Association Between Family Caregiver Oral Care Practices and Oral Health Status in Rehabilitation Ward Patients With Dysphagia

ABSTRACT

Objectives

To examine the relationship between family caregiver oral care practices and oral health status among inpatients with dysphagia who require assistance with daily oral hygiene in a rehabilitation ward.

Methods

Twenty‐five patient–family caregiver pairs at a South Korean rehabilitation hospital were studied. Patient oral health was assessed via a modified Multi‐dimensional Behavioral Oral Evaluation (M‐BOE) tool. Family caregivers completed structured interviews on oral care frequency, duration, techniques, and product use. Data were analyzed using descriptive statistics, Spearman's correlation, Kruskal–Wallis, and Mann–Whitney U tests; nonparametric regression (LOWESS) explored potential nonlinear associations.

Results

Patients receiving oral care three or more times daily exhibited significantly lower (better) M‐BOE scores. Improvements were most pronounced in gingival and buccal mucosal moisture, tongue hygiene, and denture cleanliness. Family caregiver use of oral care products correlated positively with patient swallowing ability and mucosal condition. Interestingly, extending care duration from one to two minutes was paradoxically associated with higher (worse) M‐BOE scores, suggesting that technique quality outweighs time spent. No significant relationships were found between oral health and patient cognitive function (MMSE), functional independence (K‐MBI), or number of medications.

Conclusions

Family caregiver oral care practices substantially influence oral health status among inpatients with dysphagia who are unable to perform oral self‐care independently. Educational interventions should prioritize optimal frequency, appropriate product use, and effective technique training. These findings highlight the importance of family caregiver‐focused programs to improve oral health outcomes in rehabilitation patients with functional limitations.

1. Introduction

1.1. Role of Family Caregivers in Patient Health Outcomes

Family caregivers play a crucial role in influencing the health outcomes of patients who require long‐term or assisted care. Previous studies have shown that family caregiver involvement, caregiving behaviors, and health‐related knowledge can significantly affect patient health status, treatment adherence, and overall quality of life. Active participation of family caregivers in patient care has been associated with improved patient outcomes, including better self‐care management, enhanced quality of life, and reduced healthcare utilization [1, 2]. In particular, family caregivers often provide essential daily care for patients with functional limitations, including assistance with personal hygiene, feeding, and oral health management. When family caregivers lack sufficient knowledge or appropriate care practices, patients may be at greater risk for preventable health complications.

1.2. Dysphagia and Oral Health Problems

Dysphagia is defined as the impaired ability to effectively transfer food or liquids from the oral cavity to the esophagus due to a decline in swallowing function. It is closely associated with neuromuscular disorders such as stroke, Parkinson's disease, dementia, amyotrophic lateral sclerosis (ALS), head and neck tumors, and aging, making it a common issue among older adults [3, 4]. The prevalence of dysphagia varies among countries. In Korea, 17.1% of individuals aged 60 years and older reported difficulty swallowing, while a community‐based study of older adults indicated a prevalence rate as high as 53.5% [5, 6]. In the United States, approximately 16% of adults over the age of 50 experience dysphagia symptoms, and in Japan, the reported prevalence ranges from 13.8% to 35.3% among those aged 65 and older [7, 8, 9]. Given its broad impact, dysphagia is not merely a functional impairment but also a significant health concern; if not properly managed, it may lead to a range of complications.

Although dysphagia is commonly associated with oral health problems, the deterioration of oral hygiene is often related to the underlying neurological or systemic conditions that cause dysphagia, such as stroke, neurodegenerative diseases, and other disorders affecting motor and cognitive function. These conditions may impair patients’ ability to perform adequate oral self‐care, leading to the accumulation of food residues in the oral cavity, reduced salivary secretion, and halitosis.

These conditions can lead to various oral diseases including dental caries, stomatitis, and periodontal disease [10]. When oral health deteriorates, pathogenic bacteria may be aspirated into the lower respiratory tract, thereby significantly increasing the risk of pneumonia. Aspiration pneumonia is the leading cause of hospitalization and mortality in older adults [11]. Impaired oral function adversely affects nutritional intake, potentially leading to weight loss, dehydration, reduced immunity, and delayed physical recovery. These recurring health challenges often result in prolonged treatment periods and increased hospitalization frequency, placing additional economic burdens on both patients and family caregivers [12, 13].

Because many patients with dysphagia have underlying neurological or systemic conditions that limit their functional abilities, they are often unable to perform oral self‐care independently. Consequently, family caregivers frequently assume primary responsibility for daily oral health management.

As a result, family caregiver‐related factors may play an important role in maintaining oral health and preventing complications among patients with dysphagia.

1.3. Study Purpose

Although family caregivers are often responsible for providing oral care in clinical and rehabilitation settings, most previous studies have primarily focused on patient‐centered evaluations, with relatively limited attention given to the family caregivers who perform daily oral care. Understanding family caregivers’ oral care practices and their potential relationship with patient oral health is therefore essential for improving patient outcomes.

Therefore, this study aimed to examine the relationship between family caregivers’ oral care practices and the oral health status of patients with dysphagia admitted to rehabilitation wards. Ultimately, this study seeks to provide foundational evidence for the development of family caregiver‐centered oral health education programs.

2. Methods

2.1. Study Population

This study included patients with dysphagia admitted to a single rehabilitation hospital in Korea and their primary family caregivers. Using G*Power 3.1, the minimum required sample size was calculated based on an alpha level of 0.05, effect size of 0.5, and statistical power of 0.8. The resulting sample comprised 31 patients and 31 family caregivers (n = 62). Considering a potential dropout rate of 10%, the final target sample size was set at 34 patients and 34 family caregivers, for a total of 68 participants.

During the study period, five patient–family caregiver pairs were excluded due to COVID‐19‐related isolation, and an additional four pairs withdrew due to early discharge or other reasons. A total of 25 patients and 25 family caregivers (n = 50) were included in the analysis.

From January to April 2024, recruitment was conducted through posters placed on ward bulletin boards. Family caregivers who voluntarily agreed to participate were given a detailed explanation of the study objectives and provided written informed consent.

As this was a single‐center study, all participants were evaluated using standardized diagnostic criteria and consistent assessment procedures. All patients were diagnosed with oral phase dysphagia via a videofluoroscopic swallowing study (VFSS), performed by the same board‐certified physiatrist. The selection criteria, diagnostic processes, and assessment tools remained consistent throughout the study period.

The time interval from disease onset to hospital admission and oral examination was also considered. Most patients included in this study were admitted during the subacute or chronic stage following neurological conditions such as stroke. Oral health examinations were conducted after admission during the hospitalization period while patients were receiving rehabilitation treatment. As the study was conducted in a rehabilitation ward, participants had already passed the acute phase of the disease and were undergoing ongoing rehabilitation care at the time of oral health assessment.

In the rehabilitation ward where this study was conducted, most patients with dysphagia required continuous assistance due to severe functional limitations and were unable to perform oral hygiene independently. In the majority of cases, a family caregiver, typically an immediate family member such as a spouse or adult child, remained with the patient in the ward and provided daily personal care, including oral hygiene. When family members were unable to provide care, a hired caregiver assumed responsibility for hygiene management. Nursing staff did not routinely perform oral hygiene for these patients, and all oral care activities were carried out by family caregivers or hired caregivers. Consequently, the patients themselves did not perform oral care independently during hospitalization.

The inclusion criteria were as follows: (1) diagnosis of oral phase dysphagia based on VFSS results by a specialist; (2) patients with a Korean version of the Barthel Index (K‐Barthel Index) score of less than 75, indicating the inability to perform oral health independently; and (3) family caregivers who provided daily assistance and fully understood the purpose of the study and voluntarily agreed to participate.

Exclusion criteria were as follows: (1) healthcare professionals, such as occupational therapists or nurses; (2) patients with a K‐Barthel Index score of 75 or higher; (3) Patients who were capable of independently performing oral hygiene without caregiver assistance: and (4) those undergoing dental treatment at the time of recruitment.

2.2. Measures

This study collected data on the general characteristics of both patients and family caregivers, oral health status of patients, and oral care practices of family caregivers.

The patient characteristics included sex, age, length of hospital stay (in months), oral feeding status (presence of a Nasogastric tube (NG tube)), presence of systemic diseases, number of current medications, Mini‐Mental State Examination (MMSE) score for cognitive function, and Korean Modified Barthel Index (K‐MBI) score for activities of daily living. In this study, the presence of a Nasogastric tube (NG tube) was used as an indicator of non‐oral feeding status, representing patients who were receiving enteral nutrition rather than oral intake. The MMSE has a maximum score of 30, with lower scores indicating greater cognitive impairment. The K‐MBI scores range from 0 to 100 points, with higher scores reflecting better functional independence in daily life. Medical data were obtained from electronic medical records (EMR) and accessed after the researcher obtained institutional permission and ethical approval. All data were collected in accordance with ethical procedures.

The oral health status of the patients was assessed using a modified version of the multidimensional behavioral evaluation (M‐BOE) tool [13], adapted to suit the characteristics of patients with stroke and dysphagia. The M‐BOE is a standardized clinical assessment tool commonly used to evaluate the oral health status of patients in intensive care units and individuals with swallowing disorders, including dysphagia. This tool enables a systematic evaluation of oral structures and functions and has been applied in previous clinical studies involving medically compromised or hospitalized patients. The key assessment items included swallowing ability, condition of the lips, gingiva (texture, color, and moisture), buccal mucosa (texture, color, and moisture), tongue (texture, color, and moisture), salivary condition, oral hygiene status of natural teeth or dentures, and presence of halitosis. Each item is scored on a scale from 0 to 3, with total scores ranging from 0 to 42. Higher scores indicate poorer oral health. Additional parameters, such as the presence of dentures, number of dental implants, number of remaining teeth, and maximum mouth opening were also recorded.

The oral health assessment was conducted by the researcher through direct, one‐on‐one observations of each patient. Tongue depressors, sterile polygloves, and portable lights were used to ensure consistent observational conditions. All oral examinations were performed by a single experienced clinical dental hygienist who had prior training in oral health assessment of medically compromised patients. To minimize variability related to examiner differences, the same evaluator conducted all assessments throughout the study period.

Oral examinations were conducted during the daytime while patients were hospitalized and undergoing rehabilitation therapy, when caregivers were available to assist with the evaluation process. To ensure intra‐rater reliability, repeated evaluations were conducted, resulting in a Cronbach's α of .774, indicating acceptable internal consistency across items. All evaluation results were systematically recorded using a standardized assessment form to enhance consistency and reproducibility of the data.

Family caregivers' oral care practices were assessed through one‐on‐one structured interviews conducted by the researcher. During the interviews, each survey item was verbally explained to the respondents to ensure accurate understanding, and the responses were recorded orally. The general characteristics of the family caregivers included sex, age, education level, caregiving duration (in months), and relationship with the patient. Information regarding oral care practices, including the average daily frequency of oral care, duration of oral care, brushing techniques used, and use of oral care products, was systematically recorded based on caregiver responses during the structured interviews.

2.3. Definition of Variables

In this study, the oral health status of patients refers to the overall condition of the oral cavity, including swallowing function, moisture of the mucosa and tongue, the presence of halitosis, and general oral health. These factors are important indicators of oral health in patients with dysphagia [14].

Family caregivers’ oral care practices included the frequency, duration, method of care, and use of oral hygiene products provided to patients with dysphagia. Given that these patients often have difficulty in performing oral care independently, the family caregiver's level of involvement is a critical factor that can directly influence their oral health status [15].

2.4. Data Analysis

The collected data were analyzed using IBM SPSS Statistics version 29.0 and a Python 3.11‐based analytical environment. The general characteristics of the patients and family caregivers were examined using frequency analysis and descriptive statistics, using SPSS software. Descriptive statistics, including means and standard deviations, were calculated for the patients' oral health scores.

The normality of each variable for both patients and family caregivers were assessed using the Shapiro–Wilk test. As most variables yielded p‐values less than 0.05, indicating deviations from a normal distribution, nonparametric statistical methods were employed.

Spearman's rank correlation coefficient was used to examine the relationships between the patients’ MMSE scores, K‐MBI scores, number of medications, and M‐BOE scores. Differences in patients’ oral health status according to family caregivers’ oral care practices were analyzed using Kruskal–Wallis H and Mann–Whitney U tests.

In addition, to explore and visualize potential nonlinear relationships between the independent variables (oral care practices) and the dependent variable (oral health scores), locally estimated scatterplot smoothing (LOESS) analysis was conducted using Python 3.11 environment.

In this study, the patients’ oral health status measured by the M‐BOE score was defined as the dependent variable. The independent variables included patient‐related characteristics (MMSE score, K‐MBI score, number of medications, and presence of a Nasogastric tube (NG tube)) and family caregiver‐related oral care practices (frequency of oral care, duration of oral care, brushing techniques, and use of oral care products). These variables were analyzed to examine their associations with patients’ oral health outcomes.

3. Results

3.1. General Characteristics of Patients and family Caregivers

The general characteristics of the patients and their family caregivers are presented in Table 1. A total of 25 patients participated in the study; 22 (88.0%) were female. The mean age of the patients was 63.12 years, and the average duration of hospitalization was 3.1 months. During hospitalization, seven patients (28.0%) experienced aspiration pneumonia, and eight patients (32.0%) were currently fitted with a Nasogastric tube (NG tube). The average number of medications taken by the patients was 7.48. The mean Mini‐Mental State Examination (MMSE) score, which assesses cognitive function, was 11.68, and the mean Korean Modified Barthel Index (K‐MBI) score, which evaluates functional independence, was 22.92.

TABLE 1.

General characteristics of patients and family caregivers (N = 25).

Group	Classification	N(%) M±SD
Patients	Gender
	Male	3(12.0)
	Female	22(88.0)
	Age	63.12 ± 6.24
	(At this institution) Length of hospitalization / Month	3.1±1.2
	(During the hospitalization) Aspiration Pneumonia Experience
	Yes	7(28.0)
	No	18(72.0)
	Presence of Nasogastric tube (NG tube)
	Yes	8(32.0)
	No	17(68.0)
	History of systemic disease *
	Hypertension	25(100.0)
	Diabetes	17(68.0)
	Osteoporosis	12(48.0)
	Stroke	21(84.0)
	Myocardial infarction	0(0)
	Angina pectoris	5(20.0)
	Depression	0(0)
	Thyroid disorders	0(0)
	Other	4(16.0)
	Number of Medications in Use	7.48±1.04
	MMSE‐Score (Recent assessment)	11.68±10.04
	K‐MBI‐Score (Recent assessment)	22.92±16.17
Family caregiver	Gender
	Male	3(12.0)
	Female	22(88.0)
	Age	55.72 ± 8.43
	Education Level
	Middle school graduate or below	2(7.1)
	High school graduate	16(64.0)
	College or higher	7(28.9)
	Months of Caregiving Experience	27.28 ± 58.92
	Relation to the Patient
	Spouse	9(36.0)
	Child	10(40.0)
	Relative	5(20.0)
	caregiver	1(4.0)

^*Multiple‐Answer Question.

A total of 25 family caregivers participated in the study; 22 (88.0%) were female. The mean age was 55.72 years, and the average caregiving duration was 27 months. The most common relationship between family caregiver and patient was “child,” accounting for 10 participants (40.0%).

3.2. Analysis of Patients’ oral Health Status

The oral health status of patients is shown in Table 2. The mean total score on the modified multidimensional behavioral evaluation (M‐BOE) was 19.64. Among the sub‐items, the average scores for lip condition, tongue moisture, and salivary condition was 1.00, 1.36, and 1.32, respectively, indicating a general tendency toward oral dryness. The average hygiene score for natural teeth or dentures was 2.68, and the score for halitosis was 2.52. The mean number of remaining teeth was 23.40, and the average maximum mouth opening between the upper and lower jaws was measured at 5.12 cm.

TABLE 2.

Oral health status of patients with dysphagia assessed by the modified M‐BOE tool (N = 25).

Classification	M±SD
M‐BOE(Total)	19.64±2.62
M‐BOE
Ability swallow	2.36±0.95
Lips	1.00±0.00
Gingiva
Texture	0.68±0.47
Color	1.32±0.47
Moisture	2.00±0.00
Buccal mucosa
Texture	0.36±0.49
Color	1.00±0.81
Moisture	2.00±0.00
Tongue
Texture	0.36±0.49
Color	0.68±0.47
Moisture	1.36±0.49
Saliva	1.32±0.47
Teeth or denture	2.68±0.47
Odor	2.52±0.65
Denture use
No use	20(80.0)
Only Upper	3(12.0)
Full	2(8.0)
Number
Implant	1.16±1.51
Remaining teeth	23.40±7.19
Range of mandibular opening(cm)	5.12±1.56

3.3. Associations Between MMSE, K‐MBI, Medication Use, and Oral Health Status (M‐BOE)

To identify potential factors among the patients’ general characteristics that may influence oral health status, a correlation analysis was conducted between M‐BOE scores, MMSE scores, K‐MBI scores, and the number of medications taken. Table 3 presents the results. No statistically significant correlations were found between patients’ oral health status and MMSE scores, K‐MBI scores, or number of medications.

TABLE 3.

Correlations between oral health status and general characteristics (N = 25).

	M‐BOE	MMSE	K‐MBI	Number of medications taken
M‐BOE	1.000
MMSE	0.058	1.000
K‐MBI	0.097	0.786	1.000
Number of medications taken	−0.297	0.230	−0.377	1.000

3.4. Association Between Family Caregivers’ Oral Care Practices and Patients’ Oral Health Status

The results of the analysis examining the association between family caregivers’ oral care practices and the oral health status of the patients are presented in Table 4. Patients in the group that received oral care twice daily showed significantly higher scores, indicating poorer oral health— lip condition (p = .041), gingival texture (p = .045), and gingival moisture (p = .045). Overall, as the frequency of oral care increased, the total M‐BOE scores tended to decrease, suggesting better oral health status.

TABLE 4.

Association between family caregivers’ oral care practices and patients’ oral health status (N = 25).

A
Practice	Category	N(%)	Swallow (M±SD)	p	Lips (M±SD)	p	Gingiva Texture	p	Gingiva Color	p	Gingiva Moisture	p	Buccal Texture	p	Buccal Color	p
Frequency	Twice	7 (28.0)	2.71±0.75	0.276	2.10±0.34	0.041 *	0.90±0.31	0.045 *	1.28±0.48	1.000	2.40±0.24	0.045 *	0.57±0.53	0.201	1.14±0.69	0.116
	Three times	8 (32.0)	2.50±0.92		1.90±0.21		0.71±0.48		1.62±0.51		1.82±0.35		0.12±0.35		1.37±0.91
	Four times	10 (40.0)	2.12±1.05		1.00±0.82		0.37±0.51		1.10±0.31		1.00±0.62		0.40±0.51		0.60±0.69
Duration	<2 min	13	2.80±0.90	0.477	1.50±0.81	1.000	0.58±0.51	0.414	1.41±0.51	0.414	1.86±0.35	1.000	0.33±0.49	0.698	1.16±0.83	0.373
	2–<3 min	8	2.50±1.03		1.00±0.50		0.87±0.35		1.12±0.35		1.51±0.31		0.50±0.53		0.75±0.70
	≥3 min	4	2.25±1.00		1.00±0.43		0.50±0.57		1.50±0.57		1.54±0.34		0.25±0.50		1.25±0.95
Brushing technique	Rolling	1 (4.0)	1.00	0.145	1.00	1.000	1.00	0.493	1.00	0.493	2.00	1.000	0	0.453	0	0.211
	Random	24 (96.0)	2.41±0.92		1.00±0.71		0.66±0.48		1.33±0.48		1.87±0.13		0.37±0.49		1.04±0.80
Oral care products	Use	8 (32.0)	1.75±1.03	0.028 *	1.70±0.34	1.000	0.87±0.35	0.160	1.12±0.35	0.160	2.00±0.48	1.000	0.25±0.46	0.441	0.50±0.75	0.036 *
	No use	17 (69.0)	2.64±0.78		1.00±1.21		0.58±0.50		1.41±0.50		2.41±0.25		0.41±0.50		1.23±0.75

B
Practice	Category	Buccal Moisture	p	Tongue Texture	p	Tongue Color	p	Tongue Moisture	p	Saliva	p	Oral Hygiene	p	Halitosis	P
Frequency	Twice	2.14±0.37	0.615	0.57±0.53	0.276	0.85±0.37	0.276	1.57±0.53	0.201	1.14±0.37	0.276	2.57±0.53	0.370	2.71±0.48	0.703
	Three times	2.00±0.53		0.12±0.30		0.75±0.46		1.40±0.51		1.25±0.46		2.87±0.35		2.50±0.91
	Four times	1.90±0.56		0.40±0.51		0.50±0.52		1.12±0.35		1.50±0.52		2.60±0.51		2.37±0.52
Duration	<2 min	2.25±0.30	0.048*	0.33±0.49	0.698	0.75±0.45	0.477	1.33±0.49	0.698	2.00±0.45	0.477	3.00±0.49	0.884	2.62±0.51	0.639
	2–<3 min	2.00±0.45		0.50±0.53		0.62±0.51		1.50±0.53		1.37±0.51		2.62±0.51		2.58±0.66
	≥3 min	1.62±0.51		0.25±0.50		0.75±0.50		1.25±0.50		1.25±0.50		2.75±0.49		2.00±0.95
Brushing technique	Rolling	1.00	0.041*	0	0.453	0	0.145	1.00	0.453	1.00	0.145	2.00	0.493	2.50	0.424
	Random	2.04±0.46		0.37±0.49		0.70±0.46		1.375±0.49		2.00±0.46		2.66±0.48		3.00±0.65
Oral care products	Use	1.75±0.70	0.086	0.25±0.46	0.441	0.37±0.51	0.028*	1.25±0.46	0.441	1.17±0.39	0.028*	1.62±0.51	0.692	2.04±0.71	0.712
	No use	2.11±0.33		0.41±0.50		0.82±0.39		1.41±0.50		2.62±0.51		2.70±0.46		2.62±0.51

^* p < 0.05.

With regard to the duration of oral care, patients in the group receiving care for less than 2 min exhibited significantly higher scores for buccal mucosal moisture (p = .048), indicating that a shorter care duration may be associated with poorer oral health outcomes.

Although only one family caregiver reported using the “modified Bass technique” or “circular (Fones) brushing method,” making statistical interpretation limited due to small sample size, a significant difference was observed in buccal mucosal moisture (p = .041).

When comparing the presence or absence of oral care product use, patients whose family caregivers used such products had significantly lower scores for swallowing ability (p = .028), buccal mucosal color (p = .036), tongue color (p = .028), and tongue salivary condition (p = .028), indicating that the use of oral care products was associated with better oral health status.

3.5. Analysis of the Impact of Family Caregivers’ Oral Care Practices on Patients’ Oral Health Status

A nonparametric regression analysis (LOWESS: Locally Weighted Scatterplot Smoothing) was conducted to examine the relationship between family caregivers’ oral care variables, specifically tooth brushing frequency and duration, and patients’ oral health status scores. The x‐axis represents the independent variables (oral care frequency and duration) and the y‐axis represents the dependent variable (oral health status score).

The LOWESS curve indicated that oral health status scores decreased as the frequency of tooth brushing increased, suggesting improved oral health (Figure 1). In contrast, for brushing duration, the scores tended to increase from 1 to 2 min, indicating poorer oral health, but then decreased as the duration increased from 2 to 3 min, reflecting improved oral health. However, when the brushing duration was increased from 3 to 4 min, the oral health scores increased slightly again, suggesting limited additional benefits beyond 3 min (Figure 2).

FIGURE 1.

Association between tooth brushing frequency and oral health status.

FIGURE 2.

Association between tooth brushing duration and oral health status.

Boxplot analyses were conducted to compare the differences in oral health status scores based on the use of oral care products and tooth brushing methods. The results showed that the group that used oral care products tended to have slightly lower oral health status scores than the non‐users group, indicating better oral health (Figure 3). In addition, patients whose family caregivers used the circular brushing method exhibited lower oral health scores than those whose family caregivers brushed without using any technique (Figure 4).

FIGURE 3.

Oral health status according to use of oral care products.

FIGURE 4.

Oral health status according to tooth brushing method.

4. Discussion

4.1. Family Caregivers’ Oral Care Practices and Oral Health Outcomes

This study investigated the effect of family caregivers’ oral care practices on the oral health status of inpatients with dysphagia in a rehabilitation ward. The results demonstrated that family caregivers’ frequency and duration of oral care, tooth brushing methods, and use of oral care products were associated with differences in the patients’ oral health status. Increased frequency of oral care was associated with lower M‐BOE scores, indicating better oral health. Patients who received oral care three or more times showed lower scores in lip moisture and gingival condition, suggesting that frequent oral care may be related to the maintenance of oral hygiene and health. These findings are consistent with previous research indicating that aspiration of pathogenic oral bacteria into the lower respiratory tract can lead to aspiration pneumonia and that regular oral hygiene is effective in preventing such complications [16].

Moreover, common oral issues in patients with dysphagia, such as xerostomia, food residues, and halitosis, have been reported to be associated with inadequate oral care [10]. Given that oral dysfunction may also affect systemic health, recovery, and length of hospital stay [17], our findings reinforce the importance of family caregivers' involvement in maintaining and preventing oral health problems in patients with dysphagia.

In this study, an increased frequency of oral care was associated with lower gingival dryness scores, suggesting better moisture retention and possible relief from xerostomia. This finding indicates that the frequency of oral care may be related to the management of dry mouth symptoms. A study conducted among family caregivers in Japanese long‐term care facilities reported that regular oral cleaning and use of moisturizing agents were associated with reduced oral mucosal dryness and maintenance of gingival health [18]. Similarly, repeated oral care has been shown to stimulate salivary secretion and maintain oral hydration [10]. Taken together, these findings suggest that increased frequency of oral care may be associated with reduced xerostomia. Consequently, future oral health education programs for patients with dysphagia should emphasize the prevention and management of dry mouth. Educational programs should ensure that family caregivers understand the importance of maintaining oral moisture and are equipped with specific practical strategies for implementation in daily care.

Meanwhile, the non‐linear results observed in Figure 2 regarding brushing duration revealed that the M‐BOE scores increased, indicating worsened oral health, as the brushing time increased from 1 to 2 min. This unexpected result may reflect inaccuracies in self‐reported data, particularly given the clustering of responses around the “2 min” category. It is also possible that the reported brushing duration included a range of brushing methods with varying effectiveness and that increased time alone was not necessarily associated with better outcomes. A previous study conducted in Belgian nursing homes also found that quality of care was more important than duration, as discrepancies often existed between family caregivers’ intentions and actual oral care performance [19]. Similar tendencies were observed in this study, emphasizing the need for not only longer oral care but also proper techniques and family caregiver training.

Although only a small number of family caregivers reported using the circular (fones) brushing method, patients in this group showed relatively lower oral health scores. Despite the limited statistical power, this finding highlights the potential benefits of standardized brushing techniques. Future family caregiver education programs should include detailed guidance and hands‐on training on effective tooth brushing methods, particularly techniques such as the circular method.

4.2. Clinical Implications for Family Caregiver Education and Patient Care

Additionally, the mean maximum mouth opening among the patients in this study was 5.12 cm, which may be insufficient for effective oral care. Limited mouth opening can restrict access to the posterior areas or under the tongue, which may result in poor hygiene. Indeed, restricted mouth opening has been identified as a contributing factor to poor oral hygiene in elderly individuals and patients with neuromuscular disorders [20, 21]. Therefore, family caregiver training should include the use of assistive devices such as mouth props, as well as exercises to improve jaw mobility. Training should also cover proper use, hygiene, and precautions associated with such devices, enabling family caregivers to perform thorough oral care even under challenging anatomical conditions. Furthermore, due to the unique needs of patients with dysphagia, including limited mouth opening and reduced intraoral sensation, there is a need to develop customized oral care products. These include compact tools that minimize mucosal irritation and oral cleansers with enhanced moisturizing properties, ultimately reducing family caregiver burden and improving oral health outcomes.

In this study, patients whose family caregivers used oral care products had significantly lower M‐BOE scores for swallowing ability, buccal mucosal color, tongue color, and tongue salivary condition, indicating better oral health. These findings suggest that the use of oral care products may be associated with better oral health conditions. Previous studies have shown that the use of oral cleaning aids and products containing moisturizing agents is associated with reduced dental plaque accumulation and improved mucosal condition. A study of family caregivers in Japanese long‐term care facilities also found that those who used oral care aids, such as mouthwashes, achieved better oral hygiene indices and had a lower incidence of mucosal injury than those who relied on brushing alone [22]. These findings provide further evidence for the effectiveness of oral care products in preventing or alleviating complex oral health problems in patients with dysphagia. Therefore, family caregiver education programs should include specific instructions regarding the use and selection of oral care products, ideally through hands‐on and experiential learning.

Interestingly, patient‐related health variables such as cognitive function (MMSE), activities of daily living (K‐MBI), and the number of medications were not significantly associated with oral health status in this study. Although these were examined using univariate analyses, the findings suggest that patients' cognitive status or functional independence may not directly affect their oral health. Rather, family caregivers’ oral care behaviors appeared to have a more substantial effect. In inpatient settings, where patients are often unable to perform oral care independently, family caregiver involvement is a key determinant of oral health.

In addition, family caregivers’ physical and psychological well‐being may also influence the quality and consistency of oral care provided to patients. Family caregivers experiencing fatigue, stress, or high workload may have difficulty maintaining adequate care practices, which can ultimately affect patient outcomes. Previous studies have suggested that family caregiver burden and burnout are associated with reduced care quality and decreased adherence to recommended care protocols. [23, 24] Therefore, improving family caregiver education, institutional support, and workload management may contribute not only to better caregiving practices but also to improved patient health outcomes. [25]

Thus, family caregiver education programs should be systematic and practice‐oriented, focusing not only on knowledge delivery but also on repeated training to build practical caregiving competencies.

4.3. Study Limitations and Future Research

This study has several limitations. First, the sample was drawn from a single rehabilitation ward, which may have limited the generalizability of the findings. Second, owing to factors such as COVID‐19 and patient discharge during the study period, the final sample size was reduced, potentially limiting the representativeness of the results. Third, key variables such as oral care frequency, duration, and method were based on family caregiver self‐reports, which may differ from actual practice. Fourth, owing to the cross‐sectional design, causal relationships could not be established, and the study could not assess longitudinal changes or intervention effects over time. Fifth, the responses to certain items, such as brushing methods, were heavily skewed, limiting statistical comparisons.

Sixth, a gender imbalance was observed among both family caregivers and patients, with a predominance of female participants. This pattern may partly reflect the characteristics of caregiving roles in healthcare settings, where female family caregivers are more commonly involved in direct patient care. However, it may also be influenced by the sampling process used in this study. Therefore, caution is required when generalizing the findings. Future studies should consider more balanced gender representation to further explore potential gender‐related differences in caregiving practices and oral health outcomes.

Despite these limitations, this study provided valuable empirical evidence that family caregivers’ oral care practices have a tangible impact on the oral health of patients with dysphagia. These findings can serve as a foundation for future intervention studies and policy developments. Future studies should include multicenter samples from various institutions and regions to enhance the generalizability of the findings and minimize potential demographic bias. Furthermore, large‐scale multicenter research would enable the inclusion of more diverse patient populations and caregiving environments, thereby strengthening the external validity of the results.

5. Conclusion

This study demonstrates that higher frequency of family caregiver‐provided oral care is significantly associated with improved oral health status in dysphagic inpatients, particularly in gingival and buccal mucosal moisture, tongue hygiene, and denture cleanliness. Proper use of oral care products also correlates with better swallowing function and mucosal condition. These findings underscore the need for standardized, technique‐focused family caregiver training in rehabilitation settings. Further multicenter trials are warranted to validate and extend these results.

Ethics Statement

This study was approved by the Institutional Review Board (IRB) of the National Rehabilitation Center, Korea, on December 26, 2023. Only participants who provided written consent after being informed of the study purpose and methods were included. The collected survey data were coded and electronic files were protected with passwords, while physical copies will be stored in a locked cabinet for three years. No adverse effects or risks arose from this study. This study also complies with the Declaration of Helsinki and relevant national ethical guidelines

Conflicts of Interest

The authors declare no conflict of interest.

Data Availability Statement

The data that support the findings of this study are not publicly available due to privacy or ethical restrictions but are available from the corresponding author upon reasonable request.