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GERODONTOLOGY www.stomaeduj.com
BARRIERS TO GOOD ORAL HEALTH FOR NURSING HOME
Review Articles
RESIDENTS: A LITERATURE REVIEW
Kalliopi Konstantopoulou1a* , Anastassia Kossioni1b , Hercules Karkazis 1c , Gregory Polyzois 1d
1
Department of Prosthodontics, School of Dentistry, National and Kapodistrian University of Athens, Athens, Greece
a
DDS, MSc; e-mail: kakonsta@dent.uoa.gr; ORCIDiD: https://orcid.org/0000-0002-4314-9222
b
DDS, MSc, Dr. Dent, Associate Professor; e-mail: akossion@dent.uoa.gr; ORCIDiD: https://orcid.org/0000-0003-0610-6984
c
DDS, MSc,Dr. Dent; e-mail: hkarkaz@dent.uoa.gr; ORCIDiD: https://orcid.org/0000-0002-9003-2852
d
DDS, Dr. Dent, MScD; e-mail: grepolyz@dent.uoa.gr; ORCIDiD: https://orcid.org/0000-0003-0032-039X
ABSTRACT https://doi.org/10.25241/stomaeduj.2020.7(2).art.7
Background Oral health in older adults who live in nursing homes is generally poor, with high rates of mainly
preventable oral conditions.
Objective The aim of this review was to present an overview of the barriers to good oral health for older
nursing home residents.
Data sources Electronic databases were used (PubMed, Google Scholar, ScienceDirect). Reference lists from
relevant studies and cited papers were also investigated.
Study selection The review included reports from national surveys and full papers of any study design,
systematic reviews and guidelines published in peer-reviewed journals in English published until February
2019.
Data extraction The recorded barriers to good oral health were allocated to the main categories described in
the socioecological model of health promotion.
Data synthesis The identified barriers to oral health of nursing home residents were allocated into
intrapersonal, interpersonal, organizational and public health policy issues. The main intrapersonal barriers
included the residents’ physical and mental disease, resistance to care, poor oral health literacy and difficulties
in accessing dental care. Interpersonal factors included inadequate knowledge and training of caregivers and
health professionals on oral health and care for frail older people, as well as negative attitudes of caregivers
and family members towards oral hygiene provision in nursing homes. Organizational factors included low
priority of oral health in nursing homes, limitations in time and number of staff and limited collaboration with
dental professionals. Ineffective oral health policies included lack of priority for oral health and unsupportive
oral care systems.
KEYWORDS
Barriers; Oral Health; Oral Hygiene; Nursing Homes; Older Adults.
1. INTRODUCTION pneumonia, diabetes mellitus, cardiovascular
diseases and malnutrition [2-9].
Oral diseases are a major global public health Poor oral health has a considerable impact on the
problem affecting individuals, communities, and the health care systems raising the health care costs [10-
society as a whole, as over 3,5 billion people face 13]. In addition, poor oral health may have a negative
chronic and progressive oral diseases [1]. Older adults impact on social relationships due to altered speech,
who reside in nursing homes are a particularly vulne- aesthetics, and oral comfort [13-16].
rable part of the population with high rates of oral Oral care for nursing home residents does not often
diseases. meet best practice standards [17] and several factors
Neglected oral health has severe consequences for seem to act as barriers.The aim of this review was to
the residents’ general health and quality of life and offer an overview of the barriers to good oral health
has been associated with increased risk for aspiration in older adults residing in nursing homes.
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Konstantopoulou K, Kossioni A, Karkazis H, Polyzois G. Barriers to good oral health for nursing home residents: a literature review. Stoma Edu J.
2020;7(2):131-137.
Received: November 10, 2019; Revised: December 09, 2019; Accepted: May 22, 2020; Published: May 25, 2020
*Corresponding author: Dr. Kalliopi Konstantopoulou, DDS, MSc, Department of Prosthodontics, School of Dentistry
National and Kapodistrian University of Athens, Thivon 2 str., GR-11527 Goudi, Athens, Greece.
Tel: (+30) 210-746-1206, Fax: (+30) 210-746-1240, e-mail: kakonsta@dent.uoa.gr
Copyright: © 2020 the Editorial Council for the Stomatology Edu Journal
Stoma Edu J. 2020;7(2): 131-137 pISSN 2360-2406; eISSN 2502-0285 131
Konstantopoulou K, et al.
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2. MATERIALS AND METHODS the dentures may also negatively affect oral health
Review Articles
causing denture-related stomatitis oral lesions
A literature search in PubMed, Google Scholar, [17,27,34-36].
ScienceDirect and Scopus electronic databases
was performed. The following keywords were used: 3.2. Interpersonal factors
(barriers) AND (oral health OR oral care) AND Caregivers should examine the oral health status of
(nursing home residents OR dependent older adults). the residents and provide or supervise the imple-
Moreover, reference lists from relevant studies and mentation of oral hygiene at least once a day
cited papers were also investigated. The titles and [37,38,39]. However, the oral health of nursing homes
the abstracts of the retrieved articles were screened residents does not receive the necessary attention
to decide whether full-text reading was required, and and oral care neglect is more frequently observed
full texts were retrieved for the selected articles. The compared to community dwelling elders [40]. The
review included reports from national surveys and role of formal caregivers in nursing homes is crucial
full papers of any study design, as well as guidelines, for the everyday general and oral care of frail and
published in peer-reviewed journals in English. functionally dependent residents. Inadequate theo-
Articles published until February 2019 were included. retical and practical education of nursing home staff
According to the socioecological model of health in oral health and care has been well documented
promotion, poor oral health of residents in care units [34,41-45].
can be attributed to intrapersonal, interpersonal, Caregivers have poor knowledge and skills on oral
organizational and public health policy issues. hygiene advice and assistance [18,25]. Moreover,
Therefore, the main barriers identified in the study they do not have adequate knowledge in detecting
were allocated to these specific categories. common oral pathologies such as caries, periodontitis
and stomatitis, and in the correct procedures for oral
3. RESULTS hygiene implementation [42,46]. Furthermore, they
do not use the available educational resources on
The review has identified the following barriers to oral care. Some caregivers, also, do not understand
good oral health in nursing homes: the need for certain oral care activities and they think
that the implementation of oral hygiene is based
3.1. Intrapersonal factors on their preexisting knowledge [19]. According to
A number of barriers to oral health of nursing home the caregivers’ perceptions, a major barrier to
residents are related to the residents themselves. oral hygiene provision is the residents’ negative
Intrapersonal issues include physical illness, cognitive responsive behaviors and resistance (i.e. not opening
impairment and mobility problems leading to their mouth, biting the toothbrush or the caregivers’
progressive self-care limitations and, subsequently, to hands, shouting, etc.). However, the caregivers'
difficulties in performing oral hygiene and accessing close relationships with the residents and a person-
dental care [17-21]. Lower use of dental services may centered approach can play a key role in preventing
lead to the fast progression of oral diseases, delayed or managing responsive behaviors of older adults
diagnosis and, as a result, to poor prognosis [22]. with dementia. Nevertheless, care providers are
Studies in care units revealed poorer oral hygiene in deprived of proper education in overcoming care
functionally dependent older adults compared to resistant behaviors and are unaware that aggressive
residents with better self-care capacity [23,24,25]. behaviors of residents with dementia may express
Apart from the level of care dependency, increasing pain, fear or resentment [8,47-51]. Furthermore,
age, as well as communication and behavioral caregivers believe that the residents experience oral
problems comprised additional barriers [8,26,27]. hygiene as intimate or painful. The poor cooperation
Polypharmacy is a major barrier to good oral health. among caregivers may also cause communication
In particular, cholinesterase inhibitors, atypical anti- problems [8,21,35,52-54]. Caregivers also consider
psychotics and antidepressants have significant oral oral care of low priority and believe that it is not
side effects such as xerostomia or sialorrhea, stomatitis included in their job responsibilities [19,20,43,55,56].
and dysgeusia. In addition, donepezil, galantamine, Oral care and removal of dentures is considered as
and risperidone interact with medications often an unpleasant and repulsive process, mainly due to
administered by the dentist, such as erythromycin, clari- oral halitosis and bacteria prevalence [20,25,34,57].
thromycin and ketoconazole [28-30]. Individual For some caregivers, oral care is considered as more
factors also include unhealthy dietary habits, and unpleasant compared to general care (feeding,
smoking, as well as the social determinants of health washing or changing diapers) and they feel exhausted
such as low educational level and limited income after applying oral hygiene [44,58]. Other reported
[31-33]. Τhe presence of natural teeth and dental barriers include the lack of empathy, laziness and
implants have also been characterized as barriers to belief that residents can manage oral care themselves
good oral health, because of the complexity of oral [44,59]. Lack of professional support is also associated
hygiene procedures compared to dentures. However, with the insecurity of the dentists to provide oral care
poor retention and stability, and poor hygiene of in medically compromised older people, particularly
132 Stoma Edu J. 2020;7(2): 131-137 pISSN 2360-2406; eISSN 2502-0285
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in domiciliary settings [39,60,67], as well as the limited older adults living in care units or being confined at
Review Articles
knowledge of physicians to integrate oral health into home [37,39,67].
the general medical assessment [39]. Interpersonal
factors also include barriers related to the residents’ 4. DISCUSSION
family members. Family members’ oral health literacy
is often inadequate [20,61,62] and there is lack of This review has identified several barriers to good
understanding of the need to improve the quality of oral health in nursing home residents related to
oral health and care [63]. They often do not support intrapersonal, interpersonal, organizational and
the formal caregivers in the provision of oral hygiene public policy issues. The caregivers’ lack of oral health
to the older family members [60,61,63], and do not education and increased workload, along with
purchase oral care supplies for their relatives, due to limited access to dental care for the residents were
their high cost or perceived low priority of oral care [8]. the dominant barriers.
Older residents face a rapid oral health deterioration
3.3. Organizational factors due to several risk factors which include general
Barriers to oral health associated with the orga- health factors, oral conditions and lack of social
nization of nursing home services include lack of oral and institutional support [68]. Poor oral hygiene
care routines and instructions, and unclear rationale implementation has been associated with the
for implementing oral care recommendations caregivers’ inadequate knowledge, training and
[20,21,41,54,64]. The lack of a nursing team leader skills for oral hygiene assessment and provision,
and of proper supervision, monitoring, enforcing the limitations in the number of staff and their time
and rewarding the caregivers’ oral hygiene practices availability for oral care, the poor communication with
are important determinants of proper oral hygiene the residents, the residents’ low interest or even their
implementation [8,21,65]. On the other hand, common resistance to oral care [8,17,19,21,25,34,35,52,53,69].
findings in the care units are the low numbers of nursing The main barriers regarding the provision of dental
staff and the limited time assigned to oral hygiene treatment are the limited collaboration of nursing
provision [19,20,25,34,35,52,53,62,65]. Caregivers homes with dental practitioners, the lack of suitable
face high workloads and are frequently interrupted facilities for treatment on site, the difficulties in the
while providing care to the residents [46,63,65]. transportation of the residents to the dental offices,
Therefore, the number of residents in long-term their refusal to receive dental care, the limited
care institutions seemed to have a negative impact preparedness of dentists to manage frail and care-
on oral hygiene practices [26]. Despite the nursing dependent older people, the poor oral health
staff's willingness to improve the oral health of the policies including the lack of oral health integration
residents, their increased workload posed significant into public health care coverage, and the limited
difficulties in integrating oral care into the daily care provision of domiciliary care [39, 69].
routine [17,37]. The above factors may lead to the low The study of Hilton, et al. (2016) describes findings
caregivers' satisfaction with their work, burn-out and, from a focus group of nurses and residential care
consequently, to a low quality of care [8,46,63,65]. workers identifying large discrepancies between the
Moreover, the caregivers' rush to provide timely daily existing recommendations for oral care in nursing
care may trigger the residents' aggressive behavior, homes and their actual implementation [17]. The
especially those with dementia [47,51]. Additional results revealed the caregivers’ substantial gaps in
barriers are the lack of financial resources to buy the oral care training, the limited access to appropriate
necessary oral hygiene supplies [17,18,34,35], the lack equipment and professional support, the residents’
of dentures’ labelling [34] and the absence of a dental resisting behaviors to oral hygiene, the inadequate
chair at the nursing homes’ premises [66]. It should staffing and the staff’s negative attitudes towards
also be noticed that a significant barrier to good oral the provision of oral care [17]. Difficulties in oral care
health in nursing homes is the lack of integration provision regarding dysphagia, dementia and poor
of oral health assessment into the general health fit of the dentures are common and it is of utmost
examination provided by the unit’s physician and the importance to be addressed [17]. Interestingly, the
limited collaboration with a dental professional who members of the focus group suggested that lack of
will regularly assess the oral health of the residents time should not be a barrier in converting the daily
and manage any urgent and routine oral problems [39]. implementation of oral health practices in residential
care settings to a priority [17]. This study highlights
3.4. Public policy issues the need for the implementation of appropriate oral
The lack of appropriate oral health policies is well health education programmes for nursing homes’
documented. Public dental care coverage is limited staff and of the necessary organizational interventions
in most countries, socio-economic inequalities based on the existing recommendations by the
reduce access to dental care and oral health literacy European College of Gerodontology (ECG) and the
of the public is poor [39,67]. Finally, there is poor European Geriatric Medicine Society (EUGMS) [39].
availability of domiciliary dental services and lack of These recommendations include a compulsory oral
appropriate legislation to support oral care for the health assessment together with the medical entry
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Konstantopoulou K, et al.
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assessment, daily oral hygiene provision, oral health oral health prevention and promotion in institutional
Review Articles
education for the caregivers, availability of oral care settings according to the recommendations of the
products, accessibility to emergency and routine oral European College of Gerodontology (ECG) and the
care, regular oral screenings and a healthy diet [39]. European Geriatric Medicine Society (EUGMS) should
However, there is lack of robust evidence on the be implemented [39].
prevalence, predictors and consequences of the
various barriers and facilitators to oral health in 5. CONCLUSIONS
nursing homes [8,69]. Because of the specific
characteristics of the nursing home population Several barriers in oral health prevention and
with high levels of cognitive impairment, the promotion for nursing home residents have been
implementation and testing of effective oral hygiene reported at an individual, interpersonal, organizational
protocols raise significant difficulties and demand and public policy level. A more rigorous research and
adapted procedures [70]. Based on systematic a thorough understanding of these barriers will lead
reviews’ findings, most of the related studies to the design and implementation of effective oral
generally have a low methodological quality and health promotion strategies for the vulnerable older
a high risk of bias especially in terms of sample population.
size, research tools and assessment of confounding
factors, while most studies were mainly conducted in CONFLICT OF INTEREST
high-income countries and, therefore, generalization We declare no conflict of interest of any kind.
of the findings is limited [8,68]. Future research
should include studies on the existing and novel AUTHORS CONTRIBUTIONS
oral health practices in nursing homes to thoroughly KK: protocol, data gathering, data analysis, authoring the draft. AK:
determine the barriers to the residents’ oral care concept, protocol, critically revising the manuscript. HK, GP: criti-
[17]. The development of appropriate strategies to cally revising the manuscript.
prevent and manage the residents’ negative attitudes
and behaviors and enhance the caregivers’ oral care
knowledge and attitudes is also crucial [8,39,71].
Moreover, appropriate legislation and policies for
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October 10].
Available from: https://www.sahealth.sa.gov.au/wps/wcm/con
nect/32902a8043506b6a91bef32835153af6/SADS-BOHP-Fin-
Report-Nov-09.pdf
[Full text links]
Kalliopi KONSTANTOPOULOU
DDS, MSc
Department of Prosthodontics
School of Dentistry
National and Kapodistrian University of Athens
Athens, Greece
CV
Kalliopi Konstantopoulou graduated from the School of Dentistry of the National and Kapodistrian University of Athens,
Greece in 2016. In 2019, she obtained her master’s degree in Health Promotion and Education from the Medical School of the
National and Kapodistrian University of Athens and became a postgraduate student at the Department of Prosthodontics
(School of Dentistry, National and Kapodistrian University of Athens, Athens, Greece).
136 Stoma Edu J. 2020;7(2): 131-137 pISSN 2360-2406; eISSN 2502-0285
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Questions
Review Articles
1. According to the socioecological model in health promotion, which of the following
factors may deteriorate oral health of older nursing home residents?
qa. Factors associated with the residents themselves;
qb. Interpersonal factors;
qc. Organizational and public policy issues;
qd. All of the aforementioned.
2. A common side effect of polypharmacy is?
qa. Gingivitis;
qb. Periodontitis;
qc. Xerostomia;
qd. Teeth discoloration.
3. According to caregivers’ perceptions, which is the major barrier to oral care provision?
qa. Lack of oral care supplies;
qb. Residents’ responsive behaviors and resistance;
qc. Lack of support by residents’ family members;
qd. Poor cooperation among caregivers.
4.The lack of appropriate oral health policies is related to?
qa. Poor availability of domiciliary dental services;
qb. Lack of oral health integration into public health care coverage;
qc. Poor oral health literacy of the public;
qd. All of the aforementioned.
Stoma Edu J. 2020;7(2): 131-137 pISSN 2360-2406; eISSN 2502-0285 137