Oral Health Promotion Interventions in Residential Aged Care Facilities – A Systematic Review of Behaviour Change Techniques Used in Interventions

ABSTRACT

Background

The oral health status of older people living in residential aged care facilities (RACFs) is found to be very poor. Many oral health promotion interventions have been tested in RACF settings around the world with varying degrees of success.

Aim

The aim of this systematic review is to analyse the health promotion strategies used in oral health promotion interventions in RACF settings and map the behaviour change techniques (BCTs) used in interventions to the Behaviour Change Techniques Taxonomy Version 1 (BCTTV1). This will help us identify the BCTs that are used and how effective they are in improving oral health outcomes for residents and the knowledge, attitudes and skills of caregivers in providing mouth care assistance to residents of RACFs.

Methods

A database search was conducted in MEDLINE, Cochrane CENTRAL, Cochrane Database of Systematic Reviews (CDSR), EMBASE, PsycINFO, CINAHL and Web of Sciences databases to screen for articles relevant to the topic of the review; after full‐text review a total of 31 articles comprising both randomised controlled trials and non‐randomised intervention studies were included in this review. Risks of bias in randomised studies were assessed using the ROB2 tool and ROBINS‐I was used to evaluate non‐randomised studies. The description of intervention content in each study was coded for the presence of BCTs by two independent review authors trained in coding BCTs according to BCTTv1.

Results

The most commonly used BCTs were ‘demonstration of behaviour’, ‘instruction on how to perform behaviour’ and ‘credible source’. These BCTs were effective in improving oral health outcomes and knowledge of caregivers on short‐term follow‐up. A higher number of BCTs were coded in studies that showed significant improvement in oral health outcomes of residents on long‐term follow‐up with rarely used BCTs related to ‘monitoring and feedback’ being coded in majority of studies that showed consistent improvement in oral health outcomes of residents.

Conclusion

This review identified the most commonly used BCTs used in health promotion interventions to improve oral health among older people in RACFs and found that majority of interventions were targeted towards ‘knowledge transfer’ and were inconsistent in improving oral health outcomes for residents over long‐term. Well conducted studies with use of theoretical behaviour change frameworks to develop oral health promotion interventions are needed as majority of strategies used currently do not demonstrate consistent effectiveness in improving oral health outcomes for residents of RACFs.

1. Introduction

The composition of the global population is currently undergoing a demographic transition due to higher life expectancy and lower fertility rates [1]. As a result, the composition of people aged 65 years or above has increased worldwide. Data from the United Nations' World Population Prospects 2022 report reveals that 10% of the total global population were aged 65 years or above in 2022 [2]. According to projections, the number of people aged 65 years or above in the world is going to increase further to about 1.5 billion (16%) in 2050, which translates to one in six people being aged 65 years or above [3]. It is well documented that oral disease burden among older people is high, as nearly 2.5 billion people of all ages suffer from untreated dental caries worldwide, with the highest incidence of dental caries occurring at 70 years of age [4]. The prevalence of periodontal disease is also highest in people aged 60 years and above, and nearly 30% of older adults (people aged 65 years and above) experience edentulism as a result of prior periodontal disease worldwide [4].

Globally, oral diseases contributed to 8 million years lived in disability among people aged 50–74 years in 2019, and oral diseases were one of the ten leading causes of total years lived in disability among older people aged 70 years or above [4, 5]. Poor oral health status among older people affects their general health considerably by impacting their daily nutrition intake, social relationships and quality of life [6, 7]. Maintaining good oral health is essential for older people to lead a life with good functional status, reduced mortality and increased life expectancy [8]. However, poor oral health status is prevalent among older people, and more so in older people who live in residential aged care facilities (RACFs) or similar long‐term care institutions. International studies reveal that nearly two‐thirds of residents in RACFs have untreated dental decay, and around a third exhibit signs of periodontal disease [9, 10]. Even when oral health status is stable with no evidence of disease, upon admission to RACFs, oral health deteriorates rapidly due to several reasons, including the inability to perform routine oral/denture hygiene measures due to a decline in physical or cognitive abilities, relying on caregivers to perform oral/denture hygiene measures, and xerostomia due to polypharmacy for co‐existing morbidities [4]. There is also considerable evidence to show that the oral care assistance given by caregivers to older people in long‐term care facilities is insufficient. Formal evaluations of caregivers providing oral hygiene assistance have revealed very low adherence to standard oral hygiene protocols [11, 12]. Key standards that were never met by caregivers providing oral hygiene assistance to residents included brushing the teeth for at least 2 min, rinsing with mouthwash and flossing [12].

Regular oral hygiene practices, including toothbrushing with fluoridated toothpaste twice a day, flossing and denture hygiene practices (e.g., cleaning dentures regularly every day and storing them appropriately when not in use) are positive behaviours that enable older people to maintain an adequate level of oral health [11]. A previous systematic review has found that many oral health promotion interventions targeting residents or their caregivers in RACFs have been implemented worldwide in RACF settings with varying degrees of success [13]. Maintenance of good oral hygiene among residents of RACFs requires behaviour change among residents and their caregivers to establish good behaviours. Behaviour change interventions are defined as ‘coordinated set of activities that are designed to change specified patterns of behaviour’ [14]. Oral health promotion interventions in RACFs targeting oral/denture hygiene behaviours among residents or caregivers, therefore, employ specific behaviour change techniques (BCTs). BCTs are the active ingredients of an intervention and are defined as ‘observable, replicable and irreducible components of an intervention designed to alter or redirect causal processes that regulate behaviour’ [14]. A standardised language for describing and classifying BCTs has become possible since the development of a taxonomy of behaviour change called the ‘behaviour change techniques taxonomy version 1’ (BCTTv1) [15]. The BCTTv1 is a hierarchically structured taxonomy of 93 distinct BCTs that offers a reliable way to describe, interpret and implement the active ingredients of behaviour change interventions.

Previous studies have established that interventions seeking to alter behaviour have been poorly developed because they rely on personal experiences of the researcher or a particular behaviour change theory or are based on a superficial analysis of contextual factors [16, 17]. Health promotion/behaviour change interventions are not designed in a systematic manner with consideration to the target population, specific behaviour and the context in which the interventions will be implemented. Because of this, most complex health promotion interventions are unsuccessful in improving health outcomes for patients [18, 19]. For behaviour change interventions to be successful, an understanding of the mechanisms underpinning behaviour change is essential to identify techniques that are effective. In this systematic review, we aim to map the intervention content of oral health promotion interventions in RACFs to BCTs in the BCTTv1 taxonomy. By mapping intervention content to BCTTv1, we will understand which behavioural constructs have been targeted in oral health promotion interventions in RACFs to date. In addition, mapping provides a good overview of BCTs that have already been trialled and proven to be most effective in improving the oral health of the residents of RACFs.

2. Methods

A literature review of health promotion interventions conducted in RACFs or long‐term care institutions to improve the oral health of their residents aged 65 years or older was performed. To enhance methodological rigour and transparency, the Preferred Reporting Items for Systematic Reviews and Meta‐analysis (PRISMA) guidelines were used, and the trial protocol was registered with the International Prospective Register of Systematic Reviews, PROSPERO (CRD42022375632).

3. Data Source

Relevant articles for inclusion in the review were systematically identified by searching the following databases: Medical Literature Analysis and Retrieval System online (MEDLINE), Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database for Systematic Reviews (CDSR), EBSCO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (EMBASE), Web of Sciences and PsycInfo with search terms that were relevant to the population, intervention and outcome (File S1). Search terms included MeSH headings and key words based on oral health promotion interventions in RACFs such as ‘older people’, ‘nursing homes’, ‘health education’, ‘dental health’ etc. Time restrictions were not applied during the database search. A detailed search strategy was developed for each database, based on the search strategy developed for searching the MEDLINE database. This strategy was revised for searching other databases with consideration to different subject headings/terms/key words in different databases. The search strategy used in the MEDLINE database is given in Table 1. These search terms were adapted to the databases as required. Individual search terms associated with population, intervention and outcome were combined with the OR operator before all search strings were combined with the AND operator for the final search. All the results obtained from the search were exported to EndNote and duplicates removed. Two review authors (NA and SR) independently screened the titles and abstracts of all the articles that remained after removing duplicates for relevance to the topic of the review; studies that were found to be irrelevant were excluded. In the next stage, the two review authors (NA and SR) conducted a full‐text review of the articles independently for inclusion in the systematic review. Discrepancies for inclusion of studies in the review were solved by discussions between the two review authors. The reference lists of all the included studies were also screened by the review authors to find other potential studies that could be included in the review and were subjected to the same screening process.

TABLE 1.

Search terms for screening articles in MEDLINE database.

Concept 1 (Population of interest)	Concept 2 (Intervention)	Concept 3 (Outcome)
‘Older persons in residential aged care’ OR ‘nursing home’ OR ‘nursing homes’ OR ‘residential aged care facility’ OR ‘residential aged care facilities’ OR ‘older people’ OR ‘aged care’ OR ‘older persons’ OR ‘older people residents’ OR ‘older people in long‐term care facilities’ OR ‘older people in long term care’ OR ‘older people in long term care facility’ OR ‘homes for the aged’ OR ‘old age home’ OR ‘old age homes’ OR ‘aged’	‘Health education’ OR ‘behaviour change’ OR ‘behaviour modification’ OR ‘behaviour change’ OR ‘behaviour modification’ OR ‘health promotion’ OR ‘health program’ OR ‘health programs’ OR ‘behaviour change technique’ OR ‘behaviour change technique’ OR ‘conditioning therapy’ OR ‘behaviour therapy’ OR ‘behaviour therapy’ OR ‘behaviour therapies’ OR ‘behaviour therapies’ OR ‘modelling’ OR ‘self‐efficacy’ OR ‘motivational interviewing’ OR ‘conditioning therapies’ OR ‘facilitation of behaviour’ OR ‘facilitation of behaviour’ OR ‘action control’ OR ‘maintenance’ OR ‘relapse prevention’ OR ‘practice’ OR ‘guided practice’ OR ‘health related behaviour’ OR ‘health related behaviours’ OR ‘health behaviour’ OR ‘health behaviour’ OR ‘health behaviours’ OR ‘health behaviours’ OR ‘behaviour change techniques’ OR ‘behaviour change techniques’ OR ‘locus of control’ OR ‘sense of control’ OR ‘internal external control’	‘Oral health’ OR ‘dental health’ OR ‘dentistry’ OR ‘dentist’ OR ‘dental hygiene’ OR ‘oral health related quality of life’ OR ‘dentists’ OR ‘oral hygiene’ OR ‘oral health therapist’ OR ‘dental caries’ OR ‘gingivitis’ OR ‘dental hygienists’ OR ‘dental care’

4. Study Selection

All randomised controlled trials (RCTs), quasi‐experimental studies and non‐randomised studies evaluating the effectiveness or efficacy of oral health promotion interventions in RACFs were included. Oral health promotion interventions were defined as any intervention that targets behaviour change in residents or caregivers in RACFs, such as interventions administered by health practitioners (e.g., dentists, dental hygienists or other health educators) involving health education, demonstration of brushing or denture cleaning techniques, hands‐on training in tooth brushing techniques, group discussions, practical advice and workshops etc. Journal articles published in Non‐English languages were excluded. Editorials, letters to the editor, opinion pieces, conference papers, conference reviews, books and book chapters and articles published on community‐dwelling older people not residing in RACFs or long‐term care institutions were excluded. Studies that reported outcomes related to clinical improvement in oral health status of older people, changes in knowledge, attitudes and practices of residents or caregivers, self‐rated oral health, oral health related quality of life, oral hygiene or denture hygiene behaviours etc., were included in the review.

5. Data Extraction and Synthesis

A customised data extraction form was developed and piloted before extracting data. This data extraction form was used to extract information regarding participant characteristics, study design, study setting, duration of follow‐up, intervention characteristics, outcome measures and information needed for assessment of risk of bias. For BCT coding, the intervention content was mapped to BCTs in the BCTTv1 by two independent reviewers (NA and SR) who have been trained in coding BCTs in intervention descriptions according to the BCTTv1. In case of a discrepancy, the authors met to discuss and resolve the discrepancies in coding. The presence of BCTs was coded with (+) and the confidence for their presence was indicated with (+) which indicates probably present, and a code of (++) suggests that the BCT is definitely present in the intervention.

Risk of bias (RoB) for randomised controlled trials (RCTs) was assessed using the Cochrane ROB2 tool for individual RCTs and the Risk of Bias tool for cluster trials for cluster randomised controlled trials [20]. The Cochrane ROB2 tool has five domains for assessing risk of bias including bias arising from randomisation, bias due to deviation from intended intervention, bias from missing outcome data, bias in measurement of outcome and bias due to selective reporting. An overall risk of bias assessment is made based on the determined risk for each domain, with a study being at low risk if all domains have a low risk of bias, some concerns when one or more domains have some concerns, and high risk when one or more domains are judged to bias results highly. This tool was used to report whether a study was at high risk, low risk, or had some concerns that precluded it from being a study with low risk of bias. For non‐randomised studies, the risk of bias was assessed using the risk of bias in non‐randomised studies of interventions (ROBINS‐I) tool [21]. The ROBINS‐I tool has seven domains for assessing risk of bias including bias arising due to confounding, bias from selection of participants in the study, bias in classification of interventions, bias arising due to deviation from intended interventions, bias due to missing data, bias in measurement of outcomes and bias due to selective reporting of results. Overall risk of bias for non‐randomised studies of interventions was determined based on the determined risk of bias for each domain in the ROBINS‐I tool, with a study being considered to be at low risk when all domains had low risk, moderate risk when one or more domains had moderate risk, and serious risk of bias when one or more domains were judged to be at serious risk. Risk of bias assessment for all included studies was performed independently by NA and SR, and any discrepancies were solved by discussion between the two reviewers.

6. Data Analysis

As the studies included in our review had a high degree of heterogeneity in terms of the outcomes that were reported and the instruments used to measure them, we could not perform a meta‐analysis of the studies. Instead, we have provided a narrative synthesis of the findings from the studies included in the review focusing on the study type and setting, the target population, intervention and control conditions and types of outcomes. We also performed a descriptive analysis of the implementation strategies (intervention content) of the oral health promotion interventions used in RACFs or similar long‐term care settings and coded this content according to the BCTTv1 to determine the BCTs that were used in interventions. After coding the BCTs, we analysed the effectiveness of these BCTs where we used a statistically significant positive effect on the outcome as our measure of effectiveness.

7. Results

The completed database search initially yielded 5135 references, of which 1208 were duplicates. After duplicates were removed, 3927 titles were screened for abstracts. A total of 71 articles were included for full‐text review, among which 38 were excluded due to various reasons summarised in the flow chart (Figure 1).

FIGURE 1.

PRISMA Flow Diagram demonstrating the flow of studies.

Data were extracted from 31 articles, of which 12 were RCTs and the remaining 19 were non‐randomised intervention studies. Seventeen articles compared the outcomes between the intervention and control groups. The target population in the included studies varied between residents, caregivers or both. Fourteen articles only had an intervention group and did not have a comparison arm. The sample size in the included articles ranged from 10 to 1393 residents [22, 23]. The sample size of caregivers ranged from 9 to 2212 [24, 25]. The study design, study setting, composition of the control and intervention groups, and the baseline characteristics have been summarised in Table 2.

TABLE 2.

Study setting and baseline characteristics of intervention and control groups.

S. no.	Reference	Study site	Study type	Study setting	Intervention/control	Number of residents at baseline	Number of caregivers at baseline
1	Amerine et al., 2014 [26]	Arkansas, USA	Pre‐intervention post‐intervention pilot study	Long‐term care facilities	Intervention Control	58 20	—
							—
2	Budtz‐Jørgensen et al., 2000 [27]	Val Fleuri, France	Randomised controlled trial	Long‐term care facilities	Intervention Control	122 115	—
							—
3	Cadet et al., 2016 [24]	Cape Cod and Islands, USA	Pre‐test post‐test pilot study	Nursing homes	Intervention	—	9
4	deVisschere et al., 2011 [22]	Gent region, Flanders‐Belgium	5‐year longitudinal group randomised controlled trial	Nursing homes	Intervention Control	211 1182	—
							—
5	Fallon et al., 2006 [28]	Towoomba, Australia	Pilot implementation project	Residential aged care facilities	Intervention	—	50
6	Frenkel et al., 2001 & 2002 [29, 30]	United Kingdom	Cluster randomised controlled trial	Nursing homes	Intervention Control	201 211	151 144
7	Isaksson et al., 2000 [31]	Sweden	Quasi‐experimental study with pre and post‐test	Long‐term care facilities	Intervention	240	—
8	Janssens et al., 2016 [32]	East and West Flanders, Belgium	Cluster randomised controlled trial	Nursing homes	Intervention Control	—	165 94
9	Johansson et al., 2020 [33]	Sweden	Feasibility intervention study with a longitudinal design	Nursing homes	Intervention Control	30 16	24 9
10	Khanagar et al., 2014 & 2015 [34, 35]	Bangalore, India	Cluster randomised controlled trial	Nursing homes	Intervention Control	162 160	38 40
11	Konstantopoulou et al., 2020 [36]	Athens, Greece	Quasi‐experimental study	Nursing homes	Intervention Control	—	28 27
12	Kullberg et al., 2010 [37]	Sweden	Longitudinal evaluation study	Nursing homes	Intervention	43	—
13	Le et al., 2012 [38]	Ontario, Cananda	Controlled intervention study	Long‐term care facilities	Intervention Control	41 39	46 29
14	MacEntee et al., 2007 [39]	Vancouver, Canada	Randomised controlled trial	Long‐term care facilities	Intervention Control	59 68	63 85
15	Mojon et al., 1998 [40]	Geneva, Switzerland	Randomised controlled trial	Long‐term care facility	Intervention Control	58 58	—
16	Nicol et al., 2005 [41]	Scotland, UK	Controlled intervention trial	Nursing homes and long‐stay hospitals	Intervention Control	39 39	—
							—
17	Paulsson et al., 1998 [25]	Sweden	Quasi‐experimental study with pre and post‐test	Special housing facilities for elderly	Intervention	—	2212
18	Peltola et al., 2007 [42]	Helsinki, Finland	Longitudinal intervention study	Hospital unit for chronically ill elderly	Intervention Control	139 66	—
19	Portella et al., 2015 [43]	Porto Alegre, Brazil	Quasi‐experimental study	Nursing home	Intervention	80	—
20	Pronych et al., 2010 [44]	New Hampshire, USA	Pilot study	Nursing home	Intervention	46	137
21	Red et al., 2020 [23]	Mississippi, USA	Pre/post‐intervention study	Long‐term care facility	Intervention	10	29
22	Reed et al., 2006 [45]	USA	Pre/post intervention study	Extended care facility	Intervention	137	20
23	Samson et al., 2009 [46]	Norway	Quasi‐experimental study	Nursing home	Intervention	88	—
24	Schwindling et al., 2018 [47]	Baden‐Württemberg, Germany	Controlled clinical trial	Nursing homes	Intervention Control	178 91	—
25	Seleskog et al., 2018 [48]	Varmland, Sweden	Controlled clinical trial	Nursing homes	Intervention Control	15 22	13—
26	Simons et al., 2000 [49]	West Hertfordshire, UK	Quasi‐experimental study	Nursing homes	Intervention Control	87 126	39—
27	Sjogren et al., 2010 [50]	Sweden	Longitudinal evaluation study	Nursing homes	Intervention	41	—
28	Volk et al., 2020 [51]	New York, USA	Program evaluation study	Nursing homes	Intervention	—	335
29	Zenthofer et al., 2013 [52]	Germany	Randomised controlled trial	Long‐term care homes	Intervention Control	52 17	—
30	Zenthofer et al., 2016 [53]	Germany	Longitudinal cohort study	Long‐term care homes	Intervention	93	48
31	Zusman et al., 2015 [54]	Constanta, Romania	Pilot study	Residential home	Intervention	50	49

8. Interventions

The intervention in all studies involved providing oral health education to caregivers using traditional methods, including lectures using PowerPoint presentations, practical demonstrations of brushing techniques and denture hygiene measures using models, and providing information pamphlets/booklets/guidelines on oral health and oral hygiene techniques. In 15 studies, ongoing support was provided to caregivers by dental hygienists, dental health researchers or project supervisors throughout the course of the intervention. The duration of the studies varied from the shortest being hours in pre‐ and post‐studies to the longest being six years following intervention delivery. The details of the intervention, control conditions, duration and follow‐up intervals are given in Table 3.

TABLE 3.

Intervention and control conditions, duration and follow‐up intervals, outcomes and results.

Reference	Personnel involved in intervention delivery	Intervention	Control	Outcome measure	Findings
Amerine et al., 2014	Nursing assistants Dental hygiene champion	Facility A Dental education session A8 dental hygiene champion. for 1 h with PowerPoint presentation (Topics: links between oral and systemic health, commonly encountered oral health conditions in older people residing in LTCFs and the steps to provide adequate oral hygiene care to residents). Development of a guidebook on oral health and a daily oral health protocol for residents. Hands‐on support from the dental hygiene champion for 8 weeks Facility B received all except Hands‐on support	Facility C No education No guidebooks	Self‐reported oral health status Oral Health Assessment Tool (OHAT) [55] Geriatric oral health assessment index (GOHAI) [56]	Significant improvement in OHAT from pre to post‐intervention in facility A for, Tongue health (p = 0.011) Denture status (p = 0.025) Oral cleanliness (p = 0.046). Significant improvement in OHAT for tongue health (p = 0.008) in facility B No significant improvement in OHAT in control group (facility C) No improvement in GOHAI scores in any facility
Budtz‐Jørgensen et al., 2000	Dental hygienists	Oral health education by dental hygienists to caregivers 45‐min length interactive lecture with PowerPoint slides (Topics: Aetiology of dental caries and periodontal disease, denture hygiene, preventive measures and diet) Demonstration of oral hygiene techniques using models	No health education program	Intra‐oral examinations and yeast cultures from the oral mucosa and from the fitting surface of dentures at baseline and 18 months follow‐up to detect the occurrence of oral candidiasis	Significant reduction in severity of denture stomatitis in intervention group from baseline to 18 months follow‐up (p = 0.005) in comparison to control group Significant reduction in colony counts from mucosal surfaces from baseline to 18 months follow‐up in intervention group (p = 0.008) Significant reduction in yeast cultures from fitting surfaces of dentures at 18 months follow‐up in intervention group (p = 0.05)
Cadet et al., 2016	Dental faculty researchers	Training provided to nine certified nurse's aides (CNA's) using PowerPoint, videos, case discussions and hand‐outs Oral health's influence on quality of life, consequences of poor oral health for older people in nursing homes, oral hygiene techniques and referral to dental health providers for treating complex oral health problems were discussed during training	No control group	Changes in knowledge, self‐efficacy and attitudes to future training among certified nursing aides	No significant improvement in overall health knowledge post‐intervention Significant improvement in knowledge regarding tooth brush position in mouth (p < 0.05) and frequency of tooth brushing (p < 0.05) post‐intervention No change in self‐efficacy or attitudes towards future training post‐intervention
deVisschere et al., 2011	Train the trainer principle applied to registered nurses in nursing homes Oral health co‐ordinator	Appointment of an oral health co‐ordinator for each ward with 30–50 residents Half‐day theoretical and practical training sessions for oral health co‐ordinators who then trained other care workers in their ward Individual oral hygiene plan for each resident developed by oral health co‐ordinator and integrated into daily care by call care workers	Oral hygiene was performed as usual for the control group	Silness and Loe index for dental plaque [57] Denture plaque according to Augsburger and Elahi criteria [58]	No significant improvement in dental or denture plaque between baseline and 2‐ or 5‐year follow‐up in intervention group Multivariable analysis revealed nursing home capacity (p = 0.02), presence of toothpaste (p = 0.01) to be significant influencers of denture plaque Degree of dependency (p = 0.01) and presence of mouth rinse (p = 0.01) were significant predictors of dental plaque
Fallon et al., 2006	Senior oral health therapist	1 h long oral health education session to caregivers using PowerPoint presentation (Topics: Link between general and oral health, link between nutrition, prevention and oral disease, denture hygiene techniques, brushing techniques, behavioural interventions, use of props to assist dependent older people, supplemental information on caring for oral health of residents)	No control group	Customised oral health audit tool with six categories namely lips, gingiva and oral mucosa, tongue, full dentures, teeth and/or partial dentures and saliva on which ratings could be made to determine oral dysfunction with greater scores indicating higher dysfunction Customised education evaluation questionnaire to assess knowledge after intervention	No significant difference in oral dysfunction scores of resident's post‐intervention Significant improvement in knowledge on continuing to brush in case of bleeding gums, removing and storing dentures overnight in water post‐intervention
Frenkel et al. 2001 & 2002	Experienced health promoter	1 h long oral health education session for caregivers Caregivers feelings on oral health, role of dental plaque in oral disease were discussed Brushing techniques demonstrated for natural teeth and dentures	No oral health education intervention	Customised oral health knowledge and attitudes assessment questionnaire for caregivers For residents, the following outcome measures were assessed Denture plaque using disclosing solution on four buccal and mucosal surface segments Dental plaque using simplified Oral Hygiene Index [59] Denture induced stomatitis using Budtz‐Jørgensen classification [60] Gingivitis using separate segment wise scores for buccal and lingual surfaces	Significant improvement in mean knowledge in intervention group from 16.53 at baseline to 17.86 and 18.70 at 1‐ and 6‐months follow‐up (p < 0.001) Significant improvement in mean attitude in intervention group from 17.35 at baseline to 19.71 and 22.16 at 1 and 6 months follow‐up (p < 0.001) Significant improvement in denture plaque, dental plaque and gingivitis in intervention group with adjusted difference of −1.47 (−1.80, −1.13), −0.34 (−0.53, −0.14), −0.28 (−0.42, −0.15) respectively from baseline to 6 months follow‐up Significant improvement in denture induced stomatitis in intervention group at 6‐month follow‐up (p < 0.0001)
Isaksson et al., 2000	Dental hygienists	4‐h oral health education program focused on health of the oral cavity	No control group	Mucosal Plaque Index [61]	Significant improvement in plaque index with 58 residents scoring good post‐intervention compared to 40 at baseline (p < 0.001) Significant improvement in mucosal index with 78 residents showing no inflammation compared to 59 at baseline (p < 0.001)
Janssens et al., 2016	Investigator Project supervisor Ward oral health care organiser	Establishment of oral health care team with a project supervisor and two ward oral health care organisers to implement program 1.5‐h informative presentation on oral health protocols by investigator to oral health care team 2‐h lecture and 1 h practical education on oral health by dental hygienist to oral health care team 1.5‐h theory and practical education by ward oral health organisers to nurses and nurse's aides Setting up individual oral health records and oral care plan for each resident by nurses and nurse's aides Program monitored by investigators every 6 weeks and implementation problems discussed with oral health care team	No intervention protocol implemented	Knowledge and attitudes of nurses and nursing aides	Significant improvement in knowledge scores of intervention group with mean scores increasing from 65.52 at baseline to 83.83 (p < 0.001) at six months No significant change in attitudes after intervention
Johansson et al., 2020	Dental hygienist	Oral health coaching program for nursing staff with one workshop on incorporating behaviour change methods of facilitation, modelling, feedback, consciousness raising, individualisation and discussion to change behaviour among nurses caring for residents Dental hygienists present for 4 h per week to support nurses	No intervention, daily care performed as usual	Dental Coping Beliefs Scale for nursing staff [62] Revised Oral Health Assessment Guide (ROAG) [63] Mucosal plaque scores for residents [61]	Significant improvement in intervention group on knowledge on fluoride use (B = −1.31; p = 0.018) and residents' ability to seek help when oral health care was needed (B = −1.464; p = 0.017) following the intervention Significant improvements in ROAG components of voice (B = 0.019; p = 0.044) and teeth (B = 0.698; p = 0.014) at 3 months follow‐up with change persisting for teeth (B = 0.592; p = 0.024). at the sixth month follow‐up for intervention group Mucosal plaque scores stable throughout study period with no significant improvement
Khanagar et al., 2014 & 2015	Health educator	Oral health education with PowerPoint presentation Demonstration of oral hygiene techniques using models Health education manual and compact disc (CD) provided	No intervention until the end of study period	Customised knowledge, attitudes and practices assessment questionnaire for caretakers In residents, Debris component of Simplified Oral Hygiene index [59] Turesky‐Gilmore‐Glickman modification of the Quigley Hein Plaque Index [64] Denture Plaque Index by Armbjornsen [58] Denture induced stomatitis according to Budtz‐Jorgensen criteria [60]	Significant improvement (p < 0.001) in the knowledge of caretakers in the intervention group on the significance of oral health and oral hygiene, denture care practices, management of xerostomia and the value of regular dental check‐ups for older people in comparison to the control group Significant improvement in the intervention groups debris score which reduced to 1.49 ± 0.34 at 6‐months follow‐up from 2.87 ± 0.22 at baseline (p < 0.001), plaque index reduced to 1.57 ± 0.35 at 6 months from 3.17 ± 0.40 at baseline (p < 0.001), denture plaque scores decreased to 1.21 ± 0.27 at 6 months from 3.15 ± 0.47 at baseline (p < 0.001), and denture induced stomatitis decreased to 0.29 ± 0.53 at 6 months in comparison to 1.43 ± 0.68 at baseline (p < 0.001)
Konstantopoulou et al., 2020	Research team	90‐min geriatric oral health education to caregivers using PowerPoint presentation (Topics: link between oral health and general health, common oral diseases among older people, the difference between normal and pathological oral clinical findings, oral health assessment tools, oral hygiene promotion practices and reasons for dental referrals, recommendations for dementia residents) Practical demonstration of oral and denture hygiene techniques using relevant equipment Printed and online resources on oral health	No intervention until the end of study period	Customised knowledge and attitudes assessment questionnaire for caregivers	Significant improvement in total knowledge scores in the intervention group (10.8 ± 1.3) in post‐test in comparison to the control group (8.7 ± 1.5), p < 0.001 Effects were maintained in the intervention group at 2‐months follow‐up testing where the effects of the intervention on knowledge scores (9.9 ± 1.0) did not differ significantly from the post‐test scores (10.8 ± 1.3), p = 0.11
Kullberg et al., 2010	Dental hygienist	Educational intervention to nursing staff with hands‐on training in brushing techniques using electric toothbrushes Residents main caregivers provided with individualised instructions for oral health care Residents provided with electric toothbrush and instructed to use chlorhexidine gluconate 1% gel for 1 week every month instead of fluoridated toothpaste Dental hygienist was accessible at nursing homes for 1 day/week and at all other days through telephone	No control group	For residents, Gingival bleeding index [65] Plaque index [57]	Significant improvement in median gingival bleeding index from 9.0 (1.0; 9.0) at baseline to 0.0 (0.0; 2.0) post‐intervention, p < 0.001 Significant improvement in median plaque index from 18.0 (14.0; 26.0) at baseline to 9.0 (2.0, 11.0) post‐intervention, p < 0.001
Le et al., 2012	Not given	60‐min oral care education session for support staff members of nursing homes Knowledge pre‐test administered in first ten minutes followed by 40‐min oral care video Knowledge post‐test administered in the last ten minutes Topics for oral care video: Common oral health problems in older people in nursing homes, oral health promotion, daily oral hygiene and oral care decision making strategies to help staff choose appropriate care for residents	No intervention until the end of study period	Customised knowledge assessment tool for caregivers For residents, Modified plaque index [57] Modified gingival index [66]	Significant improvement in knowledge scores increased from 15.30 at baseline to 17.59 post‐intervention in intervention group and from 15.31 at baseline to 18.00 in the control group post‐intervention, p < 0.05 Significant improvement plaque index in intervention group from 1.90 ± 0.61 at baseline to 1.62 ± 0.79 at 6 months follow‐up and from 1.83 ± 0.72 at baseline to 1.62 ± 0.83 at 6 months follow‐up in control group, p < 0.05
MacEntee et al., 2007	Dental hygienist Nurse educator	Training of nurse educator via discussions using annotated clinical photographs and text on appearance and management of common oral diseases in older people in long‐term care Trained nurse educators conducted 1 h long seminar for care aides with clinical photographs, text and educational models of teeth and toothbrushes Nurse educator was supported by dental hygienist throughout program and care aides were supported by nurse educators who provided advice where needed	The same 1 h seminar with clinical photographs, text and education models was directly delivered by the dental hygienist to the care aides without any additional support or follow‐up	Geriatric Simplified Debris Index [59] Gingival Bleeding Index [65]	No significant improvement in any clinical indices following intervention
Mojon et al., 1998	Dental hygienist	45‐min interactive lecture to groups of 8–10 caregivers with PowerPoint slides and practical demonstration of brushing techniques for dependent residents Topics of lecture: Aetiology of common dental diseases, oral health promotion, dietary recommendations Dental hygienists provided scaling to residents and evaluated residents ability to care for their oral health Following evaluation, instructions were given to nurses and nurse aides accordingly	No oral health program implemented in the control group	Plaque index [57] Customised dental caries criteria Microbial sampling for Mutans streptococci and Lactobacillus	Significant decline in prevalence of active root caries in intervention group from 19.4% at baseline to 15.3% at 18 months follow‐up, p < 0.01 Significant decrease in Mutans streptococci colony counts in intervention group from baseline to 18 months follow‐up, p = 0.01 No significant improvement in Lactobacillus counts at 18 months follow‐up No significant improvement in plaque index from baseline to 18 months follow‐up
Nicol et al., 2005	Dentist Dental hygienist	90‐min long training session to care staff with initial 30‐min lecture using illustrations of oral cavity in health and disease and discussion on basic mouth care protocols Practical demonstration of brushing techniques, denture care and oral hygiene aids Local patients with oral diseases invited to the sessions to talk about their oral health problems Participants also invited to speak about problems encountered while trying to provide mouth care to residents Video on oral health at the end of session	No intervention until the 9th month follow‐up after which the same intervention of the intervention group was provided to the control group	Intra‐oral examination of teeth for the presence of decayed teeth and oral mucosa for the presence of erythema, mucosal plaques, glossitis, candidiasis, denture induced stomatitis, ulceration and hyperplasia Denture cleanliness and frequency of denture cleaning Clinical assessment of dry mouth	Mucosal disease decreased significantly to 55% at 18 months follow‐up from 79% at baseline in the intervention group, p = 0.012 Significant improvement in denture induced stomatitis in intervention group, absence of denture stomatitis increased from 32% at baseline to 50% at 18 months follow‐up, p = 0.039 Prevalence of angular cheilitis reduced significantly with percentage of residents with absence of angular cheilitis decreasing from 72% at baseline to 94% at 18‐months follow‐up, p = 0.039 Denture hygiene significantly better in the intervention group at 18 months follow‐up in comparison to baseline, p < 0.001 No significant change in denture wearing habits (wearing dentures at night time) at 18‐months follow‐up
Paulsson et al., 1998	Dental hygienists	Oral health education program to nursing personnel with four 1‐h long lessons in groups not exceeding 30 personnel on a single occasion Slides (120 pictures), videotape and compendium on oral health containing information on oral cavity in health and disease, rationale for special oral care programs for dependent elderly, removable and non‐removable prostheses and oral hygiene care techniques for compromised care receivers was prepared and discussed	No control group	Customised knowledge and attitudes questionnaire for nursing personnel	Significant improvement in nursing personnel' ability to provide oral hygiene care to residents, ability to advice care receivers on their oral health, attitudes regarding importance of knowledge on oral cavity in health and importance of knowledge on prosthesis after the intervention was delivered, p < 0.05
Peltola et al., 2007	Dental hygienists Nursing staff	Group A Scheduled dental hygienists visits for 4 h in 3‐week intervals during study period Dental hygienists brushed residents teeth using electric toothbrushes (Braun Oral‐B D15.511) and interdental spaces were cleaned using interdental brushes (Oral‐B Mini Interdental brushes) Removable dentures worn by residents were cleaned with denture brushes and Corsodyl 1% gel (GlaxoSmithKline, Research Triangle Park, NC, USA) Group B Nursing staff trained by dental hygienists to brush resident's teeth with electric toothbrush, interdental brushing and cleaning dentures After training, nurses were instructed to brush residents teeth with electric toothbrush every day, clean interdental spaces twice per week and rinse dentures after every meal, clean dentures with soap and water every evening and brush dentures with Corsodyl 1% gel once a week Dental hygienists visited the intervention group once for 1 h every three weeks to give additional instructions for issues raised by nursing staff	Did not receive the intervention or dental hygienists visits	For residents, Customised denture hygiene assessment criteria Modified plaque index to measure dental hygiene [57]	Percentage of participants with good denture hygiene increased significantly in intervention groups and the control group, p = 0.02 Change most prominent in group B where proportion of residents with good denture hygiene increased from 11% at baseline to 56% at 11 months follow‐up Significant improvement in dental hygiene only for group B, the percentage of residents with poor dental hygiene decreased from 80% at baseline to 48% at 11 months follow‐up, p = 0.02
Portella et al., 2015	Dental students	Oral health program for caregivers via a 2‐h long lecture with both theory and practical aspects Topics: Common risk factors for oral and general health, information on dental diseases, prevention and oral hygiene care instructions Practical demonstration of brushing techniques and denture hygiene techniques using models using toothbrushes and denture brushes Discussion at the conclusion of session to answer questions from caregivers Poster with illustrations on oral hygiene for residents distributed to bathrooms and rooms of residents to serve as guideline to provide mouth care for caregivers Toothbrush, toothpaste and denture brushes provided to residents Program reinforced three times during study period Feedback collected from caregivers on difficulties encountered in providing mouth care	No control group	Mucosal plaque score (MPS) for residents [61]	Significant improvement in MPS with percentage of residents with acceptable MPS scores increasing from 47.3% at baseline to 76.4% at 1 year follow‐up, p = 0.001
Pronych et al., 2010	Dental health personnel Oral health co‐ordinator	Oral health co‐ordinator appointed to serve as link between facility and dental health personnel, resource for other nursing staff and to ensure residents were provided with daily oral hygiene care Nursing assistants given training on mouth care via a 1‐h session with PowerPoint Topics: Brushing techniques, link between oral and general health, dental caries with emphasis on root caries and behaviour management Trainer accompanied nursing assistants while providing oral hygiene care and offered advice to improve confidence Modified brushing protocols offered for highly dependent residents and residents who could not spit and rinse	No control group	Debris index‐Simplified (DI‐S) for residents [59]	Significant improvement in mean debris index scores from baseline (2.285) to (2.096) at twelve months follow‐up, p < 0.05
Red et al., 2020	Primary investigator	30‐min long educational program with PowerPoint presentation of 18 min duration Topics: Importance of oral health for older adults, oral hygiene care, denture care, oral hygiene techniques, standards of care, managing care resistant behaviour among residents was also covered Practical demonstration of brushing techniques using model Instructions on keeping record of daily oral care provided to residents using a checklist developed by research team Educational handouts on oral health	No control group	Customised knowledge, skills and attitudes assessment tool for care staff Oral Health Assessment tool (OHAT) for residents [55]	Significant improvement in mean knowledge scores from pre‐test (88.8) to post‐test (97.7), p = 0.012 Significant improvement in OHAT scores from baseline to week 1 (p = 0.012) and from week 1 to week 2 (p = 0.020) No significant improvement in skills or attitudes
Reed et al., 2006	Research project staff Dentists	8 in‐service educational workshops for caregivers using PowerPoint presentation Topics: Oral health in older people, link between general and oral health, oral cavity in disease Demonstration of oral hygiene techniques with role playing 3 additional supplemental workshops focused on hands‐on demonstration of oral hygiene techniques with models and live patients Demonstration in live patients performed by dentists with nurses observing or assisting	No control group	Customised oral health knowledge assessment questionnaire for care providers	Significant improvement in oral health knowledge from pre‐test where 67.3% of items on the knowledge assessment tool were answered correctly to 90% of items answered correctly during post‐test, p < 0.01
Samson et al., 2009	Dentists Dental hygienists	4‐h oral health program with theory and practical training course for nursing staff Individualised picture‐based cards on specific oral care needs of resident hung in the bathroom to serve as a guideline for nursing staff Distribution of electric toothbrushes, interdental brushes, toothpaste, fluoride tablets, denture brushes, liquid soap, denture storage mugs with motivational message written on top Oral care contact person appointed to serve as link between dental team and residents and to teach oral hygiene routines to temporary staff Monitoring through screening residents in an interval of 6–18 months based on risk factors Feedback on residents' oral hygiene obtained Results of screening reported to warn administrators to enable improvement	No control group	MPS for residents [61]	Significant improvement in MPS from baseline to 3 months follow‐up, p < 0.001 which persisted at the 6‐year follow‐up, p < 0.001 36% of residents had an acceptable MPS at baseline which increased to 70% at the 6 year follow‐up
Schwindling et al., 2018	Dentist	Theoretical education session for caregivers using PowerPoint presentation Topics: Common oral health problems in older people, oral hygiene techniques for natural teeth and prostheses, handling interdental brushes and advice on other oral care products such as mouth rinses Film showing examples of routine oral hygiene measures Practical training in brushing natural teeth and dentures, handling removable prostheses and various types of restorations using typodonts Supervision of caregivers while performing oral hygiene care for residents Ultrasonic cleaning devices provided for cleaning dentures	No intervention until the end of study period	Plaque control record (PCR) [67] Gingival bleeding index (GBI) [65] Community periodontal index—Treatment needs (CPI‐TN) [68] Denture Hygiene Index (DHI) [69]	Significant improvement in intervention group PCR, group difference between intervention and control group for mean PCR was −14.4 (−21.8, −6.9) from baseline to six months p < 0.001, and −16.2 (−27.7, −4.7) from baseline to twelve months, p = 0.006 Significant improvement in intervention group DHI, group difference in DHI between intervention and control group was −15.0 (−23.6, − 6.5) from baseline to six months, p < 0.001 and −13.3 (−24.9, −1.8) from baseline to twelve months, p = 0.024 No significant improvement GBI or CPI‐TN at six or twelve months follow‐up
Seleskog et al., 2018	Dental hygienist	Weekly support by dental hygienists to nursing homes 2‐h long staff meetings held with director of nursing and nursing staff at the beginning, at 6 weeks and at end of study Daily oral hygiene instructions for residents discussed in meetings Customised and individualised hands‐on and theoretical guidance to nursing staff for 2 h on 1 weekday where nursing staff were accompanied with and supported while providing oral hygiene care to residents 30‐min supplementary meeting every week with nursing staff to discuss questions or doubts Specialised and individualised oral hygiene care prescriptions for residents Prescriptions distributed to each resident room and nursing staff instructed to sign off a signing sheet every day after providing oral care according to prescription	Oral care was performed as usual	For residents, Revised Oral Health Assessment Guide (ROAG) for residents [63] Plaque Index (PI) [57] by Silness and Loe Gingival bleeding by Loe and Silness criteria [66] Oral health education program evaluation questionnaire for care staff only in intervention group	Improvement in two components of the ROAG lips (p = 0.077) and gums (p = 0.074) in intervention group Significant improvement in plaque levels in the intervention group, median dental plaque at baseline was 1.5 (0.5–2.7) in the intervention group and decreased to 0.9 (0.3–2.7) at 3 months follow‐up, p < 0.05 No significant improvement in gingival bleeding in intervention group at 3 months follow‐up Staff were able to identify their own limitations in taking care of the oral health of their residents and valued contact with the dental health team more following the intervention
Simons et al., 2000	Dental hygienists Dental therapists	90‐min‐long education session, oral hygiene demonstration session with disclosing agents to visualise plaque Brushing techniques for natural teeth and dentures Carers cleaned each other's teeth Video and information on diet Oral health assessment and individual care plan for each resident introduced Training manual, samples, oral hygiene aids and information leaflets provided after session	No carer training was imparted in the control residential homes	Customised knowledge evaluation questionnaire for caregivers. For residents, Plaque Index [57] Gingival Index [66] Customised coronal caries criteria Root Caries Index [70] Customised denture plaque criteria Customised questionnaire for evaluation of the program	Improvement in carers knowledge at 1 week follow‐up No improvement in residents' perception of carer's behaviours following training at 1 week or 12 months follow‐up Significant improvement in coronal filled surfaces at 12 months follow‐up, p < 0.05 No significant improvement in other oral health indices at 1 week or 12 months follow‐up
Sjogren et al., 2010	Dental hygienist	Residents' primary contact person/caregiver given instructions about individual needs for oral hygiene care A mix of theoretical and practical training for nursing staff with a lecture on importance of oral health for older people and hands‐on training in oral hygiene techniques Residents with natural teeth instructed to use Chlorhexidine gluconate 1% gel twice a day for 1 week every month Residents also provided with electric toothbrush Group discussions with nursing staff based on cognitive behavioural therapy to modify negative attitudes, perceptions of uncomfortableness and behaviours to provide mouth care for residents	No control group	Plaque Index [57]	No statistically significant difference in median plaque scores from baseline to 1.5 years, plaque levels remained stable following intervention after 1.5 years
Volk et al. 2020	Dental hygienists Nursing home staff	Dental hygienists coached nursing home staff on oral care techniques and oral health aides like fluoride toothpaste and mouth rinses Trained nursing home staff then trained all the nursing staff in their nursing home A champion appointed in each nursing home who was responsible for organising team and implementing program Ongoing support to nursing staff provided by dental hygienist coaches through phone calls Coaches performed oral health checks on residents in on‐site visits and submitted quarterly reports	No control group	Modified Gingival Index [71] Oral hygiene index simplified [59] Customised denture plaque criteria Self‐efficacy questionnaire for staff members	Significant improvement in gingival index, oral hygiene index and denture plaque criteria from baseline to 6‐ and 12‐months follow‐up Significant improvement in self‐efficacy mean scores from 2.9 at baseline to 3.3 at 12 months follow‐up, p < 0.05
Zenthofer et al., 2013	Research team	Three intervention groups, residents in all three groups instructed individually on oral and denture hygiene Toothbrush, denture brush, toothpaste, mouth rinse and information leaflet distributed to all residents Caregivers completed 2‐h long education session with PowerPoint, film on oral hygiene and practical demonstration using dental models After this, intervention group 1 received no further intervention Participants in group 2 were remotivated and reinstructed at 4 and 8 weeks Participants in group 3 received help from nursing home staff twice a week	No intervention in the control group	PCR [67] DHI [69] GBI [65]	Significant improvement in DHI, PCR and GBI in all intervention groups at 12 weeks follow‐up All indices significantly worse in intervention groups at last recall following 3‐years in comparison to 12 weeks follow‐up, mean DHI, mean GBI and mean PCR increased by 42.9% (p < 0.01), 17.5% (p = 0.01) and 38% (p < 0.001) respectively
Zenthofer et al., 2016	Dentist	Two‐day oral health training program for care staff with focus on improving oral hygiene for dementia residents PowerPoint used for lecture and film used to show brushing techniques, handling toothbrushes, interdental space brushes, mouth rinses and toothpaste Oral health assessment tool introduced to cares to evaluate residents' oral health Practical training of oral and denture hygiene techniques on models under supervision of dentist who provided feedback Two ultrasonic cleaning devices provided to nursing homes to clean dentures	No control group	PCR [67] GBI [65] CPI‐TN [68] DHI [69]	Significant improvement in GBI from 52.1 ± 29.2 at baseline to 37.7 ± 24.5 at six months follow‐up, p < 0.05 Significant improvement in CPI‐TN from 3.3 ± 06 at baseline to 3.0 ± 0.7 at six months follow‐up, p < 0.01 Significant improvement in DHI from 86.1 ± 20.1 at baseline to 55.3 ± 35.1 at six months follow‐up, p < 0.001 No significant improvement in PCR
Zusman et al., 2015	Dentistry students Dental hygienist	Dentistry students and staff of long‐term care institutions trained on theoretical and practical aspects of preventing oral disease by dental hygienist Each student provided 1 h of coaching every week to caregivers responsible for providing mouth care to residents for 4 months Coaching included diet planning and advice, brushing techniques using fluoride toothpaste and denture care	No control group	Customised oral health knowledge and attitudes assessment questionnaire for care givers For residents, Decayed, Missing and Filled Teeth (DMFT), WHO criteria 1997 [72] Simplified Oral Hygiene Index (OHI‐S) [59]	Significant improvement in mean oral health knowledge scores from 28.8 ± 6.6 at baseline to 40.8 ± 3.0 at 14 weeks follow‐up, p < 0.001 Significant improvement in attitude scores from 6.2 ± 0.9 at baseline to 6.6 ± 0.6 at 14 weeks follow‐up, p = 0.013 No significant improvement in OHI‐S following intervention

9. BCT Coding

BCTs to improve oral health knowledge of caregivers and oral health status of residents were identified in all intervention groups but not in control groups, except for two articles in which BCTs were also coded in control groups. The number of BCTs used in each study varied greatly ranging from two to eight. From the taxonomy of 93 BCTs in BCTTv1, 17 distinct BCTs were identified and coded in the articles included in this review. The BCT ‘demonstration of behaviour’ was coded in all 31 articles and was the most frequently used BCT across all studies included in the review followed by ‘instruction on how to perform behaviour’ which was identified in 30 articles. The BCT ‘credible source’ was coded in 27 articles, ‘social support (practical)’ in 15 articles, ‘adding objects to the environment’ in 13 articles and ‘behavioural practice’ in 11 articles. In addition, ‘information about health consequences’, ‘feedback on behaviour’ and ‘prompts/cues and non‐specific incentive’ were coded in 7 and 2 articles, respectively. The least frequently coded BCTs across studies were ‘action planning’, ‘monitoring of behaviour by others without feedback’, ‘monitoring of behaviour with feedback’, ‘framing/reframing’, ‘feedback on outcomes of behaviours’, ‘restructuring the physical environment and social support (unspecified’) which were all coded in 1 article each across 31 articles. The details of BCT coding for each study in the intervention and control group are presented in Table 4.

TABLE 4.

BCTs identified in each study.

Reference	Intervention/control	BCTs identified with confidence (+, ++)
Amerine et al., 2014	Intervention	Demonstration of behaviour (++) Instruction on how to perform behaviour (++) Information about health consequences (++) Credible source (++) Social support (practical) (++)
	Control	None
Budtz‐Jørgensen et al., 2000	Intervention	Addition of objects to the environment (++) Demonstration of behaviour (++) Instruction on how to perform behaviour (++) Information on health consequences (+)
	Control	None
Cadet et al., 2016	Intervention	Demonstration of behaviour (++) Instruction on how to perform behaviour (++) Information about health consequences (+) Credible source (++)
	No control group
deVisschere et al., 2011	Intervention	Credible source (++) Demonstration of behaviour (++) Instruction on how to perform behaviour (+) Social support (practical) (++)
	Control	None
Fallon et al., 2006	Intervention	Demonstration of behaviour (++) Credible source (++) Instruction on how to perform behaviour (+)
	No control group
Frenkel et al., 2001 & 2002	Intervention	Credible source (++) Demonstration of behaviour (++) Behavioural practice (++) Instruction on how to perform behaviour (++) Addition of objects to the environment (++)
	Control	None
Isaksson et al., 2000	Intervention	Demonstration of behaviour (+) Credible Source (++)
	No control group
Janssens et al., 2016	Intervention	Demonstration of behaviour (++) Credible source (++) Behavioural practice (++) Instruction on how to perform behaviour (++) Social support unspecified (+) Social support practical (+) Adding objects to the environment (+)
	Control	None
Johansson et al., 2020	Intervention	Credible source (++) Social support (practical) (++) Demonstration of behaviour (++) Instruction on how to perform behaviour (++) Behavioural practice (++) Feedback on behaviour (++) Information about health consequences (++) Prompts/cues (+)
	Control	None
Khanagar et al., 2014 & 2015	Intervention	Demonstration of behaviour (++) Instruction on how to perform behaviour (++)
	Control	None
Konstantopoulou et al., 2020	Intervention	Credible source (++) Demonstration of behaviour (++) Instruction on how to perform behaviour (++) Information about health consequences (+)
	Control	None
Kullberg et al., 2010	Intervention	Demonstration of behaviour (++) Instruction on how to perform behaviour (++) Credible Source (++) Behavioural practice (+) Addition of objects to the environment (++) Social support (practical) (++)
	No control group
Le et al., 2012	Intervention	Demonstration of behaviour (++) Instruction on how to perform behaviour (++)
	Control	None
MacEntee et al., 2007	Intervention	Demonstration of behaviour (++) Instruction on how to perform behaviour (++) Credible source (++) Social support (practical) (++)
	Control	Demonstration of behaviour (++) Instruction on how to perform behaviour (++) Credible source (++)
Mojon et al., 1998	Intervention	Demonstration of behaviour (++) Instruction on how to perform behaviour (+) Credible source (+) Social support (practical) (+) Addition of objects to the environment (+)
	Control	None
Nicol et al., 2005	Intervention	Credible source (++) Demonstration of behaviour (++) Instruction on how to perform behaviour (+)
	Control	Same as above following 9 months follow‐up
Paulsson et al., 1998	Intervention	Credible source (++) Demonstration of behaviour (++) Instruction on how to perform behaviour (++)
	No control group
Peltola et al., 2007	Intervention	Demonstration of behaviour (++) Instruction on how to perform behaviour (+) Action planning (+) Social support (practical) (++)
	Control	None
Portella et al., 2015	Intervention	Credible source (++) Demonstration of behaviour (++) Instruction on how to perform behaviour (++) Addition of objects to the environment (++)
	No control group
Pronych et al., 2010	Intervention	Social support (Practical) (++) Demonstration of behaviour (++) Instruction on how to perform behaviour (++) Information on health consequences (++) Feedback on behaviour (++) Non‐specific incentive (+) Credible source (++)
	No control group
Red et al., 2020	Intervention	Demonstration of behaviour (++) Instruction on how to perform the behaviour (++) Social support practical (+) Addition of objects to the environment (++) Credible source (+)
	No control group
Reed et al., 2006	Intervention	Demonstration of behaviour (++) Instruction on how to perform behaviour (++) Credible source (++)
	No control group
Samson et al., 2009	Intervention	Credible source (++) Demonstration of behaviour (++) Instruction on how to perform behaviour (++) Prompts and cues (+) Restructuring the physical environment (+) Addition of objects to the environment (++) Social support (Practical) (++) Feedback on outcomes of behaviour (++)
	No control group
Schwindling et al., 2018	Intervention	Demonstration of behaviour (++) Instruction on how to perform behaviour (++) Credible source (++) Behavioural practice (++) Monitoring of behaviour by others without feedback (++) Adding objects to the environment (++)
	Control	None
Seleskog et al., 2018	Intervention	Credible source (++) Instruction on how to perform behaviour (++) Behavioural practice (++) Demonstration of behaviour (++) Social support (practical) (++) Non‐specific incentive (+)
	Control	None
Simons et al., 2000	Intervention	Demonstration of behaviour (++) Behavioural practice (++) Instruction on how to perform behaviour (+) Credible source (+)
	Control	None
Sjogren et al., 2010	Intervention	Credible source (++) Instruction on how to perform behaviour (++) Demonstration of behaviour (++) Behavioural practice (+) Addition of objects to the environment (+) Social support practical (++) Framing/reframing (++)
	No control group
Volk et al., 2020	Intervention	Demonstration of behaviour (++) Instruction on how to perform behaviour (++) Behavioural practice (++) Social support (practical) (++) Credible source (++) Information about health consequences (++)
	No control group
Zenthofer et al., 2013	Intervention	Group I and II Instruction on how to perform behaviour (++) Credible source (+) Demonstration of behaviour (++) Behavioural practice (+) Addition of objects to the environment (++) Group III All the above plus Social support (practical) (++) Monitoring of behaviour with feedback (+)
	Control	None
Zenthofer et al., 2016	Intervention	Demonstration of behaviour (++) Instruction on how to perform behaviour (++) Behavioural practice (++) Addition of objects to the environment (++) Credible source (++)
	No control group
Zusman et al., 2015	Intervention	Demonstration of behaviour (++) Instruction on how to perform behaviour (++) Credible source (++) Addition of objects to environment (++)
	No control group

Note: + − Coded with confidence, ++ − Coded with high confidence.

10. Outcomes

The outcome measures varied widely between articles. While five and seventeen studies reported outcomes for caregivers and residents, respectively, nine studies reported outcome measures for both residents and their caregivers. The outcome measures for residents included both clinical (e.g., oral hygiene status, denture hygiene status) and self‐reported outcome measures (e.g., quality of life). The types of outcome measures used in each study, along with the follow‐up duration and the findings are presented in Table 3.

11. Caregiver Related Outcomes

Among caregivers, the outcomes were knowledge, attitudes and skills related to oral health and providing oral care assistance to residents. Among 14 studies that reported outcome measures for caregivers, one found improvement in knowledge estimated using a validated scale; all other studies used customised questionnaires or assessment tools to report knowledge, attitudes and self‐efficacy or skills. In terms of knowledge, all studies showed a significant improvement in the oral health knowledge of caregivers following intervention except one [24]. Three studies included in the review showed significant improvement in caregivers' attitudes following intervention [23, 24, 32] while three failed to show significant improvement in caregiver attitudes [25, 30, 54]. One study reported significant improvement in self‐efficacy following intervention, while two reported no significant change in self‐efficacy or skills [23, 24, 51].

12. Resident Related Outcomes

For studies involving residents, two used the Oral Health Assessment Tool (OHAT); there was significant improvement in OHAT scores in both studies, with one study showing improvement in scores for tongue health, denture status and oral cleanliness, and the other study showing overall improvement in OHAT scores following intervention [23, 26]. Among 21 studies that used plaque indices to quantify plaque, plaque control record (PCR) was used in 3 studies, simplified oral hygiene index (OHI‐S) in 3 studies, debris component of oral hygiene index in 2 studies, mucosal plaque scores in 4 studies, plaque index in 6 studies and modified plaque index in 3 studies. Of the 21 studies, 13 studies showed significant improvement in dental plaque levels among residents following intervention, 6 showed no significant improvement, and plaque levels remained stable in two studies. One study reported significant improvement in dental plaque levels following intervention at 12 weeks follow‐up, but on long‐term follow‐up, the dental plaque levels worsened and increased significantly at the 3‐year follow‐up [52].

Two studies involved microbial sampling and one study each conducted yeast cultures to test for the presence of oral candidiasis, and Mutans streptococci and Lactobacillus colony counts following intervention [27, 40]. Both studies reported significant reductions in colony counts for yeast culture and Mutans streptococci, but there was no significant improvement in Lactobacillus colony counts following intervention [40]. Ten studies evaluated denture hygiene using the denture hygiene index (DHI) or customised denture plaque criteria. Out of these, seven studies showed significant improvement in denture hygiene following intervention [26, 29, 35, 41, 42, 48, 51] while two showed no significant improvement [22, 49]. One study reported significant improvement at 12 weeks follow‐up but denture plaque levels worsened on long‐term follow‐up at three years [52]. The details of the type of outcome measures used to evaluate denture hygiene and the results are captured in Table 3.

13. Association Between BCTs and Outcomes

There was some correlation between the number of BCTs used and oral health outcomes of residents or outcomes related to oral health knowledge and attitudes among caregivers. The three most commonly used BCTs, ‘demonstration of behaviour’, ‘instruction on how to perform behaviour’ and ‘credible source’ had a significant positive effect on improving caregivers oral health knowledge in ten studies included in the review. One study showed no improvement in the oral health knowledge of caregivers following an intervention using these three BCTs in addition to the BCT ‘information about health consequences’ [24]. Among six studies that used the three most commonly coded BCTs, three showed significant improvement in attitudes following intervention, while three failed to show improvement. The association between specific BCTs and significant improvement in caregiver attitudes were inconsistent, for example, the BCT ‘behavioural practice’ was coded in two articles, of which one reported improvement in caregivers attitudes while the other found no improvement after intervention [30, 32]. Likewise, the association between BCTs and oral health outcomes of residents was inconsistent. For example, in the 21 studies that evaluated dental plaque levels, the BCT ‘addition of objects to the environment’ was coded in 10 studies, of which seven showed significant improvement while the remaining found no improvement in plaque levels. However, in 12 studies with a long‐term follow‐up of 12 months or more, the BCTs ‘feedback on behaviour’, ‘feedback on outcomes of behaviour’ and ‘monitoring of behaviour by others without feedback’ were coded and these studies reported significant improvement in dental health indices of older residents on long‐term follow‐up.

14. Quality Assessment

The results of the RoB analysis of all cluster RCTs are presented in Figure 2. All studies were at a high RoB except for studies by Frenkel et al. (2001 & 2002) and Seleskog et al. [29, 30, 48], which were judged to be at moderate RoB. The only RCT included in this review was also judged to be at a high risk of bias [52].

FIGURE 2.

Risk of bias assessment for cluster randomised controlled trials.

For non‐randomised intervention studies, the ROBINS‐I tool was used for assessing RoB. The results are presented in Table 5. Out of 19 non‐randomised intervention studies, 17 were judged to be at a serious risk of bias, and two were judged to be at a moderate risk of bias.

TABLE 5.

Risk of bias assessment for non‐randomised intervention studies.

Reference	Bias due to confounding	Bias in selection of participants into study	Bias in classification of interventions	Bias due to deviation from intended intervention	Bias due to missing data	Bias in measurement of outcomes	Bias in selection of reported result	Overall risk of bias
Cadet et al., 2016	Serious	Moderate	Low	Low	Low	Serious	Low	Serious
Fallon et al., 2006	Serious	Low	Serious	Low	Serious	Moderate	Low	Serious
Isaksson et al., 2000	Serious	Low	Serious	Low	Low	Moderate	Low	Serious
Johansson et al., 2020	Serious	Low	Moderate	Low	Serious	Serious	Low	Serious
Konstantopoulou et al., 2020	Serious	Low	Low	Low	Serious	Serious	Low	Serious
Kullberg et al., 2010	Serious	Low	Low	Low	Moderate	Moderate	Low	Serious
Nicol et al., 2005	Serious	Low	Low	Low	Low	Low	Low	Serious
Paulsson et al., 1998	Serious	Low	Moderate	Low	Serious	Moderate	Low	Serious
Portella et al., 2015	Serious	Low	Moderate	Low	Serious	Moderate	Low	Serious
Pronych et al., 2010	Serious	Serious	Low	Low	Low	Moderate	Low	Serious
Red et al., 2020	Serious	Low	Moderate	Low	Low	Serious	Low	Serious
Reed et al., 2006	Serious	Low	Moderate	Low	Moderate	Moderate	Low	Serious
Samson et al., 2009	Serious	Low	Low	Low	Low	Moderate	Low	Serious
Schwindling et al., 2018	Low	Low	Low	Low	Moderate	Low	Low	Moderate
Simons et al., 2000	Serious	Low	Moderate	Low	Low	Moderate	Low	Serious
Sjogren et al., 2010	Serious	Low	Low	Low	Moderate	Low	Low	Serious
Volk et al., 2020	Serious	Low	Low	Low	Moderate	Moderate	Low	Serious
Zenthofer et al., 2016	Moderate	Low	Moderate	Low	Low	Moderate	Low	Moderate
Zusman et al., 2015	Serious	Low	Moderate	Low	Low	Moderate	Low	Serious

15. Discussion

The aim of this review was to analyse and identify the ‘active contents’ of oral health promotion programs implemented in RACFs or similar long‐term care facilities for older people around the world and find out what BCTs have been used for improving oral health among older people. To the authors' knowledge, this is the first review that has analysed and coded oral health promotion interventions in RACFs using a taxonomy of behaviour change techniques called the BCTTv1 [15]. Thus, this review fills a gap in research and advances researchers' understanding of BCTs used to promote oral health in RACF settings. This review also provides an insight into how effective the identified BCTs have been in improving oral health outcomes for residents or oral health knowledge, attitudes and skills among caregivers who provide oral care assistance to older people in RACFs.

A total of 31 studies were included in this review and we found mixed evidence on the effects of interventions on improving oral health outcomes of residents or oral health knowledge, attitudes, skills among caregivers. Educational interventions focusing on ‘knowledge transfer’ were present in all studies with the BCT ‘demonstration of behaviour’ being the most commonly coded BCT. Most of the interventions were targeted towards caregivers of RACFs and were delivered by dental health professionals or the research team. The duration, content, involvement of the participants in the intervention, follow‐up intervals and outcomes used to assess effectiveness of interventions varied significantly between studies. The details in the description of interventions also varied widely with some reporting the interventions rigorously while others reported intervention strategies briefly. The descriptions of control conditions in comparison to intervention conditions were not sufficiently detailed in studies that used a control group, and there was also no information on the rationale for the selection of particular BCTs in most of the studies included in this review. BCTs were identified in all intervention groups and the most commonly coded BCT was ‘demonstration of behaviour’. A minimum of two BCTs were coded in every study. This is similar to previous findings from a systematic review that analysed the behavioural determinants targeted by oral health promotion interventions and found that a combination of strategies were used in all oral health promotion interventions in RACFs as opposed to a single strategy [13]. Johansson et al. and Samson et al.'s [33, 46] studies used the most number of BCTs among all studies included in this review, eight distinct BCTs were identified in both these studies. Studies by Isaksson et al., Khanagar et al. and Le et al. [31, 34, 35, 38] used only two BCTs. There was some correlation between the number of BCTs used in a study and the outcomes but this association was not always consistent. All studies using the highest and lowest number of BCTs have showed significant improvement in knowledge of caregivers or oral health outcomes of residents such as an improvement in plaque index scores and mucosal plaque scores in Le et al. and Samson et al.'s [38, 46] studies. One possible reason for significant intervention effects being observed in studies with a low number of BCTs could be due to the relatively shorter follow‐up period in these studies, while intervention effects may have been observable on short‐term follow‐up, it is uncertain whether these effects would have been maintained over a longer follow‐up period. On the other hand, studies using the highest number of BCTs had a longer follow‐up period [33, 46].

The findings of this review also indicate that the most common groupings of BCTs across all studies included were ‘demonstration of behaviour’, ‘instruction on how to perform behaviour’ and ‘credible source’, which are predominantly focused on improving knowledge and self‐efficacy on oral health and oral health‐related behaviours. This finding is similar to the previous systematic review, which reported that most oral health promotion interventions in RACFs or similar long‐term care settings used strategies that addressed the behavioural determinants of knowledge and self‐efficacy [13]. These three BCTs were used in 26 articles, among which, 21 reported significant improvement in outcome measures when these three BCTs were coded alone or in combination with other BCTs. Significant improvement in oral hygiene levels of residents measured by plaque indices were reported in some studies that used the most common grouping of BCTs. Short‐terms effects of the interventions on dental plaque were inconsistent. Among studies that had a longer follow‐up duration of 12 months or more, the majority of studies that showed significant improvement in dental plaque had BCTs related to monitoring and feedback in their intervention strategies. This finding is similar to a previous review which has found that only strategies such as ‘increasing memory’ and ‘feedback on clinical outcomes’ related to monitoring and feedback were associated with consistently improving oral health outcomes for residents [13].

Other clinical outcomes that were evaluated include denture hygiene levels of residents where the majority of studies showed significant improvement following an intervention with the most common BCT grouping. A higher number of BCTs were coded in studies that showed significant improvement in denture hygiene in comparison to studies reporting non‐significant effects. However, these were studies with a short‐term follow‐up period; intervention effects on denture hygiene were not sustained over long‐term follow‐up in studies that had a longer follow‐up period. This suggests that the most common BCTs used in oral health promotion interventions for older people in RACFs are not effective in improving denture hygiene over a long period of time. In this review, the intervention effects on gingival bleeding and Community Periodontal Index of Treatment Needs (CPI‐TN) among residents in long‐term care were inconsistent, with an equal number of studies reporting significant and non‐significant effects on gingival bleeding and CPI‐TN. The inconsistent association between BCTs used in oral health promotion interventions and the oral health status of residents was similar to findings from a previous review which found that most strategies used in interventions failed to consistently demonstrate significant positive effects on the oral health outcomes of residents [13].

The oral health of residents post‐intervention was assessed using OHAT in two studies with both showing significant improvements in some components or overall OHAT score. The most common BCT grouping was coded in these studies along with other BCTs such as ‘social support (practical)’, ‘information about health consequences’ and ‘addition of objects to environment’. However, both studies using OHAT as the outcome measure had a very short follow‐up duration of two to eight weeks which precludes us from reaching conclusions regarding the long‐term effectiveness of these strategies.

Among the studies included in our review, 13 evaluated the ‘knowledge’ gained after an oral health promotion intervention targeting caregivers working in long‐term care. Twelve studies showed significant improvement in caregivers ‘knowledge’ on oral health following intervention. The most common BCT grouping was observed in all studies showing significant effects on knowledge except for Khanagar et al. and Le et al.'s [34, 38] studies where only two BCTs were coded. Most studies assessing knowledge gain had a short‐term follow‐up period of six months or less. Johansson et al.'s [33] study evaluated knowledge gained post‐intervention after a nine month follow‐up period and reported significant improvement in caregivers knowledge on fluoride use, support for oral health, gum disease and interproximal cleaning. The highest number of BCTs used in interventions was coded in Johansson et al.'s study where 8 distinct BCTs were identified, rarely coded BCTs of ‘prompts/cues’ and ‘feedback on behaviour’ were coded in this study suggesting that rarely used intervention strategies are effective in maintaining intervention effects over long‐term follow‐up. Some studies that assessed attitudes of caregivers following intervention reported significant improvements in caregiver attitudes following intervention. The association between BCTs coded in intervention descriptions and effects on caregiver attitudes were inconsistent. Two studies assessed improvements in self‐efficacy of caregivers following intervention of which one reported significant improvement on long‐term follow‐up. Similar to studies assessing knowledge gain, a higher number of BCTs were coded in the study showing significant effects on self‐efficacy with the BCTs ‘information about health consequences’, ‘behavioural practice’ and ‘social support (practical)’ being identified along with the most common BCT grouping [51]. This suggests that providing support to the caregivers during the course of the health promotion intervention is successful in improving self‐efficacy of caregivers in providing oral hygiene assistance to elderly residents.

Out of the 31 studies included in our review, 12 studies had a long follow‐up duration of 12 months or more, with Samson et al.'s [46] study having the longest follow‐up duration of 6‐years post‐intervention. All 12 studies reported oral health outcomes for residents with 8 showing significant improvement in oral health outcomes following intervention. Higher number of BCTs were coded in majority of studies showing improvement in oral health outcomes over long‐term follow‐up. The exceptions to this were Schwingling et al.'s study, which failed to show a significant improvement in CPI‐TN, and Zenthofer et al.'s (2013) study which did not show significant improvement in PCR, DHI or GBI over long‐term follow‐up [47, 52]. However, this maybe because Schwingling et al.'s study recruited residents with Grade 3 or 4 CPI‐TN, which requires clinical periodontal treatment and does not resolve due to changes in oral hygiene habits [47]. Zenthofer et al.'s (2013) study had three intervention groups, of which 6 BCTs were coded only for one intervention group. The results of the three groups were reported together for the last follow‐up, which does not allow us to make interpretations for the long‐term effectiveness of higher BCTs in one intervention group [52]. Generally, interventions tended to be more successful over the long term when a higher number of BCTs were coded in intervention descriptions.

Rarely coded BCTs related to monitoring and feedback were observed in some studies with longer follow‐up duration of which majority reported significant improvement in oral health outcomes for residents following intervention. The BCT ‘feedback on behaviour’ was coded in Pronych et al.' study which had a ‘job shadowing’ component in addition to health education where trainers who provided training to nursing staff accompanied them while they provided mouth care to residents and offered advice where needed [44]. The BCT ‘feedback on outcomes of behaviour’ was coded in Samson et al.'s study where the oral hygiene status of residents throughout the intervention period were measured periodically by a dental hygienist and reported to the ward administration to serve as a means towards improvement [46]. In Schwindling et al.'s study, the BCT ‘monitoring of behaviour by others without feedback’ was coded, among other intervention strategies this study involved caregivers providing mouth care to residents under the supervision of a dentist [47]. All three studies reported significant improvement in oral health outcomes for residents over long‐term suggesting that rare BCTs related to monitoring and feedback have the potential to sustain intervention effects over a long period of time. This finding is similar to a previous review which found that strategies rarely used in interventions such as ‘increasing memory’ and ‘feedback on clinical outcomes’ tended to be the only studies where a consistent positive association could be observed on oral health outcomes of older people in long‐term care [13]. Providing feedback provides positive reinforcement necessary for attaining goals, awareness about potential barriers to behaviour change, enables problem‐solving and aids in development of effective future goals [73]. The importance of feedback in behaviour change has been demonstrated by a recent systematic review which concluded that interventions with feedback were more effective in improving outcomes such as diet, physical activity and weight in comparison to interventions without feedback [74].

Another finding of note is that most studies did not examine outcomes in terms of oral hygiene behaviours like changes in the frequency of toothbrushing, flossing, denture cleaning and proper storage of dentures. There was only one study that assessed denture wearing habits overnight among residents which showed no significant improvement at 18 months follow‐up while another study observed improvement in brushing frequency among residents in the evening following intervention [41, 54]. Instead, most of the studies reported outcomes related to either knowledge acquisition among caregivers after intervention or outcomes related to the oral health status of residents such as levels of dental or denture plaque and did not tie this together which the desired behaviours that would help achieve the desired outcome of improving the oral health of residents. While outcomes related to knowledge and clinical improvement of oral health is important, this must go hand‐in‐hand with measuring changes in behaviour which is necessary to determine whether a behaviour change strategy used in an intervention is successful in changing the target behaviour and thereby bring about an effect in the clinical oral health status of older residents. The finding in our study is similar to a previous review on medicine management for older people at care transition which also reported that outcomes in studies were rarely behaviour focused which makes it difficult to understand the effect of BCT's on the target behaviour [75].

The main strength of this review is that it is the first review to have examined the implementation strategies of oral health promotion interventions in RACFs or long‐term care institutions for older people in terms of the BCTs used in these interventions. Another strength of this study was that a comprehensive database search covering all major databases was performed to include all articles relevant to the topic of the review; no time limits were applied in the database search to ensure that we include a broad base of literature to further our understanding of the oral health promotion interventions implemented in RACFs to date. Likewise, the methods were robust in all stages of the review, including the screening of titles and abstracts, full‐text review, data extraction and risk of bias assessment being undertaken by two independent reviewers. This review helps in identifying the type of BCTs used in oral health promotion interventions in RACFs so far, and also to find those BCTs that remain unexplored in oral health promotion interventions in RACF settings.

The limitations of the review are that only journal articles published in the English language were included. We did not include grey literature or articles published in Non‐English language. Hence, findings from articles that were published in Non‐English language and other sources might have been missed out in our review. Another limitation is that the outcomes measured and follow‐up period in the studies included in this review had a high degree of heterogeneity that prevented us from performing a meta‐analysis. All of the RCTs included in this review had either a high or moderate risk of bias, and all the non‐randomised intervention studies also had either a serious or moderate risk of bias. The outcomes reported in the studies also showed a high degree of heterogeneity from outcome measures reporting on improvement in knowledge of caregivers following intervention to outcomes related to oral health status of residents such as levels of dental plaque and gingivitis. Likewise, the follow‐up interval also differed significantly, with most studies having short durations of follow‐up and fewer studies having long‐term follow‐up, which would help evaluate the sustainability of the effects that were observed. As most studies included reported positive effects following intervention, publication bias may also be a cause for concern, as studies that reported negative results may not have been published.

16. Conclusion

The most common BCTs used in oral health promotion interventions in RACF settings across all studies are ‘demonstration of behaviour’, ‘instruction on how to perform behaviour’ and ‘credible source’. While these BCTs tended to show a significant positive effect on the improvement of knowledge among caregivers, their effects on the oral health status of residents was inconsistent. Among few studies that had a long follow‐up duration of 12 months or more, BCTs related to feedback and monitoring were present in some and, these studies exhibited an improvement in residents' oral health status in the long‐term suggesting that these BCTs could demonstrate sustainable effects.

However, as the methodological quality of the studies and heterogeneity of outcomes are a concern, recommendations cannot be made on one or a combination of BCTs to initiate and maintain positive oral health behaviours among older people in RACFs and caregivers who provide oral hygiene assistance. Details on intervention and control conditions varied greatly, and the rationale for selecting particular strategies was not clear in many studies, while any intervention seeking to change behaviour must have a solid rationale for selecting BCTs to change target behaviour. Hence, there is a need for well‐conducted studies with good quality, where the BCT selection for oral health promotion interventions in RACFs is guided by theories of behaviour change underpinning the mechanisms by which positive oral health behaviours can be initiated and maintained long‐term.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

File S1.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.