More than a mouth to clean: Case studies of oral health care in an Australian hospital

Abstract

Objective

This study aimed to explore older patients' oral health status, their opinions about oral health care and their experiences with oral health care while in hospital.

Background

Improving older adults' oral health is considered an urgent priority at both the national and international levels, especially for hospitalised older patients who have been found to have poor oral health. However, a one‐size‐fits‐all standardised approach to oral care delivery may not be the answer.

Materials and Methods

This study was an embedded, multiple‐case study, integrating qualitative and quantitative data. Seven patients were recruited from a geriatric ward of an acute hospital in Australia and participated in semi‐structured interviews and oral health assessments using the Oral Health Assessment Tool (OHAT) in June–July 2022. Data were analysed descriptively and presented in case summaries.

Results

OHAT assessments identified oral health problems in all patients, but not all patients self‐reported problems with their mouths. Each patient valued oral health care, but the reasons given varied. Patients had established, individualised oral health care routines, which they brought to hospital.

Conclusion

Clinical observations of patient's oral health status might not match the patient's own judgement of their oral health and, if not explicitly addressed, may mask the need for oral health and hygiene intervention. Assessment and care planning needs to incorporate patients' own perceptions of their oral health and existing oral health care routines. Oral health histories may provide a means of facilitating this person‐centred oral health care for older patients in hospital.

1. INTRODUCTION

Improving older adults' oral health is considered an urgent priority internationally. ¹ , ² This is because older people are vulnerable to poor oral health, ³ which has implications for their general health and well‐being. ⁴ , ⁵ Oral health problems in older age are risk factors for frailty and the subsequent susceptibility to adverse events including falls, institutionalisation, dementia and death. ⁶ The uptake of evidence‐based oral health care and timely dental referral to prevent or limit common oral health problems in older people is poor, ² , ⁷ warranting government and health action. A pivotal timepoint to instigate oral health assessment and intervention might be when an older adult is hospitalised, particularly when admitted to a specialist geriatric unit.

Hospitalised older patients have been found to have poor oral health ⁸ , ⁹ and are vulnerable to further decline due to dependence, polypharmacy, immobility, dysphagia and cognitive decline. ¹⁰ Many are dependent on nurses to provide or assist with oral health care ¹¹ ; however, oral health care is a frequently missed component of care in hospitals. ¹² , ¹³

Much of the current literature about oral health of older people in hospital has focused on nurses' implementation of oral health care in hospital, as well as their attitudes towards and knowledge about oral health care. ¹⁴ However, as person‐centred care is considered the foundation of safe, high‐quality health care, ¹⁵ , ¹⁶ and is associated with increased patient satisfaction and increased adherence to treatment, ¹⁷ exploration of patient values and preferences is warranted. In previous studies, older adults' opinions on oral health care varied. Some healthy older adults reported that oral health care was essential for maintaining function and appearance ¹⁸ and adhering to an oral health care routine helped them to feel in control. ¹⁹ However, when hospitalised, some older adults reduced the importance they placed on oral health care because of the burden of their health complaint ¹⁹ or were not offered the assistance they needed with oral care, ²⁰ which is problematic as some older adults are hesitant to ask for help for fear of being a burden to the nurses. ²¹

To improve the delivery of evidence‐based oral health care in acute hospitals in a way that is responsive to patients' needs and values for oral health care, one must first explore the oral health status of older patients, how they experience oral health care when in hospital and how this relates to their oral care regime when at home. This study was a part of a larger research agenda which implemented a best‐practice oral health care program in a geriatric ward in a metropolitan hospital in South Australia. ²² Through the present sub‐study, we aimed to gain more detailed insights into patient perspectives of oral care while they were on this unit. The research questions for the sub‐study were: what is the oral health status of patients admitted to an acute geriatric unit? what are older hospitalised patients' opinions, expectations and experiences of oral health care while in hospital? and how does this compare to their routine at home?

2. MATERIALS AND METHODS

This study was conducted using an embedded, multiple‐case study design. ²³ Case study research allows for an in‐depth exploration of a small number of cases in their real‐life context. ²³ Through a pragmatism theoretical approach, ²⁴ this study collected both qualitative and quantitative data to explore both the oral health reality and experience of the participants. In the current study, each case constituted one unique patient.

Ethical approval was obtained from the local health network's human research ethics committee. Governance approval was also obtained from the hospital site. An Easy‐English consent form, comprising pictures and simple texts, was given to each participant and read aloud to them. Verbal and written consent was obtained from each participant. This study is reported against the STROBE for cross‐sectional studies ²⁵ (see Data S1) and SRQR ²⁶ checklists (see Data S2).

2.1. Participants

Eligible participants were patients, aged 65 years and older, from a 25‐bed geriatric ward of one metropolitan hospital in South Australia. Participants were purposefully recruited over a one‐month period, between the 6 June and 4 July 2022. A team leader, who was a nurse from the ward, determined patients' eligibility to provide informed consent. Potential participants who could provide their own informed consent were included and invited by the researcher to participate in the study. Patients who were deemed unable to provide informed consent, by either the nurse or the researcher, were excluded from participating, for example, patients with cognitive impairment, those who were too unwell to participate or who were on restrictions due to illness. Case study methodology requires a small sample size to support analysis; therefore, there was no minimum sample size. Data collection occurred up until COVID‐19 pandemic‐related restrictions no longer permitted the research team to be onsite. The research team had considered continuing data collection once the restrictions were lifted; however, aligned to case study methodology it was decided that a sufficient number of cases had been recruited and more would not be appropriate. ²⁷

2.2. Data collection

Qualitative and quantitative data were collected concurrently over a one‐month period between June and July 2022. All participants were involved in qualitative and quantitative data collection.

Patients' oral health status was assessed using the SA Dental Service (2009) adaptation of the Oral Health Assessment Tool (OHAT), originally modified by Chalmers et al. ²⁸ The SA Dental Service (2009) adaptation was chosen, as this was the recommended tool in South Australia at the time of the study. ²⁹ However, the researchers chose to use the original scoring system developed by Chalmers and collegues, ²⁸ so that the patients' scores could be quantified. The OHAT assesses eight categories of oral health: lips, tongue, gums and tissues, saliva, natural teeth, dentures, oral cleanliness, and dental pain. ²⁸ Three scores can be assigned to each category; “0” for healthy, “1” for oral health changes and “2” for unhealthy condition. A patient's total score equals the sum of each category, wherein higher scores represent poorer oral health. A Bachelor of Speech Pathology Honours student (second author) conducted most of the OHAT assessments after demonstration by the supervisor, a certified practicing speech pathologist (first author). Both of the assessors completed the oral health online training modules and performed the self‐learning quiz that is part of this training. ²⁹ Validity and reliability of the OHAT have been shown to be high when conducted by non‐dental health professionals, ²⁸ including speech‐language pathologists. ³⁰

Qualitative data were obtained from semi‐structured interviews. An interview guide was developed by the research team and was comprised of closed and open‐ended questions (see Appendix S1). The interview guide underwent two rounds of development and was peer‐checked by all members of the research team. The Bachelor of Speech Pathology Honours student conducted each interview after demonstration by the supervisor. Each interview explored patients' perception of their oral health problems, satisfaction with their mouth, opinion on the importance of oral health care, oral health care routines in the context of the patients' home and during hospital admission, and satisfaction with oral health care in hospital. Field notes were also maintained during data collection and were used to document the researcher–patient interaction, as well as the researcher's qualitative descriptions of the patients' oral health status.

2.3. Data analysis

The quantitative OHAT scores were analysed descriptively. The qualitative interviews were analysed using thematic analysis. ³¹ The researchers familiarised themselves with the data and the second author simultaneously transcribed the interviews using intelligent verbatim transcription, wherein repetitions, laughter and pauses were removed from the transcript. Each transcript was checked two times to ensure accuracy of the transcription process. The second author then commenced coding each transcript using the comment section on Microsoft Word. An inductive orientation to coding was taken, and the transcripts were coded semantically. ³¹ To aid in organisation as codes were developed, the second and senior (last) author developed a project‐specific code book which was maintained during data analysis. The code book contained broad codes such as patients' self‐perception of oral health status, opinion on oral health care and oral health care routines. Each code then contained a series of sub‐codes which detailed the differences and similarities between patients' perceptions, opinions and routines. The code book also contained definitions of each code, as well as example quotations. The code book was maintained by the second author and was peer‐checked by the senior author of this study. The second author then collated and compiled the codes into potential themes which were discussed and refined with the research team. Agreement was reached after three rounds of data analysis. All members of the research team reviewed the themes and clearly named and defined all themes.

Synthesis of the data occurred during which the data from the qualitative interviews were used to enhance, clarify and make sense of the results of the quantitative OHAT scores. The case studies presented draw on the multi‐faceted perspectives from both the qualitative and quantitative data.

All authors are women, and two have a background in speech‐language pathology: one as a Bachelor of Speech Pathology Honours student, and the other as a certified practicing speech pathologist, senior lecturer and supervisor of the Honours student. The senior (last) author, a research fellow, has a background in psychology and social constructionist research, which allowed us to be mindful of what our perspectives and backgrounds brought to the analysis.

2.4. Rigour

Patients' oral health status was assessed using the OHAT, a valid and reliable tool designed for use with older adults. ²⁸ Although the OHAT was originally tested with a population of residents from residential aged care, it has since been readily used in hospital settings, ⁹ , ³⁰ , ³² and is the recommended tool for use with older adults in South Australia. ²⁹ The researchers sought to limit contextual variables impacting OHAT scores between patient participants, by assessing their oral health status at a consistent time of the day between 10:30 am and 12:00 pm. Similarly, the researchers interviewed patient participants between 10:30 am and 12:00 pm and used an interview guide, developed and approved by all members of the research team, to ensure similar themes were explored with each participant. During the interviews, the researcher reiterated patients' responses and thus informally used member checking to confirm if the researcher accurately understood the patients' narrative.

3. RESULTS

3.1. Participants

Seven participants were recruited for the study. Three participants were male and four were female. All participants were above the age of 80 years, and their ages ranged from 82 to 94 years. All participants engaged in an oral health assessment and an interview, which ranged in length from 6 to 20 min. A summary of patient presentations is presented in Table 1 followed by the seven individual case summaries, which outline in more detail participants' demographic information, clinical presentation, oral health status and interview data.

TABLE 1.

Patient demographic and OHAT information.

	Participant
	1	2	3	4	5	6	7
Sex	M	M	F	F	F	F	M
Age	85	82	90	94			90
Patient‐reported reason for admission	Balance	Fall, Parkinson's Disease	Fall	Not reported	Back pain	Fall	Fall
Total OHAT score /16	2	5	8	7	6	5	5
Lips	0	2	1	2	0	1	0
Tongue	0	1	1	2	1	2	1
Gums and oral tissue	0	0	1	1	1	0	0
Saliva	0	0	2	1	0	0	1
Natural Teeth	1	1	1	0	N/A	1	1
Dentures	N/A	N/A	N/A	1	2	N/A	1
Oral cleanliness	1	1	0	0	0	1	1
Dental Pain	0	0	2	0	2	0	0
Researcher observations	Changes to natural teeth Food debris	Bite marks inner upper lip and cheeks Coated tongue Broken tooth	Dry mouth. Red and dry lips, tongue and oral tissues Ulcer on left cheek causing pain Dental caries	Dark discoloration inside right lower lip Dark small bumps under tongue Ulcer on oral mucosa of right cheek Dry mouth	Lower denture loose and unlabelled Ulcer on mucosa of lower jaw causing pain Fissured tongue	Dry/rough patch right outer lip Lump under tongue Worn lower central teeth Broken tooth upper centre Food debris, calculus and plaque	Broken/decayed teeth Bite mark inner right lower lip Dry fissured tongue Reduced saliva and dry mouth

3.2. Case 1: Participant 1 (P1)

A male aged 85 (P1) was hospitalised due to concerns with his balance. P1 had natural teeth and did not use a denture. He received a score of 2/16 on the OHAT and presented with problems related to his natural teeth and oral cleanliness. Food debris was present in his mouth.

3.2.1. General perceptions of oral health and oral health care

The patient did not report any current concerns relating to his oral health and was satisfied with the feel of his mouth. P1 valued his teeth and had an apparent preference for natural teeth, “I would hate to have to have a plate in there, that would be nasty.” He identified his mouth as having functional value, due to his ability to eat anything. He considered oral health care important for appearance and also identified that there would be consequences if he did not clean his teeth, “Mainly I imagine if you didn't clean them your teeth would fall out and you'd have bad breath.”

P1 discussed how his early life experiences and upbringing had likely shaped his oral health care views and regular teeth cleaning habits, “I came from a big family and my mother was fairly, right on to everything.”

3.2.2. Oral health care at home

P1 was independent with oral health care at home. He reported using a toothbrush and toothpaste to clean his mouth. His oral health care routine was variable, cleaning his mouth one or two times daily. P1 consistently cleaned his mouth at night before bed but sometimes cleaned his mouth if leaving the house, “Every night‐time before I went to bed always, and if I was going out anywhere, I'd clean them then. So sometimes twice a day, sometimes in the evening.”

3.2.3. Oral health care in hospital

P1 used a toothbrush and toothpaste to clean his mouth in hospital. He required support from a nurse to bring supplies to his bedside, “one of the nurses brings me a bowl of water and a glass of water and I can sit here and do them. Rather than in the shower or somewhere else.” The nurses supported him once daily, in the afternoon. This was earlier than his typical routine, and P1 reported that routines were different in hospital, “You're not in charge so much, you've got to do what your told ‐ and not that they're bossy, the nurses by any means, they're very helpful.”

P1 was satisfied with his care in hospital and did not wish to change it. When the researcher posed the possibility of cleaning his teeth more frequently in hospital, P1 reported, “That wouldn't worry me, I could do them twice a day …. Because I want them to last as long as I'm here.” His expressed preference was to clean his teeth after breakfast and before bed in hospital, as this was consistent with his routine from home.

3.3. Case 2: Participant 2 (P2)

A male aged 82 (P2) was hospitalised for a fall. He presented with Parkinson's disease, causing a tremor which was present throughout his interaction with the researchers. P2 presented with natural teeth and did not use a denture. He received a score of 5/16 on the OHAT due to receiving scores of 1 or 2 for lips, tongue, natural teeth and oral cleanliness. The main presenting concerns included bite marks on the inner upper lip due to his tremor, a coated tongue and a broken tooth. Despite a broken tooth, P2 reported that he did not have dental pain.

3.3.1. General perceptions of oral health and oral health care

Biting his oral tissues was the only problem self‐reported by the patient. P2 considered that he had a lack of control over his mouth, “As you see I've got Parkinson's, I can't do anything about it. Except get my tablets on time.” P2 reported that his mouth felt fine and was nothing to worry about, “It feels alright …. So why worry about it?”

P2 reported that cleaning his mouth was important at his age but could not explain why, “I can't say why it's so important. It just is, I think.”

3.3.2. Oral health care at home

P2 cleaned his mouth independently at home. He used an electric toothbrush and toothpaste and cleaned his mouth two to three times daily, “When I get up, I brush my teeth … if it feels furry … you can do it then, and last thing at night.”

3.3.3. Oral health care in hospital

P2 described that it was “not easy” to clean his mouth in hospital. P2 demonstrated that when he moved from his chair, an alarm was triggered in the ward and a nurse was sent to help him, “I got to have somebody come in. … and they go ‘what are you doing up?’ or ‘we are trying to stop you falling over.’” P2 described being frustrated by this lack of independence.

P2 kept his toothbrush and water at his bedside. After he finished brushing his teeth, he swallowed the water, rather than spitting it out. This was a deliberate decision made by the patient to avoid waiting for nurse support. P2 described that this method of cleaning his mouth was unsatisfactory but that he was doing the best that he could. He acknowledged that if asked, the nurses would support him, but he did not want to ask for help each time he wanted to move from his chair. P2 reported that they offered to help him less than once daily.

P2 desired to clean his mouth more frequently in hospital, like he had at home.

3.4. Case 3: Participant 3 (P3)

A female patient aged 90 (P3) presented to the hospital after having a fall. P3 presented with natural teeth and did not use a denture. She scored a total of 8/16. The patient's oral health problems were primarily a result of dry mouth, impacting the lips, tongue and oral tissues, which were visibly dry and red. She reported being in pain due to an ulcer on the mucosa of her left cheek. She also presented with signs of dental caries. Despite these problems, she had a normal oral cleanliness score.

3.4.1. General perception of oral health and oral health care

P3 reported soreness and dryness inside her mouth which she attributed to sleeping with her mouth open. Despite this, the patient was satisfied with the way her mouth felt. The participant felt that cleaning her mouth was important for socialisation; hence, she described cleaning her mouth more if expecting company, “I brush my teeth and if I was having anyone coming to visit me, I usually like my teeth to be clean.”

3.4.2. Oral health care at home

P3 was able to independently clean her mouth at home. She used an electric toothbrush, toothpaste and mouthwash to clean her mouth. She also used a mouth spray to manage mouth dryness. Although she previously used floss to clean her teeth, reduced fine motor control meant that she was no longer able to use this product. P3 reported cleaning her teeth at least twice daily, sometimes up to four times daily at home. This variability in routine was attributed to cleaning her mouth more when socialising.

3.4.3. Oral health care in hospital

P3 reported using a toothbrush and toothpaste in hospital, but no longer used her mouth spray due to being unable to locate it in hospital. Due to no longer using mouth spray, she reported that she was thereby only cleaning her teeth; thus, she distinguished her mouth and teeth as separate units.

P3 required nurse support to complete oral health care, which involved the nurse setting her up with a bowl of water to clean her own teeth and putting toothpaste on the toothbrush due to difficulties with her vision. The patient asked the nurses to support her to clean her mouth twice daily but thought that asking for her mouth spray was an unnecessary burden, “I think the nurses have so much work to do, and to ask them to find something like that for me seems a bit of a trivial request.”

The patient reported cleaning her teeth earlier in hospital than she would at home. She therefore identified that routines were different in hospital, “you have to fit in with the hospital routine.”

P3 was satisfied with her care in hospital, reporting that she was “very happy.”

3.5. Case 4: Participant 4 (P4)

P4 was a female patient aged 94. The patient's cause of hospitalisation was unknown and not reported by the patient. P4 presented with natural teeth on the lower jaw and an upper denture. P4 received a score of 7/16 on the OHAT. She presented with a dark discoloration on the inner side of her lower lip, dark small bumps under the tongue, an ulcer on the oral mucosa and self‐reported dry mouth. The patient's denture was not labelled with her name. Despite having dryness and an ulcer, the patient did not report any dental pain.

3.5.1. General perception of oral health and oral health care

Although the patient acknowledged she had a dry mouth, she reported having no current concerns or problems with her mouth. When asked if she was happy with the way her mouth looked and felt, P4 considered this irrelevant due to a lack of control over her mouth, “Oh well whether we're happy with it or not we are stuck with it aren't we?”

Social interaction, or a lack thereof, also influenced the way P4 thought about her oral health, “Well it doesn't matter at this stage of my life because I've got nobody that worries about my mouth …. I haven't got any old friends they're all gone …. So what do you worry about?”

P4 reported that oral health care was important for her health and for the feel of her mouth but did not think there would be consequences if oral hygiene was not completed in hospital, “Oh yes it's important … but if you didn't clean them I don't expect anything would happen to them. It's just freshening your mouth up.”

3.5.2. Oral health care at home

P4 independently cleaned her mouth at home. When asked about her oral health care at home, P4 reported that she only cleans her teeth; thus, she acknowledged her teeth and mouth as separate units.

P4 used a toothbrush and toothpaste to clean her teeth, completing this one to two times daily. The patient reported that laziness impacted her ability to complete oral health care twice daily, “just laziness …. I think that's about what it comes down to.”

3.5.3. Oral health care at hospital

P4 cleaned her mouth each morning during her hospitalisation using a toothbrush and toothpaste and needed support from a nurse to gather supplies.

She described that difficulties with her movements impacted her ability to complete oral health care, “using my arms and getting up over the bowl…you're sort of a bit handicapped with what movements you use in your arms. Well I am.”

The patient was satisfied with cleaning her teeth once a day, reporting that “you don't look for anything in bulk.”

When asked if she would like to clean her teeth twice a day she answered, “Oh I don't think it's really necessary at this old bird. Unless I had a reason. If I had a reason, yes.” She reported wanting to clean her mouth more if it was uncomfortable or had an unpleasant taste.

3.6. Case 5: Participant 5 (P5)

A female patient aged 85 (P5) presented to the hospital due to back pain. The patient had no natural teeth and used full dentures. She received a score of 6/16 on the OHAT. Her main oral health concerns are related to her dentures. She reported that her lower denture was loose, and the researcher observed that the denture was unlabelled. She had an ulcer on her lower jaw which caused self‐reported pain. She also presented with a slightly fissured tongue.

3.6.1. General perception of oral health and oral health care

P5 was aware of her ulcer and reported this as a concern she had with her mouth. Despite this, she was satisfied with the way her mouth looked and felt.

The patient thought that for hygiene purposes, it was important to clean her teeth. She also identified that her mouth was an extension of her body, reporting:

“Well your mouth should be clean and wholesome, like your body, you've got to keep your body clean, otherwise it can ‐ I believe my mother's told me in old age it makes its own nasties. Whether that's true or not I don't know, but I don't want to come to that stage.”

3.6.2. Oral health care at home

P5 reported being able to clean her mouth independently at home. She used a toothbrush and toothpaste to clean her dentures and gums, “when I do my teeth, I brush my gums first to keep them, well alive, I suppose.”

When at home, P5 cleaned her mouth at least twice a day. She reported cleaning her mouth more after meals because of the availability of her supplies, “if I just happened to be at home and had I don't know like salad or something, you always get bits stuck to your teeth, so you go and clean your teeth, you're there and its available.” The patient also soaked her dentures once a week in bleach.

3.6.3. Oral health care at hospital

P5 was able to independently clean her mouth in hospital in the bathroom and did not require nurse support. The patient cleaned her mouth twice a day in hospital, reporting that she did not want to get up to do it more like she had done at home, “that's only morning and night now because I'm not getting out of bed just to clean my teeth.” The patient was satisfied with this frequency of routine in hospital, reporting, “Yes dear yes that's all it really needs, it must be clean and it is.”

Despite not needing support, she reported that the nurses still offered her support, “Well if he's going to shower me and he's there already he will help me anyway.” The patient acknowledged that if she was unable to do it, that she could ask a nurse for help, “if I can't I suppose I can always ask the nurse to come.”

3.7. Case 6: Participant 6 (P6)

A female patient aged 87 (P6) presented to the hospital due to having a fall. P6 had natural teeth and did not use a denture. She received a score of 5/16 on the OHAT. The patient presented with a dry patch on her lip, a lump under the tongue and broken/worn down teeth. She also had problems relating to oral cleanliness, including food debris, calculus and plaque. The patient reported no dental pain.

3.7.1. General perceptions of oral health and oral health care

P6 did not report having any problems or concerns with her mouth and was satisfied with the way her mouth looked and felt. P6 considered it important to keep her teeth clean, “I think it's always important to clean them when you can.” She also considered oral health care important for a comfortable feeling mouth, “Well it feels awful if it's not clean … shouldn't be dirty anyhow.”

3.7.2. Oral health care at home

P6 was able to clean her mouth independently at home. She reported consistently cleaning her teeth once daily at night‐time with a toothbrush and toothpaste.

3.7.3. Oral health care in hospital

P6 reported being able to clean her mouth independently in hospital. She continued to use a toothbrush and toothpaste to clean her mouth. She reported cleaning her teeth twice daily in hospital, once in the morning and once at night. Despite not needing support, she reported that the nurses brought supplies to her bedside at night so that she could clean her mouth.

P6 was satisfied with her oral health care in hospital. She reported being content with cleaning her mouth once or twice daily in hospital, which was influenced by how she felt at the time.

3.8. Case 7: Participant 7 (P7)

A 90‐year‐old male patient (P7) presented to the hospital due to complications from a fall. P7 presented with natural teeth and a partial denture. He received a score of 5/16 on the OHAT. The patient was aware of his dental problems and was able to direct the researcher as to which teeth to assess. The patient had broken/decayed teeth, a dry tongue and self‐reported dry mouth. Food debris was present on his denture, and the denture was unlabelled. The patient reported being in no pain.

3.8.1. General perceptions of oral health and oral health care

P7 had an awareness of his oral health problems and wanted to see his dentist regarding the matter:

“I've got a crook tooth and I've got another one that needs to be attended to you know and my mouth needs a clean, needs a dentist clean you know, so I'm saving for that, but other things come along and take the money you know, so seeing there's no pain there it goes to the bottom of the list.”

When asked if he was satisfied with the way his mouth looked and felt he replied, “Well I've had it for you know, 90 odd years, so you've got what you've got.” He reported being able to eat and therefore didn't worry about his mouth, “I can chew my food and digest my food, so you don't worry about it.”

The patient spoke about the importance of his mouth for his health and well‐being and was concerned about the impact that a delayed dental visit could have on his health:

“Well, it's vitally important for my heart. I'm diabetic and I suffer from heart failure which is the cause of the swelling in my legs. So that is an integral part of it and it concerns me that I can't go to the dentist when it needs to be done, I have to wait to save until I've got the necessary amount of money to be able to pay for care.”

He considered it important to clean his mouth at home and similarly echoed the importance of this for his health, “Yeah its necessary to clean your mouth out, yeah its necessary to do that twice a day, in the morning when I get up and before I go to bed at night‐time.”

3.8.2. Oral health care at home

The patient was able to complete oral health care independently at home. He described using a variety of products to clean his mouth including mouthwash, dental sticks, tablets for dentures, toothpaste and a toothbrush. He described cleaning his mouth twice a day with mouthwash. P7 reported temporarily reducing the amount he brushed his teeth due to his broken tooth.

3.8.3. Oral health care in hospital

P7 was able to clean his mouth independently in hospital, without nurse support. He continued to use mouthwash and dental sticks in hospital, using the mouthwash morning and night. The patient did not have his denture tablets and instead reported soaking his denture in water. The participant reported deliberately leaving his toothbrush at home, “I think I brushed my teeth too much and things went astray so … I've not brought my brush here.” He instead reported cleaning his teeth with tissues to “get the build‐up of stuff off.”

P7 reported being satisfied with his oral health care in hospital.

4. DISCUSSION

This embedded, multiple‐case study explored older patients' oral health status, as well as their opinions of, and experiences with oral hygiene in hospital. It also explored patients' oral hygiene habits and routines in the context of their home and hospital. The three main findings were (a) discrepancies exist between researcher and patient‐identified oral health problems, (b) patients enter hospital with unique and established oral health care routines and (c) understanding patients' oral health histories may be an important part of implementing person‐centred oral health care.

Discrepancies between researcher‐ and patient‐identified oral health problems were evident as, despite oral health problems being identified in the OHAT assessment, not all patients self‐reported problem(s) with their oral health. Where patients did self‐report problems, they typically did not identify the same number of problems as the researcher. This finding is consistent with findings from other studies, where nurses or researchers described older patients' oral health status as being poorer than the patients' descriptions. ²¹ , ³³ This might indicate that older patients have poor awareness of their oral health problems. Other authors suggest that older people might expect poor oral health in old age, that is, while they are aware of their presenting oral health concerns, they might not consider them to be “problems,” but rather the expected result of old age. ³⁴ , ³⁵ Further, they might not see oral hygiene as a priority in the face of the more acute health condition that brought them to hospital. ¹⁹ This has clinical implications if oral health assessments are not conducted by a member of the multidisciplinary health care team, as oral health problems are unlikely to be self‐reported by patients and may go unnoticed and hence untreated.

Similarly, there was an inconsistency between observed oral health status and patient‐reported satisfaction with their oral health. Four patients in this study reported being satisfied with the state of their mouth, even some who reported pain. This finding aligns with previous studies that suggest oral health problems have less of an impact on quality of life, as one ages. ³⁶ , ³⁷ , ³⁸ This is concerning as poor oral function strongly predicts the risk of frailty, and prevention of oral frailty at an early stage is essential for healthy ageing and to reduce risk of progression to oral hypofunction. ³⁹

In summary, clinical observations of patient's oral health status might not match the patient's own judgement of their oral health and, if not explicitly addressed, may mask the need for oral health and hygiene intervention. These findings emphasise the need to address patients' own perceptions of their oral health, as a part of a comprehensive and person‐centred oral health assessment. ² , ²¹

Patients had unique and established oral health care routines at home. Patients' routines varied in terms of how often they cleaned their mouth, when they cleaned their mouth and the products which they used to complete oral hygiene. Not only were patients' oral health care routines unique, but they were also considered and deliberate. Patients were able to rationalise why they chose to use or not use certain products. Where patients were unable to use the same products in hospital that they had used at home, patients reported this absence. Similarly, patients could describe the different variables that impacted their oral health care routines, such as brushing one's teeth more regularly when expecting company. Patients who cleaned their mouth a minimum of two times daily at home continued to clean their mouth two times daily in hospital. Additionally, those who only cleaned their mouth a minimum of once daily at home, similarly, cleaned their mouth once daily in hospital. In the present study, each patient valued oral health care, but the reasons varied. While some considered oral health care important for appearance, others considered its importance for their general well‐being. These findings are consistent with other studies; older adults wanted to maintain self‐care practices, which they had developed over their lifetime ¹⁸ as adherence to a self‐established routine facilitated a sense of self‐worth and self‐control. ¹⁹ It is important to older adults that their requests and needs dictate their oral health care, and they want personalised‐oral health care information. ⁴⁰

Patients may also measure their satisfaction with oral health care in hospital, against how closely it aligns with their pre‐established oral health care routines from home. All but one patient from this study was satisfied with their oral health care in hospital. The one patient who was not satisfied had the biggest discrepancy between oral health care frequency between his home and hospital contexts; cleaning his mouth at least twice daily at home but only offered support to clean his mouth less than once daily in hospital. Learning of patients' unique oral health needs, preferences and values might therefore be an important component in understanding the type of oral health care that patients desire in hospital.

Figure 1 outlines how we perceive a nested relationship between elements. We posit that unless the outer circles of oral health and oral health care histories are addressed, the unique nuances of patients' oral health care preferences might not be fully understood in hospital. Health professionals might therefore lack understanding about the type or frequency of care that patients want in hospital. This therefore impacts outcomes and satisfaction with oral health care in hospital.

FIGURE 1.

Nested diagram demonstrating the relationship between patients' oral health care histories and their oral health care in hospital.

The variability of patients' needs and preferences raises questions about the appropriateness of a one‐size‐fits‐all oral health care program in hospitals. Increasingly, rigorous oral health care is viewed as more than an aspect of grooming but rather as an important infection mitigation strategy by health professionals and service providers, ⁴¹ , ⁴² hence the impetus for standardised oral health care programs in hospitals and residential aged care. In South Australia, where this study was conducted, best practice guidelines for acute and residential aged care involve an oral health assessment and developed care plan. ²⁹ While the care plan involves some personalisation based on the findings of the oral health assessment, it does not address patients' perceptions of their oral health problems or their unique preferences for oral health care. While not discounting the need for patient education about oral health care being important to mitigate infection, if standardised programs and protocols do not align with patients' preferences for product use or oral health care frequency, as this study illustrates, patients might not be satisfied with their care. Therefore, a person‐centred assessment strategy that encompasses patients' (a) perceptions of their oral health problems, (b) unique oral health needs and (c) oral health care preferences is warranted. ⁴³ A possible suggestion is the use of oral health histories. ²⁰ Oral health histories could be used to facilitate the patients' oral health care narrative, demonstrating to patients that their experiences, needs and preferences are important to the clinical process. Once the patients' preferences are understood and oral health risk factors have been identified, the health care professional and patient can then participate in shared decision making, wherein the patient's values guide the development of their unique oral health care plan. Finally, oral health histories could be used to document the patient's values and preferences for care more generally, ensuring that all members of the health care team are able to access this information. ⁴⁴

A strength of this study was the case study design, a method considered valuable to the nursing sciences and health care disciplines, as it provides an up‐close insight into health care and health care delivery. ⁴⁵ , ⁴⁶ Having multiple in‐depth cases allowed for analysis of the differences and similarities between each case, ²³ providing a rich understanding of how oral health care was experienced and perceived by a group of older patients in hospital. In addition, the use of both qualitative and quantitative data strengthened the study by reducing deficiencies or biases that come from using a single method.

A limitation of this study is that patients who were unable to give consent were excluded from participating. This means that patients with dementia, who comprise a large proportion of patients on geriatric units and who are at greater risk of oral disease and in greater need of assistance with oral care than their more able peers, ⁴⁷ were not included and are thus not represented in this study. A further limitation is that the researchers did not have ethical approval to access the patients' medical records, including information about the oral health care provided by nurses or patients' ability to complete activities of daily living. Hence, there was no way to validate the patients' responses about their oral health care in hospital.

To the best of the authors' knowledge, there are no validated oral health history tools for older patients in hospital. Therefore, there is a need for researchers to develop and evaluate the validity and reliability of a tool to assess the benefit of using oral health histories in facilitating person‐centred oral health care in hospital. In addition, to overcome the limitations of this study, future research should include a focus on patients with dementia and other cognitive impairments, to explore their oral health care in hospital.

5. CONCLUSION

This study has offered a unique perspective on the potential benefits of using a person‐centred approach to oral health care. It revealed that older adults had oral health needs, which varied in their nature and severity, but who come to hospital with individualised and established oral health care routines. This highlights the importance of context and history in individuals' health behaviours and routines. The use of oral health histories in hospital may address older patient's needs, preferences, and facilitate shared decision making. Thus, there is a need for an oral health history tool to be tested and validated for use with older adults in hospital.

AUTHOR CONTRIBUTIONS

Made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data: JP, JM, SCH. Involved in drafting the manuscript or revising it critically for important intellectual content: JP, JM, SCH. Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content: JP, JM, SCH. Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: JP, JM, SCH.

FUNDING INFORMATION

This research received no specific grant from any funding agency in the public, commercial or not‐for‐profit sectors. However, the authors thank Flinders University and the participating hospital that supported this study.

CONFLICT OF INTEREST STATEMENT

All authors declare that they have no conflicts of interest.

ETHICS STATEMENT

Ethical approval was obtained from the local health network's human research ethics committee. Governance approval was also obtained from the hospital site.

Supporting information

Appendix S1

Data S1

Data S2

Murray J, Paunovic J, Hunter SC. More than a mouth to clean: Case studies of oral health care in an Australian hospital. Gerodontology. 2024;41:486‐497. doi: 10.1111/ger.12736

DATA AVAILABILITY STATEMENT

The participants of this study did not give written consent for their data to be shared publicly. The data may be made available from the corresponding author (SCH), upon reasonable request, and pending ethics amendment.