Nursing home residents’ perspectives on oral health: An in-depth interview study

Abstract

Background

Oral health is associated with general health and care dependency, but is often neglected in nursing homes. Integration of oral care into general care is necessary, but is hampered by multiple barriers at different levels. This study is part of research into the implementation of the new Oral Health Section for use within the interRAI Long-Term Care Facilities instrument, which is used to assess care needs of nursing home residents. This new Oral Health Section evaluates nine aspects of oral health and results in two Collaborative Action Points.

Objective

To identify residents' perspectives on oral health, oral care, and on the assessment of their oral health using the new Oral Health Section

Design

Qualitative design using in-depth interviews.

Setting(s)

Three nursing homes

Participants

Residents were selected using purposeful sampling in nursing homes participating in research evaluating the use of the new Oral Health Section. The selection was based on their oral status for maximum variation and on their cognitive performance score. Twenty-two residents from three Flemish nursing homes agreed to participate.

Methods

Residents’ oral health was assessed using the new Oral Health Section and dental indices. In-depth interviews were conducted, including the validated short-form Oral Health Impact Profile to evaluate the impact of oral conditions on residents’ well-being. The interviews were coded and analysed by three researchers and mapped into a model to understand participants’ oral health behaviours.

Results

Low Oral Health Impact Profile scores indicated a low impact of oral health issues on participants’ lives. However, despite 77.3 % of the participants reporting satisfaction with their oral health, 86.4 % had poor oral hygiene and 68.2 % required referral to a dentist, suggesting a tendency to overestimate their oral health. Their oral health behaviour was determined by a lack of oral health knowledge (Capability), positive attitudes towards oral health and autonomy (Motivation), upbringing and social support (Opportunity). Participants considered assessments with the new Oral Health Section acceptable.

Conclusions

This study shows how older people perceive their oral health and oral healthcare. Understanding their wishes and needs will not only facilitate their involvement in their oral care, but is also likely to enable the improvement of their oral hygiene and the development of effective oral care strategies for the future. Policy makers and managers of care organisations may use these results to foster integration of oral care guidelines into care protocols within nursing homes, including collaboration with dentists and dental hygienists.

Tweetable abstract

Oral health assessments with the new Oral Health Section for use within interRAI were positively perceived by nursing home residents.

• •Oral care is an often neglected aspect in nursing home care, leading to poor oral health in residents.
• •Integration of oral care into general care planning for care-dependent older persons is necessary, but hampered by multiple barriers at different levels.
• •The interRAI Long-term Care Facilities instrument is a comprehensive geriatric assessment instrument for the evaluation of care needs and preferences of nursing home residents, including oral care.
• •This is the first study to report the experiences and perceptions of nursing home residents on regular oral health assessments. The assessment, using the new Oral Health Section for use within interRAI, was considered acceptable according to nursing home residents.
• •Categorising the perspectives of older persons on oral health, and on daily and professional oral care into a model of behaviour change (COM-B) showed their oral health behaviours are shaped by a lack of oral health knowledge (Capability), positive attitudes towards oral health and a strong desire for autonomy (Motivation), upbringing and social support (Opportunity).
• •This study shows that autonomy is highly valued by nursing home residents, including when oral care is concerned. An individualised, person-centred approach to oral care is therefore needed, empowering persons as to their own oral care.

1. Background

Oral health of care-dependent older people in nursing homes in general is poor (Ruiz-Roca et al., 2021; Wong et al., 2019). This is the result of various factors people are confronted with in the course of their life (Burton-Jeangros et al., 2015; Borreani et al., 2010), including individual elements such as biological aspects and lifestyle, and societal elements such as the organisation of health care, and the physical and social environment they live in (Baiju et al., 2017). Despite its importance for overall health, well-being and quality of life (Wong et al., 2019), oral health is often overlooked in older people's daily care (Ek et al., 2018; De Visschere et al., 2015; Müller et al., 2017). Research has shown that declining general health and increasing care dependency among nursing home residents are associated with further deterioration in oral health, and vice-versa (Klotz et al., 2020).

Even though there are multiple barriers (De Visschere et al., 2015; Chan et al., 2023; Harnagea et al., 2017; Niesten et al., 2021a; Niesten et al., 2021b), it is important to integrate oral care into general care planning. In order to improve oral care for care-dependent older people, the Oral Health Section for use within the interRAI Suite of instruments (OHS-interRAI) was developed and optimised for use by caregivers (Krausch-Hofmann et al., 2021; Schoebrechts et al., 2023). The interRAI Suite comprises instruments for various care settings that measure key areas of physical and cognitive functioning, mental and physical health, social support and service use. The interRAI LTCF (Long-Term Care Facilities) assessment tool has been designed specifically for nursing home residents. It not only evaluates residents' care needs, but also their strengths and preferences, which fosters person-centred care while respecting their autonomy. Including the OHS within interRAI ensures that oral care is integrated into the overall care of older people. The data collected generates “Collaborative Action Points” (CAPs) by means of trigger algorithms. These CAPs and the guidelines that go with them, alert caregivers and residents to deficiencies and show ways for improvement in oral hygiene and oral health. As older people themselves should be involved in the decision process around care priorities and care goals, it is essential to understand their perceptions of oral health and oral care. Therefore, this study aims to explore the perspectives of older individuals regarding their oral health and oral care, as well as their views on the assessment of their oral health using the OHS-interRAI.

2. Methods

2.1. Study design

This qualitative phenomenological study is part of a three-arm cluster randomised controlled trial design (cluster-RCT) study evaluating the use and the effect of the OHS-interRAI. For this exploratory study, 24 residents were invited to participate in individual interviews. Two persons declined participation because of their health condition, resulting in 22 participants. The interviews were conducted by two female master students in dentistry (authors VC and MB) who were trained by author JM (PhD) and piloted the interview guide. Prior to the interviews, the participants had an oral health screening performed by a dentist using the OHS-interRAI and three additional dental indices: the Oral Hygiene Index-OHI (Greene and Vermillion, 1960), Modified Gingival Index-MGI (Lobene et al., 1986) and PUFA-index (Monse et al., 2010). The number of teeth and/or root remnants was also recorded. These assessments were conducted in the resident's room, using a headlamp for additional illumination and a disposable dental mirror to assess the dental indices. The assessments were made at baseline, before any intervention in the cluster-RCT.

All participants agreed to participate after being informed verbally and in writing about the purpose of the research and the interviewers.

Ethical approval for the study was obtained from the Ethics Committee Research UZ/KU Leuven (B3222021000650).

2.2. Sampling and recruitment

Residents were face-to-face invited using purposive sampling in consultation with caregivers. Firstly, residents with differing oral health statuses were selected to maximise representativeness, regardless of their oral health attitudes. Next, a caregiver in each nursing home was consulted to assess whether the person's cognitive status permitted an in-depth interview. The decision was based on the individual's actual scores on either the interRAI Cognitive Performance Scale (CPS) or the Mini-Mental State Examination (MMSE) (Wellens et al., 2013). The inclusion criteria specified CPS scores between 0 (indicating no cognitive impairment) and 2 (indicating mild impairment) or between 30 (indicating no cognitive impairment) and 16 (indicating mild impairment) on the MMSE (Wellens et al., 2013). All MMSE scores were converted to the equivalent validated CPS scores (Wellens et al., 2013; Bartfay et al., 2013).

2.3. Data collection

During the individual semi-structured interview, oral health, daily oral care, dental care and the use of the OHS-interRAI assessment were discussed. The interviews were conducted 14 to 80 days after the oral health screening and were conducted privately in the resident's room. The interviews lasted 40 to 50 min, were audio-recorded and supplemented with field notes.

As some participants had mild cognitive impairment, a visual analogue scale (VAS), ranging from 0 to 10, was used to assess satisfaction with their own oral health and the importance of maintaining their teeth.

The short-form Oral Health Impact Profile (OHIP-14), ranging from 0 to 56, was used to measure residents’ perceptions of the impact of oral conditions on their well-being (Slade, 1997). The 14 items included are grouped into seven conceptual dimensions based on Locker's theoretical model of oral health (Locker, 1988): functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability and handicap.

The OHIP-14 is included in Appendix 1.

2.4. Data analysis

The interviews were transcribed verbatim and analysed thematically using an abductive approach. Initial codes were independently created by three authors, VC (BScD), MB (BScD) and PV (MBiol, DH), based on the interview transcripts. These codes were discussed with a fourth researcher, JM (PhD), to reach consensus on coding and saturation and structured into initial categories, mainly representing the overarching topics discussed.

Further analysis was performed in different steps. After multiple thorough readings, the interviews were summarised and reduced to key points (Harding, 2019). The Constant Comparative Method (Glaser, 1965) was used to identify similarities and differences within the dataset and finally to explore possible relationships within the data (Harding, 2019). According to Harding (Harding, 2019), a similarity was assumed when ¾ of the respondents provide the same answer.

Subcategories were identified within the initial categories and coding was reviewed. As a next step, the codes for daily oral care and professional oral care were categorised using the COM-B model, a framework for understanding behaviour that serves as a basis for designing behaviour change interventions (Michie et al., 2011). Debriefing sessions were held within the research team for each step in order to identify and eliminate potential bias and to reach consensus.

The NVivo 12 software package was used during the analysis.

2.5. Conceptual framework

To gain insight into the oral health situation of care-dependent older people, it is important to understand their oral health behaviour, including daily oral care and dental care. This understanding is crucial for the implementation of the OHS-interRAI in nursing homes. After all, the residents themselves are key to their daily and professional oral care. Improving this care requires their cooperation and may require behavioural changes. To develop effective interventions for older people, it is crucial to comprehend their perspectives on oral health and oral health behaviours. The COM-B model was selected as the basis for behaviour change in this study. This model considers behaviour as the result of a person's Capability, Motivation and Opportunity. It provides the central base for guiding behaviour change according to the Behaviour Change Wheel (BCW) (Michie et al., 2011), which supports decisions about intervention functions and policy categories.

Capability and Motivation are the internal factors that determine behaviour. Capability refers to a person's physical and psychological ability to perform a behaviour, including knowledge and skills. Motivation is defined as all the brain processes that drive and reinforce behaviour, including habits, emotional responses (automatic motivation) and analytical decisions (reflective motivation). Opportunity refers to the external factors that determine a person's behaviour, both through physical and social environment.

3. Results

3.1. Quantitative results

The general characteristics of the participants are shown in Table 1. Eight men and 14 women, aged between 67 and 97 years old (mean 84.5, SD ±8.2) were interviewed. Three participants exhibited mild cognitive impairment (CPS=2). Individual characteristics are shown in Appendix 2.

Table 1.

Descriptive characteristics of the participants.

	Total (N = 22)
Age, mean ±SD	84.5 ± 8.2
Female, n (%)	14 (63.6)
CPS1, n (%)
0	13 (59.1)
1	6 (27.3)
2	3 (13.6)

Abbreviation: CPS, Cognitive Performance Scale.

¹CPS-scores: 0= intact; 1= borderline; 2= mild impairment.

As presented in Table 2, half of the participants was edentulous with full dentures, and 3 of them had implants. The other half still had natural teeth or tooth remnants, ranging in number from 6 to 23 (mean 15,0, SD ±6.4). Five participants had residual roots, ranging from 1 to 6 per person. For the dentate participants, the OHI-score (total range: 0–12) ranged from 0.8 to 5.6, indicating oral hygiene was acceptable to moderate. Four individuals scored below 2, which is ‘acceptable’ according to Mühlemann (Mühlemann, 1976). The MGI-score (total range: 0–4) for the same participants ranged from 0 to 3 meaning that participants had mild to moderate inflammation of their gingival tissues. The PUFA-index indicated that 6 participants had at least one decayed tooth with pulpal involvement or total destruction of the coronal tooth structure, with scores ranging from 1 to 6. Additionally, 5 individuals had dentures alongside natural teeth.

Table 2.

Participants’ oral health status and dental indices scores.

	Total (N = 22)
Dentates, n (%)	11 (50.0)
Number of teeth, mean ± SD	15.0 ± 6.4
Dentates with root remnants, n (%)	5 (45.5)
Number of root remnants, mean ± SD	3.0 ± 2.1
Removable dentures, n (%)
Full dentures	2 (18.2)
Partial dentures	3 (27.3)
Dental indices, mean ± SD
OHI	2.8 ± 1.7
MGI	0.8 ± 0.8
PUFA>0	2.7 ± 2.1
Edentulous persons, n (%)	11 (50.0)
Removable dentures, n (%)
Full dentures	11 (100.0)
Implant-supported dentures1	2 (18.2)
Fixed bridge on 4 implants1	1 (9.1)

Abbreviations: OHI, Oral Hygiene Index; MGI, Modified Gingival Index; PUFA: Pulp Ulceration Fistel Abscess index.

¹Persons with implants in lower jaw combined with full upper dentures.

Results of the OHS-interRAI assessments are shown in Table 3. In 19 of the 22 subjects, the CAP Oral Hygiene was activated, highlighting the need to improve daily oral hygiene and/or denture hygiene. Out of the 11 people with natural teeth evaluated, 9 demonstrated unacceptable oral hygiene when assessed by OHS-interRAI. Denture hygiene could be assessed for 15 persons and was unacceptable for 12 of them. For 15 participants, the OHS-interRAI suggested referring them to a dentist. This was mainly due to teeth and gum problems.

Table 3.

Participants’ oral health problems or deficiencies, registered with the OHS-interRAI.

	Total (N = 22)
Self-reported oral problems OHS-interRAI, n (%)
Chewing difficulty	2 (9.1)
Pain in the mouth	4 (18.2)
Dry mouth	8 (36.4)
Observed oral problems OHS-interRAI, n (%)
Denture hygiene1	12 (80.0)
Oral hygiene2	11 (84.6)
Teeth3	6 (54.5)
Gums	11 (50.0)
Tongue	0 (0.0)
Palate, lips and cheeks	7 (31.8)
CAP Oral Hygiene, n (%)	19 (86.4)
CAP Referral to a dentist, n (%)	15 (68.2)

Abbreviations: OHS-interRAI, Oral Health Section for use within the interRAI suite of instruments; CAP, Collaborative Action Point.

¹Denture hygiene could be assessed for 15 persons.

²Oral Hygiene could be assessed for 11 persons with teeth and 2 persons with implants.

³Condition of teeth assessed for 11 dentates.

3.2. Oral health impact

The OHIP-14 was used to measure the perceived impact of oral health issues on the participants' lives. The results are outlined in Appendix 1. Four participants experienced an impact on 4 to 8 items, indicating the highest (worst) OHIP-14 scores that ranged from 10 to 17 (see Appendix 1, table 1). During the interview, one of them was particularly impaired as his lower denture was in the dental clinic for repair.

When evaluating the different domains of the OHIP-14 among the participants, physical pain (13/22), functional limitation (6/22) and physical disability (6/22) were the most frequently reported effects of oral health problems (see Appendix 1, table 2). In terms of physical pain, seven people sometimes or quite often found it uncomfortable to eat because of problems with their teeth, mouth or dentures, and six people sometimes or quite often had painful mouth sores. Four participants had difficulty articulating words and three reported a decline in their sense of taste. These functional limitations, caused by problems with their teeth, mouth, or dentures, were reported to occur sometimes or quite often. None of the participants reported an impact due to issues with their teeth, mouth or dentures on the dimension of psychological disability.

The highest individual scores per domain (5/8) were observed for physical pain (2/22), functional limitation (1/22), and psychological discomfort (1/22).

3.3. Qualitative results

Fig. 1 shows the results of the application of the COM-B model to the qualitative findings of the study. At the centre of the model, participants’ oral health experiences are presented.

Fig. 1.

Perspectives on oral health and oral health behaviours in the COM-B model indicating facilitators (+) and barriers (-).

3.3.1. Oral health experience

Seventeen participants reported satisfaction with their oral health, scoring it 7 or more on a VAS scale with a maximum of 10. However, one-third admitted the necessity to adjust their dietary or eating habits. Despite the satisfactory results, one individual was dissatisfied with an aesthetic aspect of her oral health condition, while another stated that he accepted the situation as it was.

‘It's fine for me. I am used to it. I can't do anything about it either. It's no problem for me.' (P12)

Five participants expressed dissatisfaction with their oral health. The main complaints were problems with dentures and discomfort because of the appearance of their mouth.

The vast majority of respondents was able to chew well when questioned directly. However, over a third of participants adjusted their dietary patterns by avoiding hard foods, taking longer to finish meals, or reducing portion sizes. Only one participant immediately reported chewing difficulties, due to the lower denture undergoing repair at the dentist.

‘Do you experience any problems with chewing?’

‘No. But of course I have to take my time. It's not like before. … Of course I avoid hard foods, because I can't chew them.’ (P18)

Oral health experiences are determined by oral health behaviours, including daily and professional oral care, as shown in Fig. 1. These are shaped by their decisive oral health behaviours concerning daily and professional oral care, encompassing the components capability, motivation, and opportunity. These 2 behaviours and the 3 components, as presented in Fig. 1, are discussed below under COM-B.

3.3.2. COM-B

• 1. Behaviour: Daily oral care

The majority of participants was mainly responsible themselves for their daily oral hygiene. Few reported being completely dependent on caregivers for their denture hygiene.

Nearly all participants reported brushing their teeth or dentures at least once a day. Two individuals with natural teeth used electric toothbrushes. Two other persons rarely or never practised oral hygiene.

Almost all of those who self-managed oral or denture hygiene perceived it as going smoothly. Three participants experienced difficulties, including fear of damaging their teeth, lack of courage or physical limitations (such as difficulty reaching the back of the mouth, or tremors).

• 2.Behaviour: Professional oral care

Seventeen participants had not visited a dentist for several years. The shortest reported period was more than three years and the longest was more than twenty years. A number of them explicitly stated that they had not been to the dentist since their admission to the nursing home, despite visiting the dentist before.

Only five participants had visited a dentist, since their admission to residential care. Three of them had issues with their dentures, while the other two had regular dental check-ups. The CAP referral to a dentist was not triggered during the assessment for those two individuals.

Sixteen of the 18 participants who were asked to consider seeing a dentist in the nursing home refused. The main reason for this was the perception of having no oral health problems. However, some participants expressed fears about dental treatment or the costs involved. One person preferred not having any treatment any more, including dental treatment.

‘It's not necessary. Because I think she will end up with "all the teeth removed and false dentures fitted". But no, it's not necessary. I feel good like this. And it doesn't bother me.’ (P11)

Fig. 1 shows the bidirectional relationship of daily and professional oral care, linked to the capability, motivation and opportunity of individuals to perform these behaviours, according to COM-B.

• 3.Capability

For these participants, there was a clear lack of psychological capability, including knowledge (Michie et al., 2011). This affected both daily and professional oral care. When asked about the importance of oral to general health, the vast majority agreed. When questioned further, they mainly highlighted functional reasons, such as the ability to eat and speak correctly, while a few mentioned appearance. Although three individuals had some knowledge, it appeared that no one was aware of the links between oral and general health, such as diabetes or cardiovascular diseases.

‘When you have bacteria in your body, you spread them throughout your body.’

‘Indeed, that's right. Has anyone ever told you that?’

‘Oh, but that's normal anyway. That's not how they told me. That's how I say it.’ (P15)

‘Healthy teeth make for a healthy body.’ (P18)

‘Bad teeth are unhealthy for the mouth and the rest of the body. I understand all this now, but not so much in the past. ’ (P6)

• • 3.1
    Daily oral care

In terms of daily oral care, a few wheelchair-bound participants reported that caregivers took over their denture hygiene due to physical limitations. Three others received help when asked for. Again, this was mainly for denture hygiene.

Another person mentioned that daily oral hygiene had become more challenging due to reduced manual dexterity, but she refused to ask for help.

Moreover, when describing their oral hygiene routine, it was clear that participants lacked knowledge, particularly about denture hygiene. Almost all denture wearers used an incorrect or outdated procedure or lacked appropriate materials. A regular toothbrush and toothpaste were used to clean dentures, even among those receiving help from caregivers. Only one person reported using a denture brush.

‘I put them in water in the evening and in the morning I scrub them with a toothbrush and toothpaste.’ (P7)

‘I take the upper dentures out in the evening and put them in water and in the morning they are rinsed or I rinse them and then put them back in. And then I clean the lower ones with a brush [in the mouth].’ (P13)

For those with natural teeth, the practices described were slightly better. However, two out of three people with dental implants failed to adequately maintain the denture retainers. Further questioning revealed that only one individual brushed below the denture retainer.

• • 3.2
    Professional oral care

When it comes to visiting the dentist, participants experienced physical constraints mainly related to transportation. For wheelchair users, accessibility of the dentist's office was perceived an additional challenge. Furthermore, some residents faced financial barriers.

‘I can't go to the dentist anymore because it's upstairs.’ (P21)

Psychological capability also played an important role. Various misconceptions concerning dental visits were identified, particularly among edentulous people.

‘I have a full set of dentures. I can't have any more pain. … You shouldn't go if they [removable dentures] are still good, hey.' (P1)

‘I don't have any teeth, so I don't need a dentist.' (P22)

According to the COM-B model, an individual's capability can influence their motivation to perform a behaviour, as illustrated in Fig. 1.

• 4.Motivation

The desire to preserve teeth is an important automatic driver of oral health behaviour. All participants who still had natural teeth or implants expressed the desire to preserve them. Again, the functional aspect of being able to chew and eat properly was accentuated.

‘Then you can't eat anymore. When you have dentures on the top and bottom of your mouth, things don't go well. I know this from my mum and dad.’ (P5)

Additionally, the perceived relationship between oral health and well-being can be regarded as an important automatic driver. Some participants spontaneously mentioned the importance of the mouth to their well-being. However, when specifically asked, almost all confirmed that the mouth was important to their well-being, mentioning aesthetics, eating and chewing, talking, feeling clean, and being free of pain.

Remarkably, even the participant who neglected daily oral hygiene and only visited the dentist once in her life emphasised the importance of maintaining teeth and daily oral hygiene. Her perspective was the result of recognising how her declining oral health was affecting her life. She expressed multiple negative emotions driving her current behaviour, including regret, shame and resignation, issues that were shared by other participants.

‘I understand all that now, but I did not understand it before. … But it's too late. … I just have to bear the consequences of my past negligence.’ (P6)

On the other hand, three people explicitly expressed gratitude for their oral health. For them, oral care had been an important part of their upbringing.

A reflexive motivator that can positively influence oral health behaviour is the importance that people attach to oral health and their mouth. All participants considered their mouth and teeth as important. Although their reasons varied, almost all considered it crucial to be able to chew or eat properly. A majority also considered the aesthetic aspect of the mouth. Speaking and feeling clean were mentioned less.

Moreover, another important reflexive motivator for these participants was autonomy, or a desire for it. This emerged as a major theme from the interviews and was particularly evident in relation to daily oral care, where participants expressed a desire to perform daily oral care themselves, as long as they can.

‘I try to rely on care as little as possible. I try to look after myself as well as I can for as long as I can. It is also part of your own pride to take good care of yourself. I also just washed myself.’ (P18)

Participants’ desire for autonomy was also reflected in their reluctance to ask for (extra) help with daily oral care. However, there were more differences between individuals in this regard. Those who clearly indicated a willingness to ask for help when needed, were participants who perceived daily oral care as important. However, even among individuals who found daily oral care important, performed it (partly) themselves every day, and considered it a daily routine, some people said they would not ask for help or expressed doubts about it. Caregiver-related barriers perceived by residents to seeking help were mistrust of knowledge and skills, and lack of time. Patient-related barriers were reluctance or inability to ask for (additional) help. For professional oral care, participants explicitly stated their unwillingness to burden family or others.

‘I think I'm a bit of a difficult patient. Because I try to do everything myself. I don't like to be helped.’ (P17)

Moreover, it was evident from the interviews that a level of autonomy was required to maintain sufficient attention for oral care. Several participants emphasised their personal responsibility to ask for help with daily oral care or to visit the dentist.

The two participants who still had regular preventative dental check-ups were individuals with high autonomy, despite their advanced age (83 and 91 years). They showed full initiative in contacting the dentist's office, organizing an appointment, and arranging transport. These participants noted ‘Things don't happen if you don't ask for them.’

Some people prioritized other areas above oral care.

‘I always had my teeth well taken care of until my husband became seriously ill. … I had lost my husband so I didn't think about it anymore. … I have too many other inconveniences to take that [dental visit] in.’ (P17)

• • 4.1
    Daily oral care

For oral hygiene, a daily routine is a key driver and facilitator. Almost all participants had a daily oral care routine, but not always according to current evidence-based guidelines. Those who did not have an everyday routine, reported several barriers: resignation to the situation (‘It is no longer worth it.’), lack of courage to do it, fear of doing something wrong, and not perceiving the need to do it every day. Two individuals who rarely or never practised daily oral hygiene, had never established a consistent oral hygiene routine.

‘It's like taking a bath or shower. If you haven't done it, you don't feel clean. It's a habit, isn't it? I also use an electric toothbrush.’ (P14)

All but four participants considered daily oral care to be important. The four who did not were all edentulous. One of them had their daily denture hygiene provided by caregivers and was one of two for whom the CAP Oral Hygiene was not activated.

• • 4.2
    Professional oral care

In the context of professional oral care, previous experiences with dentists or dental treatments are influential automatic motivators. While one participant avoided going to the dentist because of a negative childhood experience, the others had positive experiences with no negative events in the past. However, a quarter of the participants found a visit to the dentist unpleasant. Three persons said they were somewhat afraid of it.

Only two participants were intrinsically motivated to attend regular preventative dental check-ups.

‘For a check-up. I do that at least once or twice a year. I want it to be fine all the time. … So now I go to the dentist twice a year. I think that's normal. I want that for myself. I have it checked to see if everything is all right, which it usually is, but then I have peace of mind for a year.’ (P20)

Remarkably, they even perceived the dental visit from a dentist's point of view.

‘If you only go [to the dentist] when you have a problem, people will ask you why you didn't come before. If I were a dentist, I would say: 'You haven't had that since today, why didn't you come before?’ (P20)

Two persons in their nineties considered themselves too old for a dental treatment. One would have liked implants for more comfort, while the other refused new removable dentures.

The COM-B model suggests that an individual's motivation to perform a behaviour is influenced by the opportunity to do so. Physical and social opportunities are external factors that affect individuals. The opportunities discussed in this study are also illustrated in Fig. 1.

• 5.Opportunities

The cultural environment can influence a person's mindset towards daily and professional oral care. Social opportunities are often shaped by upbringing and education. Three participants explicitly stated that their oral care routine was influenced by their upbringing and childhood experiences. They specifically mentioned the role of their mother and the army in shaping their habits. Two of them were among those aware of the importance of oral health for overall health and two of them were those who regularly attended dental check-ups.

‘Listen, I was brought up by a mother for whom this was very important. … Yes, then I would ask [assistance]. Absolutely, because we have been trained to brush our teeth since childhood …

We went to the dentist more than we would have liked. I think I'm pretty lucky. I don't have any problems with my mouth, but I don't try too hard. Maybe it is because of my mother's strictness that I am doing so well now.’ (P15)

‘I was in the army for 33 years. You always had to be pico bello there. You always had to make sure you're in order, also in terms of dress, posture, table manners, clean shaven, etc.’

‘And did that include brushing your teeth?’

‘Yes, brushing teeth was part of it. … I am grateful to have had that learning experience. That I have that self-discipline.’ (P18)

• • 5.1
    Daily oral care

The physical opportunities for daily oral care mentioned by the participants were mainly at the level of the caregivers and the nursing home. The participants required assistance, but did not receive it or did not ask for it due to various reasons. Participants experienced that caregivers lacked time, a shortage of staff and too many tasks for staff. Some participants also reported a lack of skills or a lack of confidence in caregivers' skills. A few mentioned inadequate supervision, including for oral care.

‘Look at my teeth. How can I explain? You always have to rely on someone, and the bell… Sometimes they come immediately, sometimes it takes half an hour. And then you sit and wait and wait. It's not pleasant. I prefer to do it myself and not have to bother anyone.’ (P11)

Regarding social opportunities, only two participants indicated that family members placed great importance on daily oral care and provided limited assistance. This included children and a partner monitoring daily oral care.

• • 5.2
    Professional oral care

In terms of physical opportunities, the barrier to visiting the dentist mentioned by participants was that they had lost contact with dental care after the dentist retired.

The social opportunities for reporting oral problems was discussed with eighteen persons. One participant explicitly stated that she had no one left and did not want to bother anyone, and therefore would not report any oral problems. The other participants would report oral health problems to either caregivers or family. Some explicitly stated that they did not want to bother their family, or no longer had family members, and therefore reported only to caregivers. Others chose to report only to their family. This was particularly the case for those who had recently moved into the nursing home. Some would report to both caregivers and family. It was explained that the family would be responsible for transport to the dentist.

‘That's because we happen to have children who want to help us right away. That our son was free. If we didn't have that, how would I get to a dentist?’ (P9)

Regarding social opportunities, it is noteworthy that for some participants, the lack of personal contact with their dentist due to changes in the organisation of the dental practice is a barrier.

3.3.3. OHS-interRAI

Two participants could not recall the oral health screening conducted by the dentist, as it had taken place 53 and 68 days before the interview, respectively. Despite having no cognitive impairment, this period may be too long for 92 and 97 years old participants.

Almost all participants considered the oral health screening to be good and/or important. However, a few mentioned that it was particularly important if they had pain or problems in the mouth. In terms of acceptability, participants reported that the oral health screening went smoothly and was not time-consuming.

Participants’ experiences of the oral health screening varied and were not necessarily related to the importance they attached to it. Just over half of the respondents said they were not bothered by the oral health screening. Of those who found it somewhat unpleasant, the reasons given were psychological, physical or practical. Someone reported feeling uncomfortable during the screening. This aligns with the feeling of shame, regret and resignation about their own oral health and oral care expressed elsewhere in the interview. Several participants said they did not like having their mouths examined, citing difficulty in keeping their mouths open and oral dryness during the screening.

‘I don't find it pleasant. No, I'm honest about that.’ (P8)

‘I'm okay with that. I'm not keen on it, but I am positive about it.’ (P18)

4. Discussion

This study explored nursing home residents’ perspectives on oral health and oral care, and their perceptions of regular oral health assessments (OHS-interRAI) by their caregivers. Research on the perspectives of nursing home residents regarding their oral health and oral care is limited (Wårdh et al., 2002; Niesten et al., 2013; Donnelly et al., 2016; Mendes et al., 2020; Malekpour et al., 2023), as is the case for community-dwelling older people (Kc et al., 2021). To our knowledge, no studies have specifically investigated their perspectives on oral health assessments. However, in order to provide integrated patient-centred care, it is essential to respect the preferences of these older persons and empower them to participate in their health care (WHO 2023).

Participants most frequently emphasised the importance of oral health in terms of chewing and appearance, followed by speech and feeling clean. According to the literature, older individuals tend to evaluate their oral health based on physical characteristics, such as the presence of teeth and the absence of pain, as well as functional and social aspects (Borreani et al., 2010; Donnelly et al., 2016; Koistinen et al., 2021; Brocklehurst et al., 2015). Participants' VAS and OHIP-14 scores indicated general satisfaction with their oral status, suggesting a limited perceived impact of oral problems on their daily lives. This positive subjective perception of their oral health aligns with other studies among older people in nursing homes (Wårdh et al., 2002; Mendes et al., 2020), short-term care (Koistinen et al., 2021; Andersson et al., 2018; Koistinen et al., 2019) or community-dwelling settings (Borreani et al., 2010; Andersson and Nordenram, 2004; Bots-VantSpijker et al., 2021). However, this perception is not always consistent with the objective assessment by dentists or dental hygienists (Mendes et al., 2020; Andersson et al., 2018; Koistinen et al., 2019; Bots-VantSpijker et al., 2021). This study revealed that 72.2 % of participants perceived their oral health positively, although 86.4 % needed to improve their oral hygiene, and 68.2 % needed referral to a dentist based on the activated CAPs. Additionally, a considerable proportion of participants made dietary adjustments in response to oral health issues. This was also observed by Malekpour et al. (Malekpour et al., 2023).

Good daily oral hygiene and regularly visiting a dentist and/or dental hygienist, as well as reducing sugar intake and eating frequency are key behaviours for good oral health (Tonetti et al., 2017). In-depth interviews with older individuals provided insight into the barriers and facilitators of oral health behaviours, which were classified according to the COM-B model (Michie et al., 2011). This insight is essential for introducing interventions to improve oral health (Michie et al., 2011; McNeil et al., 2022).

Motivation is a crucial component of behaviour. A daily oral hygiene routine, the desire to preserve teeth and the belief in the link between oral health and well-being were important facilitators of automatic motivation. In addition to the reflexive understanding of the importance of oral health, daily oral care and the mouth, the participants in this study generally had positive attitudes towards oral care. This contrasts with caregivers’ perceptions of residents' attitudes towards routine oral care in some reports (De Visschere et al., 2015; Wårdh et al., 2002). Niesten et al. (2013) investigated frail older persons’ perceptions on their oral health behaviours and suggested that positive attitudes and beliefs were more important for oral care behaviour than perceived needs, except for pain (Niesten et al., 2013). In the present study, participants' positive attitudes and beliefs towards oral care did not fully correspond with good oral hygiene and health. Other factors may have negatively influenced the outcome.

Almost all participants performed their own oral hygiene care and considered it good. This is consistent with research on older adults’ oral hygiene self-efficacy, which found a correlation with their self-reported oral health and self-reported satisfaction with oral health, among other factors (Allen et al., 2022). However, only one of the dentate study participants was observed to have adequate oral hygiene. This finding aligns with caregivers’ perceptions reporting that residents incorrectly believed that they were still able to adequately clean their natural teeth and/or dentures (De Visschere et al., 2015). A Swedish study evaluating an oral health care program for caregivers, reported that at baseline only 24.0 % of the residents was able to manage their oral care without assistance from others (Wårdh et al., 2002).

It is noteworthy that daily oral care was considered important by almost all participants, whereas only two individuals considered visiting the dentist important. As reported in literature (Wårdh et al., 2002), most participants had not visited a dentist since their admission to residential care, despite their generally positive attitudes towards oral health and oral care. Additionally, residents did not want a dental check-up in the nursing home because they did not experience any pain or discomfort. This aligns with Niesten's research, where older people showed reduced or lost interest in visiting the dentist due to their proximity to death, which they perceived as reducing the benefits of dental visits, except in cases of excruciating pain (Niesten et al., 2013). Moreover, research has shown that older people were unwilling to pay for preventive advice from oral health professionals (Allen et al., 2022).

Our study revealed a significant need for autonomy among the participants. They expressed a preference for self-care and avoided asking for assistance, which is consistent with previous research (Niesten et al., 2013; Koistinen et al., 2021). Maintaining autonomy in oral hygiene not only increases self-esteem, but also preserves a sense of control and independence (Niesten et al., 2013; Johnson et al., 2022). In frail older persons, psychological and social factors were found important for oral care behaviour, particularly among institutionalised older people (Niesten et al., 2013). The reluctance to burden family with their oral care also applied to going to the dentist. Loss of independence was identified as a barrier to visiting the dentist. This structural barrier was also found in Niesten's research (Niesten et al., 2013). Additionally, similar to other studies, participants did not feel the need to visit the dentist because they experienced no problems (Borreani et al., 2010; Niesten et al., 2013; Mittal et al., 2019). Furthermore, participants gave contextual reasons for the decline in dental visits, including losing sight of the dentist because of retirement. Some participants explicitly mentioned the loss of personal contact with the dentist as a barrier. Others mentioned having no social support from family. Interestingly, studies reported that nursing home residents did not know whom to report oral health problems to or were not aware that they could ask for help with oral care (Wårdh et al., 2002; Niesten et al., 2013).

However, some participants also mentioned facilitators in the social context. The participants who had regular preventive dental check-ups were very self-sufficient, and shared the view that their oral health behaviour and the importance they attached to it came from their upbringing and education. This was also mentioned in other reports (Donnelly et al., 2016; Andersson and Nordenram, 2004). For some participants, family appeared to be an important facilitator in this social context. Research exploring family perceptions has shown that family can play an important role in oral care for residents with dementia (Lowman et al., 2021), such as maintaining transparent communication with caregivers, monitoring and advocating care goals, and providing oral hygiene supplies. Additionally, family members indicated the importance of caregivers promoting the independence of residents and involving them actively in their own care, recognizing their changing abilities (Lowman et al., 2021).

An important constraint observed in the study participants was their psychological capability. Participants were not really aware of the link between oral and general health. Despite the importance they attached to oral hygiene, it was noticeable that none of them maintained proper denture hygiene. This clear lack of knowledge was evident in both residents and caregivers. The procedures, products and materials used for denture hygiene did not meet current evidence-based guidelines (Felton et al., 2011). Misconceptions and a lack of knowledge concerning oral health, dental visits and dental treatments were also reported in other studies (Borreani et al., 2010; Wårdh et al., 2002; Horn et al., 2018; McQuistan et al., 2015; Wong, 2020).

Older people's behaviour and attitudes towards oral health are influenced by determinants throughout their lives (Borreani et al., 2010; Andersson and Nordenram, 2004; Lowman et al., 2021; Freeman, 1999). Oral health and oral health behaviours are multifactorial and should be considered from a life-course perspective. Stowe and Cooney (2014) described this as a 'dynamic lifelong process, embedded in historical time and place, and influenced by the web of relationships to which individuals are connected, as well as more distal social structural factors' (Stowe and Cooney, 2015).

De Visschere et al. (2015) conducted qualitative research on integrating oral care into daily care (De Visschere et al., 2015). The study found that caregivers believed it was important to respect residents' self-determination, even when they are dependent on others. The ability to decide on their own care was seen as crucial to maintaining their dignity and self-esteem. Johnson et al. (2022) explored residents' views and perspectives on oral care in residential care, specifically how they experienced support from healthcare providers (Johnson et al., 2022). Residents considered their mouths a private and important part of their identity and felt it was important to care for their own mouths for independence. Staff consulted with residents to ensure this independence (Johnson et al., 2022).

An integrative review of older people's perceived autonomy indicates that autonomy is linked to their individual capabilities, including their level of independence, physical and mental competence, personal characteristics and the extent to which relatives share and support their perceived autonomy (Moilanen et al., 2021). Individuals’ cognitive and physical conditions are not static and tend to deteriorate with age. Respecting this autonomy and whether or not to assist residents with their daily oral care therefore needs to evolve. This requires an individualised, person-centred care approach (Johnson et al., 2022), in which residents are encouraged to participate as full partners (Lowman et al., 2021). Of interest in this context is the concept of age-friendly primary health care, advocated by the WHO (Towards age-friendly primary health care 2004). A scoping review on age-friendly healthcare concluded that nurses should collaborate with older people to help them manage their health and promote self-care by increasing knowledge and autonomy, thereby ensuring quality and dignity of care (Gomes et al., 2022).

The use of the OHS-interRAI allows an individualised, person-centred approach to oral care. Most residents in the present study insisted on their independence. However, as objective oral hygiene and oral health are often inadequate, discussing possible oral care support while respecting autonomy as much as possible is important (Lowman et al., 2021). Including oral health items as part of the interRAI assessments can provide a good basis for this discussion and can lower the threshold, even for residents who would not spontaneously ask for help. It is also important to consider the facilitating role that family members can play and to clarify everyone's role and responsibilities in oral care, including those of the older person (Lowman et al., 2021).

To implement an oral health policy in nursing homes, where oral health care is fully integrated into general care and care planning, requires the involvement of all stakeholders, including the residents themselves (Niesten et al., 2013; WHO 2023; Lowman et al., 2021). Deficits have been identified in key oral health behaviours of daily and professional oral care among older people. To successfully plan interventions tailored to older people that can help change their behaviour, it is important to understand the main components that determine their behaviour and what needs to be changed (Michie et al., 2011). This study identified a common deficit in older people's psychological capability, being knowledge on oral health, oral hygiene and dental visits. Based on the BCW this can be improved through education, training and enablement (Atkins et al., 2017). Education and training on evidence-based guidelines for oral hygiene, especially denture hygiene, can be beneficial. Enabling interventions could include ensuring that everyone has the appropriate materials for daily oral care. Regarding reflexive motivation, this study confirmed the importance of involving older people as full partners in their oral care, respecting their autonomy and empowering them in their own oral care. Additionally, this study highlighted the importance of maximising social opportunities by involving families and informal caregivers. However, additional policy measures may be required to improve access to dental care for this population (Chan et al., 2023; Harnagea et al., 2017; Tonetti et al., 2017).

Although participants did not want a dental visit in the nursing home, they considered the oral health assessment with OHS-interRAI to be good and acceptable. To our knowledge, this study is the first to explore older persons’ perspectives on oral health assessments by caregivers. It not only provides an opportunity to involve them as partners in implementing regular oral health assessments in nursing homes, but also provides insight into how empowering them to manage their own oral health care.

4.1. Limitations

Although a point of saturation was reached interviewing these 22 persons, the results of this study cannot be generalised to the entire population of care-dependent older people in nursing homes. Furthermore, the OHS-interRAI assessments in this study were carried out by dentists. This could be seen as a limitation, as the assessments may have been easier to perform than by a non-dental caregiver, for whom the OHS-interRAI is designed. The associated guidelines and training should enable non-dental caregivers to carry out the assessment smoothly.

4.2. Implications

This study investigated the perspectives of care-dependent residents on oral health, oral care, and the oral health assessment with the OHS-interRAI. In the light of the implementation of interRAI in nursing homes, this knowledge is valuable to facilitate the acceptance of regular oral health screenings. A successful implementation of the OHS-interRAI will identify oral care needs and integrate oral care into general care planning to improve residents’ oral health.

These research findings can serve as a basis for the development of an intervention to empower older persons in their own oral care.

5. Conclusions

The study provided information about older persons’ perceptions of their own oral health, oral care, and OHS-interRAI assessment. Learning about their experiences and perceptions helps to identify their wishes and needs, enabling improvement of oral care and proactive strategies to provide effective oral care for the future older population. Policy makers can use these results to foster the integration of oral care guidelines into care protocols in nursing homes, and to support collaboration with dentists and dental hygienists in care facilities.

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work the author(s) used DeepL Write in order to improve the academic English. After using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the publication.

CRediT authorship contribution statement

Patricia A․ I․ Vandenbulcke: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Validation, Visualization, Writing – original draft, Writing – review & editing. Johanna de Almeida Mello: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Valerie Cornette: Conceptualization, Formal analysis, Investigation, Methodology, Software, Validation, Writing – review & editing. Marijke Brabants: Conceptualization, Formal analysis, Investigation, Methodology, Software, Validation, Writing – review & editing. Emilie Schoebrechts: Validation, Visualization, Writing – review & editing. Jan De Lepeleire: Conceptualization, Methodology, Supervision, Validation, Writing – review & editing. Anja Declercq: Conceptualization, Methodology, Supervision, Validation, Writing – review & editing. Dominique Declerck: Conceptualization, Funding acquisition, Methodology, Resources, Supervision, Validation, Visualization, Writing – review & editing. Joke Duyck: Conceptualization, Data curation, Funding acquisition, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.