Oral health care in older people in long term care facilities: A systematic review of implementation strategies

Abstract

Objectives

Oral hygiene is necessary to maintain oral health and quality of life. However, the oral hygiene and the oral health care of older people in long term care facilities are poor. This indicates that care is not in compliance with the available guidelines and protocols, and stresses the importance of a clear evidence-based implementation strategy to improve oral health care. The aim of this study is to review implementation strategies used to promote or improve oral health care for older people in long term care facilities from the perspective of behaviour change, to code strategy content at the level of determinants, and to explore their effectiveness.

Design

Systematic review of literature.

Data sources

The digital databases of the Cochrane Library, PubMed and Cinahl have been searched up to September 2011 for relevant articles.

Review methods

After a systematic selection process, included studies were quality assessed by three researchers. We extracted the study characteristics using the EPOC Data Collection Checklist and Data Abstraction Form. Strategy content was extracted and coded by using the Coding Manual for Behavioural Change Techniques. This manual groups the behaviour change techniques under relevant behavioural determinants.

Results

Twenty studies were included in this review. Implementation strategies were delivered by dental hygienists or dentists. Oral health care was performed by nurses and nurse assistants in all studies.

All studies addressed knowledge, mostly operationalized as one educational session. Knowledge was most often combined with interventions addressing self efficacy. Implementation strategies aimed at knowledge (providing general information), self-efficacy (modelling) or facilitation of behaviour (providing materials to facilitate behaviour) were most often identified as successful in improving oral health.

Conclusions

Knowledge, self-efficacy and facilitation of behaviour are determinants that are often addressed in implementation strategies for successful improvement of oral health care in older patients. Strategies addressing increasing memory, feedback of clinical outcomes, and mobilizing social norm are promising and should be studied in the future. However, as the quality and heterogeneity of studies is a reason for concern, it is not possible to unequivocally recommend strategies or combinations of strategies for improving oral health care in the older population. When choosing strategies to improve oral health care, care professionals should thoroughly examine the setting and target group, identify barriers to change and tailor their implementation strategies to these barriers for oral health care.

Introduction

Oral health influences how someone talks, chews, eats and tastes food, and behaves socially (Sheiham, 2005). A bad set of teeth and a deteriorating oral health can lead to malnutrition, pain, and social isolation. It is also associated with diseases such as diabetes mellitus, atherosclerosis, pneumonia, endocarditis and even mortality (Coleman, 2002).

Oral hygiene is necessary to maintain oral health and quality of life (Coleman, 2002). However, international studies show that oral health care of institutionalized older people is poor (Arpin et al., 2008, Jokstad et al., 1996, Samson et al., 2008, Simunkovi et al., 2005, Stubbs and Riordan, 2002, Unlüer et al., 2007, Vanobbergen and De Visschere, 2005). Not only the oral hygiene level of the remaining teeth scored low (Frenkel et al., 2000, Jokstad et al., 1996) but also most denture-wearing patients living in nursing homes wore unhygienic dentures (Frenkel et al., 2000, Pietrokovski et al., 1995). Research in the Netherlands showed that 40% of the institutionalized patients with natural teeth and 10% of the patients with a prosthesis had food remainders, plaque or tartar in their mouth (Kalsbeek et al., 2006).

As older patients in nursing homes are often no longer able to perform oral health care, they have to depend on nurses, nurse assistants or caregivers for this. Several guidelines and protocols have been developed to support these nurses, nurse-assistants or caregivers (Artsennet, 2007, SIGRA, 2006, Coleman, 2002, Roberts, 2000a, Roberts, 2000b, Roberts, 2000c). Although differences between institutions exist, e.g. some have protocols and others do not, almost every institution gives some kind of oral health care, since oral health care is part of the daily care for patients in long term care facilities (Vanobbergen and De Visschere, 2005). Nevertheless, the oral hygiene and the oral health care of older people in long term care facilities is insufficient (Coleman, 2002, Coleman and Watson, 2006, Kalsbeek et al., 2006, Samson et al., 2008). For example, Coleman and Watson (2006) observed morning care provided to 67 dentate nursing home residents requiring extensive to full staff assistance with activities of daily living. They found that oral care was provided for only 16.4% of the residents. Half of these residents had their teeth brushed by the nursing assistant and the other half brushed their own teeth under supervision. None of the residents had their teeth brushed for 2 min. Nursing assistants brushed for 16 s on average. Residents brushed longer (39 s) but were always prompted to stop brushing by the nursing assistants (Coleman and Watson, 2006).

This indicates that care is not in compliance with the available guidelines and protocols, and stresses the importance of a clear evidence-based implementation strategy to improve oral health care.

Many strategies have been designed and evaluated to address the problem of poor compliance to guidelines, but most of the effects are small to moderate and often short term (Van Achterberg et al., 2008, Grimshaw and Eccles, 2004, Grimshaw et al., 2004a, Grimshaw et al., 2004b, Grol and Grimshaw, 2003). In order to identify effective implementation strategies, it is important to analyse the content of the strategies used in the studies that aim to improve oral health care. As improving oral health care implies behaviour change, focussing on determinants of behaviour change, derived from behaviour and behaviour-change theories (Abraham and Michie, 2008, De Bruin et al., 2009), is an approach that might provide insight into the content of implementation strategies and their effectiveness.

The aim of this study is to review implementation strategies used to promote or improve oral health care for older people in long term care facilities from the perspective of behaviour change, to code strategy content at the level of determinants, and to explore their effectiveness.