This project was based around an epidemiological survey aiming to assess oral health status and needs of older people living in nursing homes across Islington. The nursing homes participating in this survey also took part in an oral health needs assessment survey in 2009. The new oral health programme embarked in 2009 was assessed in the 2013 epidemiological survey.
The information was collected through clinical examination, interviews with the residents and interviews with the managers and carers. The later survey identified the key issues in relation to oral health and dental care provision to residents of nursing home and produced recommendations on oral health improvement that are in accordance with NICE guideline on oral health for adults in care homes, particularly the recommendations in section 1.3 on mouth care assessments and personal care plans.
Aims and objectives
To assess the oral health status and care needs of older people living in nursing homes across Islington, and obtain views of nursing care home managers and staff about issues related to oral health of the residents and the impact of the implementation of oral health initiatives.
• Measure the current clinical oral health status and dental treatment needs of residents in nursing homes across Islington
• Assess the perceived oral health status and the impact of oral conditions on the quality of life of nursing home residents in Islington
• Assess perceptions of senior management and other staff in nursing homes regarding the oral health care needs of residents and the impact of the initiatives implemented to improve oral health for residents
Reasons for implementing your project
An oral health needs assessment survey was carried out in nine Islington nursing homes in 2009, showing that there were large proportions of residents with high levels of oral health needs. This was also reflected in the fact that many residents reported that their oral health had negatively affected their quality of life. Furthermore, the 2009 survey identified key issues in relation to lack of oral health promotion and dental care provision among nursing home residents. In view of the 2009 survey findings, the nursing homes have since embarked on an oral health improvement programme and a new set of standards has been set.
This included the following components:
• oral health risk assessment of all new residents,
• daily records of oral hygiene practices,
• residents being assisted to carry out their daily oral hygiene routine and
• improvement of referral pathways that resulted in higher numbers of referrals to dental services.
Furthermore, the nursing homes staff have since been trained to undertake all these duties successfully as part of their responsibilities. The aforementioned components of the oral health improvement programme were also aligned to the CQC guidance in terms of providing specific examples of good practice that could be used during the inspection process, therefore further facilitating their implementation. Additionally, the 2009 survey findings resulted in the commissioning of a high concentration fluoride toothpaste programme for older people in nursing homes in Islington in December 2012, seen as one of the parts of the overall oral health promotion programme.
An oral health survey of older people living in nursing homes across Islington was carried out in 2013, four years after the initial survey, following the same methodology, data collection procedures and use of outcome measures. This included a clinical examination and an interview of the residents, as well as interviews with nursing home managers and carers.
Clearly, this was not, and could not be, a follow-up of the sample of the earlier survey due to the relatively short duration of stay of older people in nursing homes. However, it was possible to look at overall differences in the oral health and quality of life of nursing homes residents following the implementation of the aforementioned programmes.
How did you implement the project
The nine nursing homes that took part in the original survey were again contacted to participate in 2013. There were 448 registered residents, but 45 were younger than 65 years and therefore not eligible for the survey. Overall, 331 residents participated (response rate: 82%).
The survey consisted of three parts:
- A questionnaire-led interview for nursing home managers and carers
- A clinical oral examination of the residents
- A questionnaire-led interview of the residents.
An information sheet, explaining the purpose and procedures of the survey and declaring confidentiality of the data, was distributed to the registered residents, along with a consent form to participate in the study. Residents were recruited to the study following verbal or written consent. Verbal consent was also obtained from managers and carers, prior to their interviews. The managers’ and carers’ questionnaires were based on those developed and tested in the 2009 study in order to facilitate comparability of the results between 2009 and 2013.
The questions covered aspects about health related policies in nursing homes, access of residents to dental services, oral assessment of residents by nursing home staff, education and training of staff. A non-invasive clinical examination of the residents was carried out on 325 residents (6 refused to undertake that part of the survey) by a trained dentist, supported by a dental nurse; cross-infection was adhered to according to British Dental Association Cross infection guidance.
The residents’ questionnaire contained validated questions and was administered by a trained oral health promoter. For comparability purposes, it was again based on the respective questionnaire employed in the 2009 Islington nursing homes study. It consisted of questions on: self-rated oral health and general health, satisfaction with oral health status and with dentures (where applicable), oral symptoms, oral health-related quality of life (assessed though the Oral Impacts on Daily Performances questionnaire) and perceived needs for dental treatment. Questions on demographic information and social questions were also included.
Before the interview, a simple cognitive screening test assessed the cognitive ability of the residents. As 151 residents did not satisfactorily answer the cognitive screening questions, they were excluded from the interview which were carried out on 180 residents.
The results of the 2013 survey showed that in general the provisions for oral health in nursing homes as well as the oral health of the nursing home residents in Islington were better compared to those from 2009.
In 2013, all homes had an oral health plan and trained staff carried out oral health assessments of new residents and they also assisted them with oral hygiene. There were proportionately fewer edentate residents (those without any natural tooth), while among the dentate (those with natural teeth) tooth mobility was much less common, the prevalence of tooth caries was slightly lower and there were more filled (restored) teeth.
There was also a marked increase in dental residents being treated by the Community Dental Service. More importantly, the prevalence of toothache was much lower and the residents in 2013 reported markedly better ratings than those in 2009 in terms of the way their oral conditions affected their quality of life.
Despite this overall improvement, 17% of dentate residents reported experiencing toothache in the last 6 months and still 20% of dentate and 31% of edentate said that their daily life was negatively affected by their oral conditions. The most common oral impact was difficulty eating. Dry mouth was among the most commonly reported oral health problems for both dentate and edentate residents (with 41% and 40% affected respectively), while loose or ill-fitting dentures were reported by 34% of edentate.
Clinical oral health markers also indicated that there is still a considerable amount of treatment need. Our results from the 2013 survey showed that 62.1% of residents were dentate and 37.9% were edentate; among the latter, only 40.7% wore a denture. Among the dentate residents, 31.2% had at least one mobile tooth and 22.8% had significant plaque deposits on 7.5 teeth on average. Reinforcing the existing oral hygiene initiatives may therefore be appropriate to further improve the periodontal health of the residents. Furthermore, 41.1% had active tooth caries and 64.9% had active root caries.
Overall, high levels of dental treatment needs persisted, as 79.7% of residents were clinically assessed to need some form of dental treatment. Addressing the burden of dental caries among the dentate residents may require a multifaceted strategy targeting the consumption of sugars, the provision of services and the availability of fluoride to delay the caries process.
Key learning points
Despite the overall better arrangements for oral health promotion and provision of dental care, supported also by the more favourable oral health and quality of life of the residents, there is still work to do to consolidate previous beneficial initiatives and also bring necessary further improvements.
The key learning points and recommendations span across different themes:
• The high levels of need and oral impacts of the residents highlight the importance of broader health promotion interventions that help residents maintain an acceptable level of oral health and functioning.
• In Islington nursing homes, the main oral health priorities refer to caries prevention and treatment, as well as to provision and repair of dentures.
• Addressing the high prevalence of dry mouth, both among dentate and edentate residents, should also be seen as priority in future health programmes in the homes. Linked to medication and considering that this population is also burdened by co-morbidities and dementia in particular, this poses challenges for cooperation to carry out oral hygiene and also in terms of receiving dental care.
• The high nursing home staff turnover is a considerable challenge. Periodical oral health training of nurses and carers can help the residents maintain decent oral health and address their basic dental care needs.
• Annual review of the oral health initiatives and supportive management are both essential factors for the success of the programmes.
• Appropriate clinical care pathways and a domiciliary care service should complement the arrangements for referral for dental care of the residents.
• All these require that the main stakeholders, such as the local authority, nursing homes managers and staff, relatives, dental care and health and social services and the voluntary sector, are well aware of the importance of oral health among the residents and are keen to collaborate in taking appropriate action to improve it further.