as potentially problematic and time consuming. As their calls for assistance go unanswered, visible minority women complained of feeling invisible. Taken in context of historical and contemporary interethnic relations, these women regarded such avoidance patterns as evidence of racism. Obstetrical nurses, too, understood that the new economy of care wrought by health care restructuring has altered nursing practice and patient care to the detriment of minority women.     

Oral health care in long‐term care facilities for elderly people in southern Brazil: a conceptual framework

doi:10.1111/j.1741‐2358.2009.00280.x
Oral health care in long‐term care facilities for elderly people in southern Brazil: a conceptual framework Objective: To present a theoretical model for understanding oral health care for the elderly in the context of long‐term care institutions (LTCI). Methods: Open‐ended individual interviews were conducted with the elderly residing in LTCI, their carers, nursing technicians and nurses, directors of care, dental surgeons and managers of public health services. A grounded theory methodological approach was adopted for data collection and analysis. Results: The emerging core category revealed a basic social process: ‘Promoting oral health care for the elderly based on the context of LTCI’. This process was composed of two contradicting yet correlated aspects: the oral health care does not minimise the poor oral epidemiological condition, and at the same time, there was a continued improvement in the oral care expressed by better care practices. These aspects were related to the: attribution of meaning to oral health, social determination of oral health, the ageing process, interactions established in the oral health care practices, oral health care management in LTCI, inclusion of oral health care into the political–organisational dimension and possibility of conjecturing better oral health care practices. Conclusion: The core concept of ‘Promotion of oral health care for elderly people based on the context of LTCI’ is capable of explaining the variations in the structure and process of LTCI, as well as in helping to understand the meaning of the oral health care practices for the institutionalised elderly.