Oral health promotion among older persons and their care providers in a nursing home facility

Or ig ina l a r t i c l e

Oral health promotion among older persons and their careproviders in a nursing home facility

Rebecca Reed1, Hillary L. Broder1, George Jenkins1, Evan Spivack2 and Malvin N. Janal3

1Department of Community Health, UMDNJ-NJ Dental School, Newark, NJ, USA; 2Special Care Treatment Center, UMDNJ-NJ Dental School,

Newark, NJ, USA; 3Department of Psychiatry, UMDNJ-NJ Dental School, Newark, NJ, USA

Gerodontology 2006; 23; 73–78

Oral health promotion among older persons and their care providers in a nursing home facility

Objectives: To assess oral health status and oral health-related quality of life (OHRQoL) of residents in an

extended care facility and to assess the care providers’ oral health attitudes and knowledge.

Methods: Participants included 137 residents (58.1% female, age range 32–94 years, 91% African–

American) and 22 care providers. Residents received an oral examination and completed the Oral Health

Impact Profile (OHIP-14), an OHRQoL questionnaire. Care providers completed an oral health knowledge

(OHK) questionnaire before and after the on-site geriatric oral health education and training programme.

Results: Oral examinations showed that 58% of the residents had extensive oral health needs. On the

OHIP-14, the mean severity was 9.2 (SD ¼ 12.0), extent (number of items rated as ‘fairly often’ or ‘often’)

was 1.2 (SD ¼ 2.6) and prevalence (participants rating at least one item at least ‘fairly often’) was 37.8%.

Most prevalent negative impact items were about ‘oral pain’, ‘appearance’ and ‘self-consciousness’.

Regarding OHK, caregivers’ knowledge improved following instruction from 65% correct on the pre-test to

90% correct on the post-test (p < 0.05). Subsequent to the eight in-service workshops, providers reported

that physical limitations, fear of getting bitten and time constraints were barriers to providing oral hygiene

to their residents.

Conclusion: Examination data showed a high level of dental needs among the majority of residents,

accompanied by significantly reduced OHRQoL. Although care providers’ OHK improved following the

geriatric service programme, they reported specific barriers regarding their provision of oral hygiene care to

the residents.

Keywords: OHIP-14, nursing home, care providers, oral health promotion, oral hygiene, oral health

knowledge, geriatrics.

Accepted 10 March 2006

Introduction

Previous studies have shown widespread oral

health problems among nursing home residents,

including poor oral hygiene, high levels of dental

needs and low rates of dental care utilisation1,2. No

studies were identified that provided a simulta-

neous study of oral health quality of life, caregiver

oral health education and access to dental care.

Within nursing homes, a number of barriers pre-

vent access to professional care or prevent residents

from receiving daily oral hygiene3. The loss of

functional independence may both impede a per-

son’s ability to access dental care outside of the

institution and impair manual dexterity4. While

the level of dependence of nursing home residents

varies from patient to patient, most residents

require some assistance to complete oral hygiene

regimens. As the population of the dependent

elderly continues to increase and with it the

number of those persons maintaining a partial

dentition, the challenges to nursing home person-

nel regarding oral health care services will continue

to increase.

In evaluating the outcome of oral health pro-

motion programmes, it is critical to measure the

individuals’ perceptions oral health conditions,

namely oral health-related quality of life

� 2006 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2006; 23: 73–78 73

(OHRQoL) as well as the clinical needs of the target

group5. Similarly assessment should consist of

amelioration to dysfunction, discomfort and dis-

ability (referred to collectively as ‘social impact’).

Recent interest in OHRQoL emphasises the rele-

vance of such subjective evaluations. Several

reports link the relationship between oral health

status and psychological and functional well-being

as well as satisfaction in old age6,7.

The purposes of the study were: to examine oral

health needs in this geriatric sample and relate

those needs to reported OHRQoL; to assess and

improve oral health knowledge (OHK) among the

caregivers at an extended care facility.

Materials and methods

Sample

Subjects consisted of residents living in an urban

extended care facility. Employees at the facility also

participated in the oral health education seminars

and oral health surveys. Upon protocol approval by

the University-approved Investigational Review

Board (IRB), staff from the Department of Com-

munity Health and third year dental students

from an urban dental school completed an oral

examination of residents in a local nursing home.

Informed consent was either obtained from the

patient or from the appropriate legal guardian. The

study population comprised of all consenting resi-

dents who were physically able to participate.

Therefore, the sample was non-random and self-

selecting. Additionally, the sample of care providers

was non-random and self-selecting in as much as it

consisted of those employees who worked either

first or second shift.

Data from resident participants

Face-to-face interviews were conducted to collect

information related to oral health behaviours and

health-related quality of life assessments using the

OHIP-14. The oral examination included an oral

cancer screening, and notation of Decayed, Missing

and Filled Teeth (DMFT). All examinations were

supervised and reviewed by calibrated examiners.

Results were also placed in the patients’ nursing

home record.

Data from care providers

Care providers were given an OHK questionnaire

pre-test specifically designed for the study project.

Project staff conducted eight in-service education

workshops and were blinded to the actual OHK

questionnaire. Following the pre-test, care provid-

ers attended PowerPoint presentations on related

oral health issues among the elderly. Workshops

included issues relevant to the relationship

between medical and dental health, oral manifes-

tations of disease, as well as a hands-on presenta-

tion of oral hygiene techniques with role-playing

(see outline in Appendix A). Workshops were

scheduled to accommodate both day and evening

nursing shifts. At the termination of the project, a

post-test examination was given with the nursing

home staff.

Because of initial findings of the poor oral

hygiene of the nursing home residents as well as

high levels of oral health needs and low OHRQoL,

three additional in-service oral health promotion

workshops were created. These workshops provi-

ded problem solving as well as ‘hands-on’ oral

health hygiene demonstrations with tooth models

and live patients.

Each of these three additional ‘hands-on’

demonstration workshops culminated in the team

dentist (RR) using a ‘live’ resident chosen by the

nursing staff. The purpose of using live people was

to address the staff members’ perceptions regarding

behaviour management (e.g. compliance with oral

hygiene) and to illustrate the techniques in daily

mouth care. The nursing staff either observed or

assisted the dentist. Initially each resident exhibited

some difficult behaviour – ranging from aggression

to extreme passivity. Using a traditional toothbrush

and toothpaste the dentist brushed the resident’s

teeth, thereby demonstrating appropriate finger

placement away from the occlusal plane so as not

to get bitten. A plastic cup with water and towel

were used to remove the excess toothpaste. At the

close of the demonstration, staff members

expressed surprise with the demonstration and

optimism about their ability to perform oral

hygiene in the future.

Instruments

The OHIP-14 is a widely used reliable and valid

instrument normed on older adults. It consists of 14

items that evaluate psychosocial impacts of oral

health8. The OHIP-14 provides three summary

scores: a severity score – computed as the sum of

ratings; an extent score – computed as the number of

items rated as ‘fairly often’ or ‘often’ and the pre-

valence score – computed as the number of partici-

pants rating at least one item at least ‘fairly often’).

Based on clinical experience and review of the

literature, the OHK Questionnaire is a 20-item

� 2006 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2006; 23: 73–78

74 R. Reed et al.

questionnaire developed specifically for this pro-

ject. It includes items related to oral hygiene, sys-

temic conditions and oral health, quality of life, as

well as oral manifestations of specific diseases such

as oral cancer (see Appendix B).

Data analyses

Frequencies, mean and SDs were used to identify

the demographic status of the residents and nur-

sing home staff participating in this study. One-

sample tests of a difference in proportions were

used to compare population data from the

National Health and Examination Survey III

(NHANES) to the residents’ data and to compare

this sample to normative data from the OHIP-14.

Lastly, paired t-tests were used to compare OHK

before and after the training.

Results

Demographics

Of the 139 participants screened at the Extended

Care Facility, 110 (79.1%) provided at least some

data and 95 (68.3%) were examined. Participants

were 58.1% female, with a mean age of 67.7 years

(SD ¼ 16.5, range 32–94 years). The majority of

participants (91.0%) were African–American with

remaining subjects self-identified as Hispanic or

White. When queried about the time since their

last dental visit, the mean (SD) response was

1.3 years (SD ¼ 1.6 years) ago. Approximately

one-third of the sample reported avoiding visits to

the dentist. Most (78.2%) participants reported

having Medicaid insurance, 4.5% reported having

Medicare and the remainder either had no insur-

ance or did not respond.

Twenty care providers participated in the initial

oral health sessions and 18 completed training and

post-test evaluation. Among them 64.3% were

female, with a mean (SD) age of 44.3 years (SD ¼8.1 years). On average, they had 12.9 years (SD ¼7.2 years) of experience. Most participants (43.8%)

were Registered Nurses (RNs), 18.8% were

Licenced Practical Nurses (LPNs) and 37.5% were

home health aides.

Oral health/quality of life

Sixty-seven resident participants (67.1%) reported

owning a toothbrush. Among those reporting

brush ownership, 93.1% reported brushing their

teeth at least once a day. Thus, only about 60% of

the sample brushed regularly.

Ninety resident participants completed the OHIP-

14. The mean (SD) severity score was 9.2 (12.0),

the mean extent score (number of items rated as

‘fairly often’ or ‘often’) was 1.2 (2.6), and the mean

prevalence (participants rating at least one item at

least ‘fairly often’) score was 37.8%. Further ana-

lyses showed that OHIP-14 severity and extent

scores were similar in the edentulous and dentate

participants [mean (SD) ¼ 11.4 (16.3) vs. 9.0

(11.5) and 1.4 (3.0) vs. 1.1 (2.5), respectively].

Males reported lower OHRQoL than women: [for

severity, mean (SD) ¼ 11.7 (12.6) vs. 7.1 (11.6);

and for extent, 1.6 (2.9) vs. 0.9 (2.4), respectively].

Clinical assessment of the participants’ oral

health status is depicted in Table 1. Plaque was

present in 61.9% of the sample and calculus was

noted in 55.4%. Thereby indicating poor hygiene

among the majority of the sample. Participants

presented with a mean (SD) of 2.4 (3.7) diseased

teeth, 20.1 (20.5) missing teeth and 1.2 (3.7) filled

teeth and 29 subjects were edentulous. Using the

DMFT (diseased, missing and filled teeth) equation,

there was a mean (SD) DMFT of 23.8 (8.9). By

comparison, this result is greater (p < 0.01) than

that reported among the 1590 African–Americans

above the age of 50 examined in NHANES III,

where the mean (SD) was 19.5 (7.7). The majority

of participants, 58.9%, were referred for further

treatment because of one or more oral health

needs; 37.3% for caries, 42.7% for periodontics,

10.0% for prosthodontics and 2.7% for each of

endodontics and oral medicine.

Care providers’ Oral health knowledge

Eighteen providers responded to a survey of the

effects of aging on oral health, participated in an

Table 1 Summary of unmet oral health needs from oral

health examinations among residentsa.

No. of patientsa 137

Unresponsiveb (unable to evaluate) 19 (16)

Poor hygiene 64 (54)

Cariesa 9 (8)

Periodontitisa (gum disease) 15 (13)

Caries and periodontitisa 33 (28)

Root cariesa 2 (2)

Dentures (replacement,

adjustment, or creation)

9 (8)

Oral lesions 13 (11)

Values in parentheses are percentages.aOnly including residents for whom a complete oral

examination was possible.bNo oral health status, dental observations or referral

information obtained.


Oral health promotion among older persons and their care providers 75

in-service training on this topic and then re-took

the survey approximately 2 month later. Results

from the care providers’ OHK questionnaires are

summarised in Table 2. On average, care providers

answered 13.4 (of 20) or 67.3% items correctly on

the pre-test and answered 18.0 (of 20) or 90.0%

correctly on the post-test; indicating a significant

improvement (p < 0.01). Years of provider experi-

ence were strongly associated with pre-test

knowledge, even when controlling for provider age

(partial correlation (pr) ¼ 0.76, p < 0.01).

Because of continued poor oral hygiene, 33 cer-

tified nursing assistants attended additional work-

shops in which they observed and practiced oral

hygiene techniques. Qualitative data regarding oral

hygiene behaviours with the residents were ascer-

tained to better understand potential barriers to

care for the residents.

During the hands-on demonstration workshops,

the care providers expressed specific barriers to

providing consistent and thorough oral hygiene/

care to their residents. The most frequently

expressed barriers were: ‘fear that a patient may bite

me’, ‘the patients refuse to open their mouths’ and

‘patients’ bad breath’. Also mentioned was the fact

that oral health care was not specifically included in

their job responsibilities and that there was insuf-

ficient time to brush teeth after every meal/or daily.

Thus, both structural and attitudinal barriers to the

provision of oral hygiene were reported.

Discussion

The oral health promotion programme at the nur-

sing home was unique in three critical areas: (i)

oral health assessments and follow-up care were

completed; (ii) assessment of OHRQoL was

obtained; (iii) assessment of OHK was accom-

plished and (iv) hands-on training in oral health

care and education was provided.

The findings from the oral health examination

indicated that over half of the patients have varied

oral health needs warranting a referral for care.

This data is consistent with other reports on oral

health status of nursing home residents6,9. Oral

lesions warranting biopsies were observed in 13

(10%) of the residents. It has been estimated that

some 5–10% of routine dental patients have some

unusual findings in the oral cavity10. Results from

the OHIP-14 confirm that the resident’s poor oral

health status negatively impact their quality of life.

By comparison, Slade11 reported mean severity

scores for this age group of 3.6 (SD ¼ 6.0) and 6.5

(SD ¼ 6.5) in dentate UK and Australian commu-

nity samples, respectively; extent scores of 0.36 and

0.46, respectively; and prevalence scores of 15.9

and 18.2, respectively. Thus, the current sample

appears to have lower OHRQoL scores than age-

matched subjects from two representative com-

munity samples (p < 0.05)11. It is noteworthy that

25% of the residents were unable to respond to the

questionnaire – seemingly related to cognitive

impairment and/or behavioural issues.

Additional findings regarding care provider atti-

tudes and oral hygiene were consistent with prior

studies of oral health care of nursing home resi-

dents1,3. The OHK among the nursing home staff

appeared low, as almost half of the items were

incorrectly answered by about half of the care

providers at the pre-test. Results of the pre-test

indicated that 40% of the questions were answered

£60% correctly. However, it is noted that improved

OHK was achieved through the in-service work-

shops. Post-test results revealed that only one

question was answered £60% incorrectly. Com-

parison of pre- and post-test results concludes that

OHK was successfully increased. However, it is

unclear at this time whether increased knowledge

will be result in behavioural change. Follow-up

reinforcement of OHK is suggested.

During the hands-on sessions, an intense dis-

cussion ensued amongst the staff as to which shift

was responsible for brushing the patient’s teeth.

Similar findings regarding staff and time restrictions

are key issues as reported6. Additionally, the same

faculty member who conducted the hands-on

Table 2 Pre-and post-test question topics and percent-

age correct.

Item number and question subject Pre-test Post-test

1. Tooth loss and the aging process 56.3 100

2. Appearance 50.0 95.0

3. Systemic disease and oral health 85.7 84.2

4. Diabetes and oral health 94.1 95.0

5. Weight loss and oral health 81.3 100

6. Oral cancer mortality rates 75.0 60

7. Xerostomia 43.8 100

8. Medication and xerostomia 70.6 100

9. Oral hygiene 70.6 100

10. Oral manifestations of oral cancer 82.4 90

11. Periodontitis and aging 60.0 95.0

12. Denture care 82.4 100

13. Caries, hygiene and health 43.8 100

14. Oral hygiene and depression 93.8 100

15. Denture maintenance 80.0 100

16. Oral cancer 29.4 100

17. Nutrition and oral health 41.2 95.0

18. Xerostomia and health 82.4 100

19. Periodontitis and health 58.8 100

20. Quality of life and oral health 70.6 100.0


76 R. Reed et al.

sessions with a patient for the nursing home staff

was the same dentist who provided follow-up

dental treatment. While many nursing home staff

and administrators expressed the need for dental

services for their residents, only 39 (28.5%) of the

residents examined had follow-up dental treatment

at the dental school faculty practice. Adherence to

care was variable among the 39 residents receiving

dental care. A broad range of general dental servi-

ces was provided including dentures, restorations

and extractions. Barriers to care were cited such as

transportation to and from nursing home, lack of

personnel to escort patients to dental visits and

inability of patients to be moved from wheel chair

to dental chair. It was noted by this dentist/lead

author that all of the referred patients continued to

display poor oral hygiene despite all of the team’s

efforts to address this issue. Comparative studies

have yielded similar results2,9.

Conclusions

In summary, 58% of the resident participants had

extensive oral health needs, and about 30%

reported severe impacts on their OHRQoL. While

an oral examination and the OHIP-14 was used to

ascertain the oral health status and related quality

of life, additional instruments need to be explored

particularly for those who are unable to respond to

the questionnaire. Despite increase levels of OHK

among the care providers, structural and attitudinal

barriers to support routine oral hygiene for the

residents were observed by the team and expressed

by the care providers.

Acknowledgements

The Healthcare Foundation of New Jersey suppor-

ted the investigation. The investigators appreciate

the interest of the administration and personnel

from the New Community Center. We thank

Dr Yede Dennis for her participation. We thank

Ms Juanita Hobson for data entry.

References

1. Hawkins RJ. Functional status and untreated dental

caries among nursing home residents aged 65 and

over. Spec Care Dentist 1999; 19: 158–163.

2. Pyle MA, Suchitra N, Sawyer D. Nursing assist-

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3. Fiske J, Lloyd HA. Dental needs of residents and

carers in elderly peoples’ homes and carers ‘attitudes

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6. MacEntee MI, Thorne S, Kazanjian A. Conflicting

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Dentist 1999; 19: 166–172.

7. Kiyak HA, Mulligan K. Studies of the relationship

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8. Slade GD, Spencer JA. Development and evalua-

tion of the Oral Health Impact Profile. Community Dent

Health 1994; 11: 3–11.

9. Australian Institute of Health and Welfare. The

AdelaideDental Study of NursingHomes. The University of

Adelaide, Australia: AIHW, Cat. No DEN 63 1999: 1–6.

10. Drinnan AJ. Screening for oral cancer and precancer

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Correspondence to:

Dr Rebecca Reed,

Department of Community Health,

UMDNJ-NJ Dental School,

110 Bergen Street, Room B-852 Newark,

NJ 07103-2400, USA.

Tel.: 973 972 2287

Fax: 973 972 0363

E-mail: [email protected]


Oral health promotion among older persons and their care providers 77

Appendix A Workshop content outline*

Session 1. Introduction – overview – interrelationship between oral and overall health

Nutrition and oral health

Oral health related quality of life (e.g. eating and smiling)

Session 2. Oral disorders and diseases frequently found in older adults

Oral manifestations of specific conditions (e.g. diabetes, oral cancer, xerostomia and caries)

Session 3. Key skills in oral hygiene

Video tape presentation: Skills of daily mouth care: a caregiver’s guide

Session 4. Demonstration with giant dental model and role play utilising key skills in oral hygiene

*Questions and interactive discussion occurred at each session.

Appendix B Oral Health Knowledge Questionnaire

Please complete:

Age____ No. of years as a health provider _____

Please circle: Male Female

Specialty area: (circle)

MD/DO RN LPN other (please specify)__________________

Please read each statement below and check whether the statement is true or false.

True False

1. As people age, it is natural for them to lose their teeth

2 Few older* adults in the US report caring about the appearance of their smiles

3. Poor oral health can lead to pneumonia

4. Poor oral care can cause complications among patients with diabetes

5. There is a correlation between weight loss and poor oral health

6. African–Americans have a higher mortality rate from oral cancer than whites

7. Dry mouth is a normal part of the aging process

8. Only a few medications have known detrimental oral effects

9. Older persons should brush their teeth one time each day

10. Red or pink spots (patches) may be indicative of oral cancer

11. Receding gums are a normal part of the aging process

12. Persons with dentures should sleep with the dentures in their mouths

13. Carious teeth are associated with oral cancer among older persons

14. Poor oral hygiene can be associated with depression

15. If dentures are made correctly, they should not need to be adjusted or replaced over time

16. If identified early, the cure rate for oral cancer is approximately 50%

17. Eating a soft diet is healthier for the older adult’s mouth

18. Dry mouth does not cause any known oral-related problems

19. Periodontal (gum) disease is associated with heart problems

20. Most older persons report that their teeth or mouth negatively impact their quality of life

*Older persons refer to people at least 65 years of age.


78 R. Reed et al.

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Oral health promotion among older persons and their care providers in a nursing home facility