Oral care in nursing homes

imagesOne challenge to our future healthcare system will come from the care requirement of frail patients living in residential care. Data suggests that the size of the UK population aged over 65 will rise by 60% to 16 million over the next 25 years, 5% being over 85 years old (Batchelor 2015). 80% will end up live in some form of residential home, being looked after by professional staff rather than family members (Broad et al. 2013). Two major barriers exist:

  • Residents responsive behaviour – defined as physical or verbal actions, such as grabbing, screaming, and resisting care, in response to a negatively perceived stimulus.
  • Residents lack of motivation or ability to perform their own oral hygiene.

The objective of this review is to evaluate the effectiveness of strategies that nursing home care providers can apply to either prevent/overcome residents’ responsive behaviours to oral care, or enable/motivate residents to perform their own oral care.


The review followed the PRISMA statement (the protocol was also registered on the International Prospective Register of Systematic Reviews (PROSPERO) database.
Searches were carried by two independent researchers using Medline, Embase, Evidence Based Reviews-Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science. Databases were searched up to April 2016 with no language restrictions, and manual searches were also carried out in the relevant major journals.

Inclusion criteria were as follows: Qualitative observational studies and mixed-methods studies including reviews relating to strategies that formal care providers can use to motivate oral health care and overcome responsive behaviour for frail older adults in residential care. Exclusion criteria were non-empirical and qualitative research, healthy or independent residents or care provided by family, students or managers.

Study outcomes were resident’s oral health scores, self-performed oral care, responsive behaviour and level of staff assistance. 
Quality appraisal was carried out by two independent reviewers using the Quality Assessment Tool for Quantitative studies and Estabrooks Quality Assessment and Validity Tools for Cross Sectional Studies.


  • From 7362 records only 7 studies fulfilled the inclusion criteria, four of which report different aspects of one research project. Therefore. 3 prospective cohort studies and 1 cross-sectional study were included.
  • Methodological quality was low/moderate for one study and weak for three studies.
  • Plaque index scores reduced by approximately 40%
  • Bleeding index scores reduced by approximately 35%
  • Denture plaque scores reduced by 23%
  • Resistance to care reduced by approximately 45%


The authors concluded: –

Potentially promising strategies are available that nursing home care providers can apply to prevent/overcome residents’ responsive behaviours to oral care or to enable/motivate residents to perform their own oral care. However, studies assessing these strategies have a high risk for bias. To overcome oral health problems in nursing homes, care providers will need practical strategies whose effectiveness was assessed in robust studies.


This review highlights the lack of studies relating to the important issue of oral health maintenance of frail older patients. As our population ages this problem is only going to increase in complexity. Though the results were good but the sample sizes are very small (5,7,13 and 97 patients respectively) and the duration of the study was very short (2-8 weeks).

Other longer-term observational studies not identified in this review of routine care have shown a degrading of oral hygiene irrespective of maintenance regime, and regression to 40% had unacceptable hygiene, high levels of resistance and cleaning being left largely undone with assisted tooth brushing times as low as 16 seconds (Willumsen et al. 2012; De Visschere et al. 2015; Carter et al. 2009). The reasons being increased frailty and cognitive capacity over time with the average patient staying in high dependency residential care for 16 months, compounded with high turn-over of trained care staff.   In addition the recent Cochrane review by Albrecht et al (Dental Elf – Oct 10th – 2016):-

found insufficient evidence to draw robust conclusions about the effects of oral health educational interventions for nursing home staff and residents.


Original Post: Dental Elf – June 30th – 2017

Primary paper

Hoben M, Kent A, Kobagi N, Huynh KT, Clarke A, Yoon MN. Effective strategies to motivate nursing home residents in oral care and to prevent or reduce responsive behaviors to oral care: A systematic review. PLoS One. 2017 Jun 13;12(6):e0178913. doi:10.1371/journal.pone.0178913. eCollection 2017. PubMed PMID: 28609476.

Review Protocol on PROSPERO

Other references

Batchelor, P. The changing epidemiology of oral diseases in the elderly, their growing importance for care and how they can be managed. Age and Ageing, 2015 44(6), pp.1064–1070.

Broad JB, Gott M, Kim H, Boyd M, Chen H, Connolly MJ. Where do people die? An international comparison of the percentage of deaths occurring in hospital and residential aged care settings in 45 populations, using published and available statistics. Int J Public Health. 2013 Apr;58(2):257-67. doi: 10.1007/s00038-012-0394-5. Epub 2012 Aug 15. Erratum in: Int J Public Health. Int J Public Health. 2013 Apr;58(2):327. PubMed PMID: 22892713.

Carter, K.D. et al., 2009. Caring for Oral Health in Australia Residential Care. Australian Institute of  Health and Welfare, (48), pp.1–53.

De Visschere L, de Baat C, De Meyer L, van der Putten GJ, Peeters B, Söderfelt B, Vanobbergen J. The integration of oral health care into day-to-day care in nursing homes: a qualitative study. Gerodontology. 2015 Jun;32(2):115-22. doi: 10.1111/ger.12062. Epub 2013 Jun 20. PubMed PMID: 23786637.

Willumsen T, Karlsen L, Naess R, Bjørntvedt S. Are the barriers to good oral hygiene in nursing homes within the nurses or the patients? Gerodontology. 2012 Jun;29(2):e748-55. doi: 10.1111/j.1741-2358.2011.00554.x. Epub 2011 Oct 24. PubMed PMID: 22023222.



Methodological Quality of Consensus Guidelines in Implant Dentistry (Faggion et al. 2017)

Clinicians rely heavily on consensus guidelines when they develop treatment protocols for their patients. The idea is that the most experienced clinicians and academics meet and systematically develop what they feel is best practice in their particular field. Health care providers and regulators then rely on this distillation of knowledge, experience and evidence in their decision making. A systematic review of guideline quality in peer-reviewed medical literature was conducted in 1999  and found only a 43% adherence to reporting standards (Shaneyfelt et al. 1999). In 2003, a generic tool was created by the AGREE (Appraisal of Guidelines, REsearch and Evaluation) collaboration to create “common standards to improve the quality process and reporting of guideline development” (Cluzeau et al. 2003). With use the protocol evolved into AGREE II (Brouwers et al. 2010) which is made up of 23 items in 6 domains:

  1. Scope and Purpose
  2. Stakeholder Involvement
  3. Rigour of Development
  4. Clarity of Presentation
  5. Applicability
  6. Editorial Independence

The research question reference consensus guidelines in implant dentistry was: “Do consensus guidelines published in high ranked implant journals meet the requirements proposed in the AGREE II instrument? A secondary objective was to evaluate whether the inclusion of systematic reviews conducted to support the consensus guidelines improved their methodological quality.


Two authors (KA,MA) independently searched and evaluated consensus guidelines from the 6 highest impact implant dentistry journals (assigned by Journal Citation Reports) and Medline database via PubMed. The search was limited to May 2009 – February 2016 in line with the publication of AGREE II. Reasons for papers to be excluded was recorded.

Four authors (KA,TA,LM,MA), following assessor training then independently applied the AGREE II tools to the consensus guidelines as described in the user’s manual. Domain scores were presented as median percentages of the maximum possible with their respective interquartile ranges. Domain scores were divided into consensus guidelines, and consensus guidelines with systematic reviews.


  • From an initial 258 publications 27 consensus guidelines fulfilled the inclusion criteria of which 19 was included for comparison
  • The journals were: Clinical Oral Implants Research (COIR), Clinical Implant Dentistry and Related Research (CIDRR), European Journal of Oral Implants (EJOI), The International Journal of Oral and Maxillofacial Implants (JOMI), Journal of Oral Implantology, and Implant Dentistry.
  • 26 guidelines were developed after meetings in Europe.
  • The European Association of Osseointigration (EAO) developed the most guidelines (n=9)
  • The number of authors ranged from 2-27 (median, 9)

Primary Outcomes

AGREE II Domains Consensus guidelines only.

Median is % of maximum score

Consensus guidelines plus systematic reviews.


Domain 4 (Clarity of presentation) Median, 75; (IQR 15.30) Median, 84.70;(IQR, 9.80).
Domain 1 (Scope and Purpose) Median, 69.40; (IQR, 36.20). Median, 79.20; (IQR, 73)
Domain 2 (Stakeholder Involvement) Median, 41.70; (IQR, 17.70) Median, 76.40; (IQR,18.10)
Domain 6 (Editorial Independence) Median, 41.7 ;(IQR, 83.30) Median, 56.30 (IQR, 34.40)
Domain 3 (Rigour of Development) Median, 30.70; (IQR, 26.50) Median, 50 (IQR,44.40)
Domain 5 (Applicability) Median, 26;(IQR, 12.50) Median, 26; (IQR, 20.80)

Conclusion (the author concluded)

“Methodological improvement of consensus guidelines published in major implant dentistry journals is needed. The findings of the present study may help researchers to better develop consensus guidelines in implant dentistry, which will improve the quality and trust of information needed to make proper clinical decisions”.


For the clinician in practice placing or restoring on dental implants this is a very important paper and goes a long way in explaining the disjoint between what is presented on the international conference circuit and what we see in day-day practice.

To help with interpreting the authors data I have modified it slightly to present the data as median with 95% confidence intervals and place the meta-analysis it in a forest plot.

The first chart show the AGREE II scores relating to the consensus guidelines that did not include the use of systematic reviews. The highest scoring domains were Domain 4. (Clarity of Presentation) and Domain 1. (Scope and Purpose) which score in the 70’s. There is a gap and the next four Domains in rank order are; 6. (Editorial Independence), 2. (Stakeholder Involvement), 3. (Rigour of Development) and lastly 6. (Applicability). These narrative guidelines therefore only fulfil 50% of the AGREE II criteria.

Agree II narr

The second chart show a meta-analysis comparing the narrative guideline scores compared with the consensus guidelines + systematic reviews, and there is roughly a 9% improvement bringing the score up to 60% compliance with AGREE II.

Forest plot

What becomes obvious however is that 18% improvement came out of Domain 3. (Rigour of Development) but 34% from Domain 6. (Editorial Independence). Going back then to the meta-analysis of consensus guidelines + systematic reviews the improvement has been weak and polarises the results.

Agree II SR

From a clinicians point of view what options do we have available to us to improve consensus guidelines?


  • Domains 1 (Scope and Purpose) and 4 (Clarity of Presentation) are good, we know what questions to ask and how to present them.
  • Domain 6 (Editorial Independence) is improving but there still needs to be more clarity over the editorial independence from funding bodies and conflicts of interest from the funding bodies and authors.
  • Domain 3. (Rigour of Development) More effort needs to be spent in this area as is is the foundation on which the guidelines are built, based on validated systematic methods for assessing and analysing the relevant primary research. Analysis also needs to include health benefits, side effects and complications. The guidelines should also be externally validated prior to publication.
  • Domain 2 (Stakeholder Involvement) at present is dominated by University professors and private practitioners with strong academic connections. This area would benefit from the views of clinicians working outside of specialist practice, health care providers, funders and patient groups.
  • Domain 6. (Applicability) is the weakest domain, this may be in part due to the lack of input at the stakeholder level . For clinicians in practice, and their patients cost implications are a major barrier to applying guideline recommendations.


 Primary paper

Faggion, C.M.J. et al., 2017. Methodological Quality of Consensus Guidelines in Implant Dentistry. PloS one, 12(1), p.e0170262. Available at: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=prem&NEWS=N&AN=28107405.

 Other references

Brouwers, M.C. et al., 2010. AGREE II: Advancing guideline development, reporting and evaluation in health care. Journal of Clinical Epidemiology, 63(12), pp.1308–1311.

Cluzeau, F. et al., 2003. Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project. Quality & safety in health care, 12(1), pp.18–23. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1743672&tool=pmcentrez&rendertype=abstract.

Shaneyfelt, T.M., Mayo-Smith, M.F. & Rothwangl, J., 1999. Are guidelines following guidelines? JAMA: The Journal of the American Medical Association, 281(20), pp.1900–1905.