Preventive oral health intervention among old home care clients

Abstract

Background

poor oral health is common among older people dependent on supportive care and it affects their quality of life. Cognitive impairment and functional dependency may increase the risk of compromised daily oral hygiene.

Aim

to investigate the effectiveness of a tailored preventive oral health intervention among home care clients aged 75 years or over.

Patients and methods

the intervention group comprised 151 patients (84.4 ± 5.6 years) and the control group 118 patients (84.7 ± 5.2 years). An interview and a clinical examination were carried out before a tailored intervention of oral and denture hygiene. The participants in both groups were re-interviewed and re-examined after 6 months.

Results

the intervention significantly reduced the number of plaque covered teeth and improved denture hygiene. In addition, functional ability and cognitive function were significantly associated with better oral hygiene.

Conclusions

the intervention had a positive effect on oral hygiene, however the number of teeth with plaque remained high, even after the intervention. Multiple approaches based on individual needs are required to improve the oral health of vulnerable older adults, including integrating dental preventive care into daily care plan carried out by home care nurses.

Introduction

Good oral health has positive effects on the general health and daily functioning of older people and improves their quality of life and their diet and nutrition [1, 2]. Since the prevalence of edentulousness is falling worldwide, poor oral health is alarmingly common among older populations [3, 4]. Risk factors for oral diseases accumulate throughout life and many older adults are in continuous need of both preventive and operative oral health care. Especially among frail, cognitively impaired and more dependent older persons, oral health can deteriorate rapidly [5, 6]. According to a recent WHO report on Aging and Health, oral health is a decisive and often neglected area of healthy aging [7]. Pain, infection and tooth loss are the most common consequences of poor oral health. In addition, strong evidence supports the oral-systemic link between oral diseases and cardiovascular, cerebrovascular, respiratory diseases and diabetes, mainly by inflammatory aetiology [8–10].

Multimorbidity in turn increases the risk for oral diseases. The burden of multimorbidity is high among the older population; 82% of people aged over 84 years are likely to suffer from two or more chronic disorders [11]. An increasing trend among the care-dependent older people is to live at home as long as possible with the help of domiciliary care and home nursing. Especially among older people with cognitive impairment and compromised functional capacity, good standards of oral hygiene are difficult to obtain. This challenges home care personnel, who must offer the necessary daily assistance in oral hygiene in order for their clients to maintain good oral health. Up to now, information on the oral health behaviour and the level of oral hygiene among older home care clients has been limited. Most preventive intervention studies have focused on the institutionalised elderly or older people living independently at home [12–15].

The hypothesis behind the present study was that preventive interventions are positively associated with improved oral and denture hygiene among older home care clients. Thus, the purpose of our study was to evaluate the possible effect of targeted preventive intervention on oral health behaviour and oral hygiene outcome.

Materials and methods

This research is part of the larger NutOrMed—Nutrition, Oral health and Medication intervention—study. Details of the study protocol, sample calculations and participant selection have been published in 2015 [16].

Study population

The study population included home care clients aged 75 years or over living in three communities in Eastern and Central Finland. A random sample of 250 home care clients from Community I (105,141 inhabitants) was allocated to the intervention group. A random sample of 75 home care clients from Community II (20,224 inhabitants) and total sample of 115 home care clients from Community III (7,524 inhabitants) comprised the control group. Home care nurses gave written and oral information about the study to the clients or their caregivers in the sample. There were no exclusion criteria. Almost the same proportion of the intervention sample (n = 151, 60%) and the control sample (n = 118, 62%) signed the written consent and participated in the clinical oral examination.

Interview

At the baseline, trained home care nurses collected information about socioeconomic factors, living arrangements, general health status and health-related behaviour, cognitive functioning and functional ability. Cognitive status was assessed with the Mini Mental State Examination (MMSE) on a scale from 0 to 30, scores 18–24 indicating mild cognitive impairment and scores <17 severe cognitive impairment.

Functional ability was assessed with the Activities in Daily Living (ADL) index using the 10-item Barthel Index (scale 0–100), scores 91–99 indicating slight dependency, 61–90 moderate dependency, 21–60 severe dependency and <20 total dependence and Instrumental Activities of Daily Living (IADL) index using 8-Item Lawton and Brody scale (from 0–8), higher scores indicating better functioning.

A nutritionist collected information on weight, height and daily eating routines. The Mini Nutritional Assessment (MNA) test was used to detect malnutrition and risk of malnutrition; scores 17–23.5 indicate a risk of malnutrition and <17 malnutrition.

A pharmacist collected information on drug use. Information about each prescription and over-the-counter medication used regularly or as needed, if the participant had taken them within the past week were noted by interview, medication lists, packages or prescriptions. Drug use was classified in three categories: use of 0–5 drugs was classified as non-polypharmacy, 6–9 drugs as polypharmacy and 10 or more drugs as excessive polypharmacy.

Three trained and calibrated dental hygienists interviewed the participants before carrying out a clinical oral health examination. The interview comprised questions about the use of oral health services, self-perceived need for care, self-reported oral health, xerostomia, presence of removable dental prosthesis, oral health-related behaviour, problems related to cleaning of teeth and mouth.

If the home care client was not able to reply to the interview questions due to cognitive impairment, a caregiver or nurse was interviewed.

Clinical examination

Dental hygienists conducted the clinical examinations using mouth mirrors, WHO periodontal probes and a headlamp with the participant were sitting or lying down. At first the presence and status of removable dentures was examined outside of the mouth. Denture hygiene was marked as good if no visible plaque or calculus were found. The intraoral examination begun with an examination of the oral mucosa. After that, the number and condition of the teeth were recorded. The modified Silness and Löe index was used to register plaque [17]. Plaque was measured in buccal surface of each tooth and registered as no visible plaque, visible plaque in gingival margins, visible approximal plaque or visible plaque elsewhere. The highest value was recorded and the indicator describing oral hygiene was the number of teeth with any visible plaque.

Intervention

After the dental hygienist interview and the clinical examination, an individually targeted preventive intervention was carried out on those participants in need of the intervention group ‘See Supplementary data, Appendix 1, available in Age and Ageing online’. The intervention included at least one of the following oral and written instructions: dental hygiene instructions, denture hygiene instructions and cleaning of the oral mucosa instructions. Intervention instructions were given to the participant or to the caregiver or nurse.

The participants in both intervention and control groups were re-interviewed and re-examined after 6 months in order to assess the effectiveness of the targeted intervention. In each group, nine participants were lost to follow-up and two participants in the intervention group and four in the control group declined to participate in the second examination.

Ethics

The Research Ethics Committee of the Northern Savo Hospital District in Kuopio, Finland approved the research protocol. Those willing to participate gave their written consent and in the case of cognitive impairment, the consent was given by a family member or trustee.

Statistical analysis

Data were analysed by means of IBM SPSS version 21 (Statistical Package for the Social Sciences). The analysis included descriptive statistics giving proportions, means and standard deviations. Intervention analyses were carried out only for participants who had had two examinations. The impact of the intervention on oral hygiene was evaluated by linear mixed-effect regression model for number of teeth with plaque and by a generalised estimating equation (GEE) model with binary logistic regression for good denture hygiene. The IADL index was excluded from the regression analyses due to high correlations with other independent variables. P < 0.05 indicated a significant difference.

Results

Study subjects

Baseline comparison of participants (Table 1) showed acceptable comparability between the two groups for variables on demographic characteristics, health-related characteristics such as cognition, polypharmacy and daily functioning. In the control group, there were more participants suffering from continuous xerostomia (P = 0.009). The mean age of the intervention group (84.4 years) was close to that of control group (84.7 years). The oldest participant was 100 years old in the intervention group and 96 years old in the control group.

MMSE was under 24 among 39.3% (n = 55) participants in the intervention group and among 44.1% (n = 49) in the control group. The risk of malnutrition, 82.6% (n = 119) in the intervention and 78.7% (n = 92) in the control group, was high in both groups and six participants in each group were malnourished.

In the intervention group, 18.4% (n = 26) had poor ADL with high dependency on assistance and 37.6% (n = 53) had moderate ADL. These values in the control group were 11.3% (n = 13) and 40.9% (n = 47), respectively.

In the intervention group, 60.6% (n = 91) of the participants were dentate compared with 47.5% (n = 56) in the control group (P = 0.036).

Changes in the oral health behaviour and oral hygiene status and the effect of intervention

A modest positive change (2.3%) in frequency of twice daily toothbrushing among the dentate was observed in the intervention group, as the use of electric toothbrushes increased slightly (3.4%), but in the control group there was a notable decrease in twice daily brushing (−12.0%) (Table 2). The mean number of teeth with plaque decreased in the intervention group by 1.7 teeth; a small increase was noted for the control group (0.2 teeth with plaque). In both groups, overnight denture care in dry storage increased.

Benefit from the intervention was evidenced by a significant reduction in the number of teeth with plaque (Estimate 2.6, 95% CI: 0.3; 4. 8) and improvement on cleanliness of dentures (OR 2.1, 95% CI: 0.7; 3.4) (Table 3). Those who brushed their teeth less than twice daily had higher number of plaque teeth (Estimate 2.7, 95% CI: 0.3; 5.1). Those with higher MMSE scores had lower risk for teeth with plaque (Estimate −0.3, 95% CI: −0.5 ;−0.4) as well as those with higher ADL scores (Estimate −0.08, 95% CI: −0.1; −0.01). Those reporting continuous xerostomia had better denture hygiene.

At the baseline, 17 participants (15%) in the intervention group declared problems in cleaning the mouth and dentures, mainly due to reduced dexterity, reduced cognition and pain. After intervention, this proportion increased to 21% (n = 28). In the control group, 20 participants (19%) reported the same problems (mainly decreased dexterity) in daily hygiene during both examinations.

Discussion

This study shows that individually tailored preventive oral health interventions had a positive short-term effect on the cleanliness of teeth and dentures among home care clients aged 75 years or older. However, despite this positive effect, nearly half of the teeth had plaque, even after the intervention and about one in five reported problems in carrying out adequate oral hygiene. Poor functional ability and cognition play a significant role in cleaning one's own teeth, but less for denture hygiene.

Poor oral hygiene, poor nutrition and dry mouth are common risk factors for oral diseases. They are particularly common among vulnerable older adults who make up a high risk group; their dentition and oral function can be rapidly destroyed by root caries and periodontal disease [3]. Declined dexterity, problems in cognition and pain were the main reasons for compromised oral hygiene in our study. This is not surprising, as almost 40% in intervention group and 44% in control group had cognitive impairment and 56% in the intervention group and 52% in the control group were severely or moderately dependent of assistance from others. Even for those dependent of assistance cleaning mouth at least twice a day is important; our study shows that those brushing less than twice daily had significantly more plaque tooth. There is recent evidence that powered toothbrushes are more efficient in reducing plaque than manual toothbrushes [18] and could be used more especially by those with manual dexterity problems. As only 8% of participants in both groups brushed their teeth twice a day with a powered toothbrush, in principle daily oral hygiene of many older people could be easily improved by increased use of electric toothbrushes. However, persons with cognitive impairment may have difficulties in learning to use a powered toothbrush. The use of powered toothbrushes should be promoted already earlier in life, so that the habit then could continue into old age.

The high number of teeth with plaque is also alarming as poor oral hygiene increases the risk for aspiration pneumonia especially among frail older adults who have problems in chewing and swallowing and impaired resistance to infections [19]. According to a systematic review approximately every tenth case of death from pneumonia in older nursing home residents could be prevented by improving oral hygiene [10].

Caretakers for older person should have adequate oral health knowledge and skills to help older people that need daily help with oral hygiene procedures. Oral health education should be offered both to the aged care workforce and family members. It is a responsibility of the oral care personnel to plan an individualised and realistic preventive regime that can evolve according to the patient's changing needs and can be integrated into their care plan, as suggested also by Lewis et al. [20]. Dental hygienists’ role should be emphasised; hygienists can provide necessary preventive oral health care at home and assist in selecting individually customised oral hygiene aids. Simple denture care is insufficient today for older people whose mouths are getting more and more complex to clean as heavily restored teeth are retained into old age. Support for daily oral hygiene is the primary responsibility of family members or domiciliary care nurses. The results of our study are promising, but clearly multiple innovative approaches are needed to prevent oral diseases effectively in older persons, especially those with declined cognition and function affecting self-care.

In future, the proportions of older people needing supportive care and living at home will increase as longevity increases and therefore preventive programs will have to be researched and modified. The strengths of our study include non-institutionalised home care clients as a target population, a population-based design and a multidisciplinary approach. As there were no exclusion criteria, our results can be applied directly to everyday life. Another strength of this study is the individually tailored counselling on oral hygiene provided to participants or their caregivers, as it can be assumed that an individualised approach to intervention is more likely to be adopted by participants or caregivers.

This study has limitations. Randomisation was done before the baseline measurements and in this study there were more dentate subjects in the intervention group. However, achieving adequate oral hygiene is much more difficult in dentate mouths and requires more dexterity than cleaning removable dentures. The short follow-up of 6 months was also a limitation but a clear improvement in oral hygiene due to intervention that was noted and this could lead to improved oral health status with a longer follow-up. Another limitation is that clinical examinations were conducted at home by dental hygienists. Possibly, more precise information could have been gathered in dental clinics by dentists.

Poor oral health does not have to be a new geriatric syndrome [5], as the provision of effective and individualised preventive oral care for vulnerable older people is neither very technical nor expensive and could easily be integrated in a daily care plan. A clean, healthy mouth and a functional dentition could make a vast difference to the health, nutrition and quality of life of older home care clients.

Supplementary data

Supplementary data are available at Age and Ageing online.

Conflict of interest

None declared.

References