Children vs dependent older people – facilitators and barriers to providing oral hygiene


Like children, many older people are dependent on a third party to provide adequate oral hygiene measures. Unlike children, oral hygiene skills do not improve over time for dependent older adults. Our ageing population are retaining their teeth for longer and have more complex restorations with a greater level of difficulty to maintain, therefore oral health is an increasing priority which has been recognised by NICE and previously discussed (Dental Elf Blog – July 2016). The CQC Smiling Matters: Oral health in care homes progress report 2023 demonstrates an increase in awareness of the NICE guidance recommendations since 2019, however it states that access to dental services including domiciliary care, therefore contact with dental professionals, has reduced.

The aim of this review was to compare barriers and facilitators to providing oral health measures for both children and dependent older adults, and for this knowledge to be used for informing intervention strategy and policy design.


This systematic review searched publications from 2018 to 2023, as well as summarising previous similar systematic reviews. The authors searched PubMed, CENTRAL, Web of Science and Google Scholar for original studies that assessed knowledge, attitudes and behaviours acting as barriers or facilitators for provision of oral hygiene care for children or dependent older adults. All interventions were considered, however effectiveness was not explored. Third party involvement was required, and independent toothbrushing was excluded. Studies were screened by two authors and required both to be in agreement for inclusion.

Both qualitative and quantitative data on attitudes, knowledge, beliefs of all involved in daily oral hygiene as well as environmental factors influencing behaviours were collected. These were categorised into barriers that prevent oral hygiene provision or facilitators that promote oral care, and then compared between children and dependent older adults. Data extraction was performed independently, and conflicts discussed.

Findings were firstly aligned to the theoretical domains framework (TDF) and classified as barriers or facilitators. They were then further classified into the capability, opportunity, motivation and behaviour (COM-B) domains of the Behaviour Change Wheel (BCW) to support the applicability of findings for future interventions and policies. The Newcastle-Ottawa Scale was used for quality and bias assessment.


  • 17 articles were included (children N=9, older adults N=8), one study was excluded due to poor quality.
  • Children are almost exclusively depending on parents, mainly mothers, and professional care givers are mostly responsible for older adults, for their oral care.
  • Oral care in general is not regarded as important as other aspects of care by parents/caregivers.
  • More barriers and facilitators were presented for older adults vs children.
  • There were more barriers than facilitators reported for both groups.
  • The most common barrier for providing oral hygiene for both groups was the knowledge/skills of the people responsible for implementation as per the TDF domains.
  • According to the COM-B domains, common barriers for dependent older adults were knowledge (capability), environmental context and resources (opportunity), behavioural regulation and emotion (motivation), whereas knowledge and goals for children were the most common.
  • Regarding facilitators, skills (capability) and environmental context and resources (opportunity) were mostly reported for older adults, and knowledge (capability) for children.
  • Summary of previous studies identified similarities in the barriers providing oral care to dependent older adults vs children including lack of knowledge and patient resistance, child behaviour and environment. Facilitators were identified as education, training and presence of a dental professional for older adults vs knowledge, social environment and attitudes for children.


The authors concluded:

Most factors (barriers and facilitators) playing a role in third-party oral care in children are also relevant in older people. To improve oral health in dependent older people, successful implementation of oral hygiene measures by third parties will depend on low threshold, easily accessible training and further education. In addition, the importance of third-party brushing in dependent older people should be raised in the public awareness. Further research is needed to see whether effective strategies to overcome barriers and to increase facilitators in providing oral care in dependent older people can be achieved by linking the TDF to the BCW and the associated behaviour change techniques. Our findings provide approaches for the development of strategies for the regular implementation of oral hygiene measures in dependent older people.


This study followed a previous systematic review in 2018 which provides updated evidence on areas of improvement for implementing better oral hygiene measures for children and dependent older adults. This study suggests that lessons on oral health interventions can be learned and applied to both children and dependent older adults. The success of public health strategies such as Childsmile ( are widely recognised therefore transferability could be considered to improve the oral health for dependent older adults. In Scotland, the Caring for Smiles initiative ( ) aligns with the NICE guidelines on Oral Health Care for adults in care homes, however evidence on its effectiveness is lacking. A Cochrane review found insufficient evidence on the impact of oral health education for care home staff (Dental Elf – October 2016).


Primary paper

Hillebrecht AL, Höfer K, Blasi A, Wicht MJ, Barbe AG. Comparison of facilitators and barriers to providing oral hygiene measures in dependent older people and young children: A systematic review. Gerodontology. 2023 Mar 16. doi: 10.1111/ger.12684. Epub ahead of print. PMID: 36924414.

Review protocol on PROSPERO

Other references

Dental Elf – 11th Jul 2016

Oral Health should have same priority as general health in care homes says NICE

Dental Elf – 10th Oct 2016

Oral Health in nursing homes: education for staff and residents

Oral health for adults in care homes NICE guideline [NG48] Published: 05 July 2016. Accessed 10th July 2023

Smiling matters: Oral health care in care homes progress report 2023. Accessed 10th July 2023

Evaluating childsmile, Scotland’s National Oral Health Improvement Programme for children. AJ.Ross, A.Sherriff, J.Kidd, L.Deas, J.Eaves, A.Blockland, B.Wright, P.King, AD.McMahon, DI.Conway, LMD.Macpherson. Community Dentistry and Oral Epidemiology 2023; Vol 51

Childsmile: The Child Oral Health Improvement Programme in Scotland. LMD.Macpherson, GE.Ball, P.King, K.Chalmers, W.Gnich. Primary Dental Journal, Volume 4, Number 4, pp 33-37. November 2015.

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Photo by Nikoline Arns on Unsplash



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Gemma Gaw

Gemma is a Specialty Registrar in Special Care Dentistry in NHS Greater Glasgow and Clyde. She was awarded her BDS from the University of Dundee in 2018. Following 2 years in NHS general practice, Gemma undertook DCT posts in the Public Dental Service, Oral Surgery and Oral and Maxillofacial Surgery, prior to commencing Specialty Training in 2022.

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Suzy Harkness is a Specialty Registrar in Special Care Dentistry working across NHS Tayside. She graduated from Queen’s University Belfast in 2018 before moving to Edinburgh for dental foundation training. Suzy completed three years of dental core training in Oral and Maxillofacial Surgery, Restorative and Special Care Dentistry before commencing specialty training in 2022. Suzy enjoys working with adult patients with additional needs and has an interest in teaching, completing a postgraduate certificate in clinical education with Queen’s University Belfast in 2021.

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Emma O'Donnell

Emma O'Donnell is a clinical lecturer at the University of Glasgow and honorary speciality registrar in Special Care Dentistry with NHS Greater Glasgow and Clyde. She graduated from the University of Glasgow in 2016 and following time within general practice and dental core training, she embarked on specialist training in 2020. She is currently working towards a MEd Academic Practice at the University of Glasgow.

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