/home/opencode/cpanel/stomaeduj_hacked/uploads/stomaeduj-2-2020-article-7.pdf 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. www.stomaeduj.com 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 Nursing home residents www.stomaeduj.com 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 Stoma Edu J. 2020;7(2): 131-137 pISSN 2360-2406; eISSN 2502-0285 133 Konstantopoulou K, et al. www.stomaeduj.com 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]. 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[cited 2019 [Full Text Links] Google Scholar 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 www.stomaeduj.com 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