Oral Health in nursing homes: education for staff and residents

All the evidence relates to care homes and there is hardly any evidence for any other setting.

A marked shift in population structure is being seen in many high-income countries with increasing numbers of older people. This population group has important levels of morbidity and care dependency with many requiring residential nursing home care. While previous generations of older people were mainly edentulous thanks to improvements in oral health many more have natural teeth requiring care and maintenance. Many nursing home residents will require support for optimal oral care and nursing staff and other caregivers have a crucial role to play as good oral health can have a positive effect on general health and quality of life.

The aim of this Cochrane review was to assess the effects of oral health educational interventions for nursing home staff or residents, or both, to maintain or improve the oral health of nursing home residents.

Methods

Searches were conducted in the Cochrane Oral Health Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, CINAHL, Web of Science Conference Proceedings ClinicalTrials.gov the World Health Organization International Clinical Trials Registry Platform and the reference lists of identified articles with no restrictions on language or date of publication.

Randomised controlled trials (RCTs) and cluster-RCTs comparing oral health educational programmes for nursing staff or residents, or both with usual care or any other oral healthcare intervention with a follow up period of at least two weeks were considered. Two reviewers independently selected studies retrieving data bout the development and evaluation processes of complex interventions on the basis of the Criteria for Reporting the Development and Evaluation of Complex Interventions in healthcare: revised guideline (CReDECI 2). Study quality was assessed using the Cochrane risk of bias tool

Results

9 RCTs (7 cluster RCTs) involving 3253 nursing home residents were included.
4 studies were considered to be at high risk of bias, 4 at unclear risk.
The average age of the residents was 78-86 with the majority being female (66%).
Edentulousness ranged from 32% to 90% across studies with 62% to 87% having dental prostheses.
8 studies compared educational interventions with information and practical components versus (optimised) usual care, while the ninth study compared educational interventions with information only versus usual care.
All interventions included educational sessions on oral health for nursing staff (five trials) or for both staff and residents (four trials), and used more than one active component. Follow-up of included studies ranged from three months to five years.
None of the trials assessed our predefined primary outcomes ‘oral health’ and ‘oral health-related quality of life’. All trials assessed our third primary outcome, ‘dental or denture plaque’.
Meta-analyses showed no evidence of a difference between interventions and usual care for dental plaque (mean difference -0.04, 95% confidence interval (CI) -0.26 to 0.17; six trials; 437 participants; low quality evidence) or denture plaque (standardised mean difference -0.60, 95% CI -1.25 to 0.05; five trials; 816 participants; low quality evidence).
None of the studies assessed adverse events of the intervention.

Conclusions

The authors concluded;

We found insufficient evidence to draw robust conclusions about the effects of oral health educational interventions for nursing home staff and residents. We did not find evidence of meaningful effects of educational interventions on any measure of residents’ oral health; however, the quality of the available evidence is low. More adequately powered and high-quality studies using relevant outcome measures are needed.

Comments

This review has followed the usual methodologically robust Cochrane approached and identified a small number of trials addressing what is a growing issue. As the authors’ note all the included studies have adopted complex interventions using more than one active component with the number of interventions varying between the studies. In included studies also tended to focus on surrogate measures such a plaque levels rather than oral health-related quality of life and oral health.

In the UK it is estimated that 440,000 people over the age of 65 currently live in care homes and NICE has recently issued guidance for oral health care (Dental Elf – 11^th July 2016). One of the points highlighted was the economic cost of providing training on oral health care so having additional information about effective oral health education in these would be helpful. IT also notes that a significant proportion of these residents will also be suffering from dementia.

Links

Primary paper

Albrecht M, Kupfer R, Reissmann DR, Mühlhauser I, Köpke S. Oral health educational interventions for nursing home staff and residents. Cochrane Database of Systematic Reviews 2016, Issue 9. Art. No.: CD010535. DOI: 10.1002/14651858.CD010535.pub2.