Abstract
Aim
The aim was to identify planned and completed preventive interventions among older persons with oral health problems receiving municipal health care. A further aim was to determine the correspondence between oral health problems and planned preventive interventions among older persons with oral health problems receiving municipal health care.
Design
Cross‐sectional register study.
Methods
Oral health data from the Swedish national quality registry, Senior Alert, were extracted for 4,024 older persons (≥65 years) receiving municipal health care in a county in Southern Sweden. Data were statistically analysed.
Results
A large majority of older persons (97.4%) with assessed oral health problems had at least one planned preventive intervention, and approximately three quarters of the planned interventions were completed. There seemed to be a mismatch between type of oral health problems and preventive interventions as not all older persons had a planned preventive intervention related to their specific oral health problem.
Keywords: nursing, oral health, prevention, risk assessment, Senior Alert
1. INTRODUCTION
Oral health is known to impact on the quality of life in older persons (Lindmark et al., 2020; McGrath & Bedi, 1991; van de Rijt et al., 2021), and oral health is experienced as central for the sense of self‐esteem and thus is perceived as a priority by older persons (McKenzie‐Green et al., 2009). Importantly, poor oral health is associated with malnutrition (Lindroos et al., 2019; van Lancker et al., 2012) and is a risk factor for aspiration pneumonia among older persons (van der Maarel‐Wierink et al., 2011), which in turn increases the risk for death (Welte et al., 2012). However, a recent review (Manger et al., 2017) shows strong evidence that the incidence of pneumonia can be reduced by regular oral hygiene interventions, that is through the use of chlorhexidine in mouthwash or gel among older persons. Another review (van der Maarel‐Wierink et al., 2013) concludes that tooth brushing after each meal, cleaning dentures once a day and professional oral health care once a week reduce the incidence of aspiration pneumonia among frail older persons.
2. BACKGROUND
It is to be noted that poor oral health among older persons is common both internationally and nationally, and a systematic review (Wong et al., 2019) reported that a majority of older persons had problems with oral cleanliness and health. Moreover, the prevalence of poor oral health in Italian nursing homes has been estimated to be approximately 44% and even higher among those with cognitive impairment (54%) and those with higher dependency on assistance (56%) (Chiesi et al., 2019). In Norwegian nursing homes, 40% had poor oral health (Willumsen et al., 2012), and in Swedish nursing homes, 42% had oral health problems and men had more oral health problems than women (Bellander, Andersson, Nordvall, et al., 2021). Importantly, the prevalence of oral health problems differs between types of housing, where oral health problems are more common in home health care than in nursing homes (Czwikla et al., 2021). A recent study (Neziraj, Hellman, et al., 2021), conducted in southern Sweden, shows that the prevalence of the risk for poor oral health was approximately 34% among older persons receiving municipal health care, that is community care service of older persons. The care of older people is in Sweden primarily a municipal responsibility and mainly financed by taxes (Swedish Institute, 2021). Although the prevalence of the risk for poor oral health varied in different types of housing – 31% among older persons in short‐term nursing care, 28% among older persons living in their own homes and receiving municipal health care, and 34% in nursing homes – the prevalence of the risk for poor oral health was greatest among older persons in dementia care units (42%) (Neziraj, Hellman, et al., 2021).
Essentially, increasing dependence on others in everyday life and decreasing cognitive ability among older persons leads to poorer oral health status and increased need for assistance with oral care (Zenthöfer et al., 2014). Although promoting oral health is a responsibility for nurses as being one of the fundamentals of nursing care (Kitson et al., 2010), assisting older persons with their oral health is often overlooked by nurses (Costello & Coyne, 2008; Ek et al., 2018). Reasons for this oversight have been related to lack of knowledge, education and training in providing oral care, time constraints, general dislike of oral care among the nursing staff (Wårdh et al., 2012). Other reasons have been related to working experience, that is nurses with shorter experience seem less likely to provide oral care (Edman & Wårdh, 2022). A recent review (Oda et al., 2022) found that barriers for nurses to provide oral care were lack of clear guidelines and protocol for the provision of oral care. Another reason is older persons' resistance to receiving help with oral care (Hoben et al., 2017; Oda et al., 2022). Altogether, this can be reflected in a large unmet need for oral care among older persons, which has been shown in a Swedish study by Forsell et al. (2009) reporting that only 6.9% of those in need of assistance with oral care actually received it. There is, as far as we know, nothing to suggest that this problem has changed for the better over time.
Despite the fact that oral health problems are common among older persons worldwide and constitute a risk for morbidity and mortality, oral health care seems to be a nursing element with room for improvement, and there is a need for increased knowledge about preventive interventions especially in elderly care in Sweden.
Consequently, the aim of the current study was to identify planned and completed preventive interventions among older persons with oral health problems receiving municipal health care. A further aim was to determine the correspondence between oral health problems and planned preventive interventions among older persons with oral health problems receiving municipal health care.
3. THE STUDY
3.1. Design
The current study is part of the research project PROSENIOR, which focuses on the prevention of common risk factors such as poor oral health among older persons receiving municipal care (https://mau.se/en/research/projects/prosenior/). The design was a cross‐sectional register study based on oral health data extracted from the Swedish national quality registry called Senior Alert, which is one of the largest and most frequently used quality registries in Sweden. Senior Alert is a well‐integrated tool for the prevention of pressure ulcers, falls, malnutrition, and poor oral health among older persons (≥65 years). Prior to registration, older persons are informed about the registry by their healthcare providers, and they give their oral consent for registration. Thereafter, healthcare providers register data from the conducted risk assessments and planned and completed preventive interventions. The intention of the registry is to systemize the preventive care work, reduce risks and improve patient safety (Edvinsson et al., 2015; Senior Alert, 2021). The current study followed the STROBE guidelines (von Elm et al., 2008).
3.2. Method
3.2.1. Study population
The current study was based on 4,024 older persons (≥65 years) receiving municipal health care in a county in Southern Sweden and whose oral health problems and associated preventive interventions were registered in Senior Alert.
3.2.2. Data extraction
Oral health data from Senior Alert were extracted for the period August 1, 2018, to July 31, 2019. The extracted data constituted the first reported risk assessment and associated planned and completed preventive interventions based on the Revised Oral Assessment Guide‐Jönköping (ROAG‐J) registered during this time period. The total sample consisted of 12,518 persons aged ≥65 years, which were registered in Senior Alert in the selected county in southern Sweden during the set time period but oral health data including associated preventive interventions were only available for 4,024 older persons.
3.2.3. Instrument
The Revised Oral Assessment Guide (ROAG), which is used for oral assessments in older persons, has shown both good inter‐rater reliability (Andersson et al., 2002) and reproducibility (Ribeiro et al., 2014). In Senior Alert, a somewhat modified version, the ROAG‐J, is used to assess risks for poor oral health. ROAG‐J also includes recommendations about what interventions to undertake for the different types and causes of oral health problems. The ROAG‐J evaluates oral health by assessing the condition of the following nine categories: Voice, Lips, Mucous membranes, Tongue, Gums, Teeth, Dentures, Saliva and Swallowing. Each category is measured on a scale of 0–3, where scores of 0 and 1 indicate no risk, while scores of 2 and 3 indicate risk for oral health problems. According to ROAG‐J, the nursing staff should plan and implement a preventive intervention when the older persons score a 2, while a dentist should be consulted and offered when the older persons score a 3 on any assessment (Senior Alert, 2021).
3.2.4. Definitions
The type of housing was defined according to Neziraj, Hellman, et al. (2021):
Short‐term nursing care: a shorter stay facility for older persons at special municipal residential care homes that offer rehabilitation, aftercare, diagnosis and assessment of needs.
Home health care: receiving health care in one's own home.
Nursing home care: receiving municipal health care in residential care homes.
Dementia home care: receiving municipal health care in residential care homes for older persons with dementia diagnosis.
3.3. Analysis
SPSS version 26 (IBM Corp) was used for statistical analyses. Descriptive statistics (frequencies, percentages, means and standard deviation [SD]) were used to describe the study population. Chi‐square tests were used to test differences in proportions between men and women. p‐values < .05 were considered statistically significant. Missing data were handled according to the listwise deletion, that is in analyses including planned interventions the complete cases were used (Kang, 2013).
3.4. Ethics
Data in the current study were used after approval from Senior Alert and the Regional Ethical Review Board at Lund University in Sweden (DNR 2015‐484). The quality registry Senior Alert is one of 100 registries in Sweden used to develop the quality of care and offers a unique opportunity for performing research in health care. The use of register data is meticulously controlled in accordance with Swedish law under The Swedish Code of Statutes (SFS), Patient Data Act (2008:355). Senior Alert must ensure that the information is formulated in such way that it is clear to the older person that the registry data may be used in research and that the older person has the legal right to have their personal information removed from Senior Alert at any time (SFS, 2008:355).
4. RESULTS
The total sample consisted of 4,024 older persons at risk for oral health problems (64.1% women) with a mean age of 85.4 (SD 8.0) years and a majority (67.5%) living in nursing homes (Table 1). The proportion of any planned intervention for oral health problems was 97.4% in the total sample and was similar in both women and men. Approximately 98% of the older persons in short‐term nursing care had a planned intervention and 94.6% in home health care. Regarding planned interventions that were registered as completed for oral health problems, the highest proportion was found in dementia care units (80.3%) and the lowest in home health care (63.5%) (Table 2).
TABLE 1.
Background characteristics of the study participants with risk for poor oral health (N = 4,024)
| Total sample | Women | Men | |
|---|---|---|---|
| N (%) | N (%) | N (%) | |
| Sex | 2,578 (64.1) | 1,446 (35.9) | |
| Type of housing | |||
| Dementia home care | 727 (18.1) | 486 (18.9) | 241 (16.7) |
| Home health care | 432 (10.7) | 259 (10.0) | 173 (12.0) |
| Short‐term nursing care | 147 (3.7) | 65 (2.5) | 82 (5.7) |
| Nursing home care | 2,718 (67.5) | 1,768 (68.6) | 950 (65.7) |
| Age (mean, standard deviation) | 85.4 (8.0) | 86.9 (7.5) | 82.8 (8.0) |
TABLE 2.
Distribution of any planned and completed interventions for oral health problems among older people presented for the total sample and by sex and type of housing
| Total sample, N = 3,761 | Women, N = 2,400 | Men, N = 1,361 | Dementia home care, N = 697 | Home health care, N = 392 | Short‐term nursing care, N = 142 | Nursing home care, N = 2,530 | |
|---|---|---|---|---|---|---|---|
| N (%) | N (%) | N (%) | N (%) | N (%) | N (%) | N (%) | |
| Any planned intervention for oral health problems a | 3,664 (97.4) | 2,331 (97.1) | 1,333 (92.2) | 683 (98.0) | 371 (94.6) | 139 (97.9) | 2,471 (97.7) |
| Total sample, N = 3,452 | Women, N = 2,204 | Men, N = 1,248 | Dementia home care, N = 656 | Home health care, N = 326 | Short‐term nursing care N = 129 | Nursing home care, N = 2,341 | |
|---|---|---|---|---|---|---|---|
| N (%) | N (%) | N (%) | N (%) | N (%) | N (%) | N (%) | |
| Any completed intervention for oral health problems b | 2,560 (74.2) | 1,642 (74.5) | 918 (73.6) | 527 (80.3) | 207 (63.5) | 84 (65.1) | 1,742 (74.4) |
Missing n = 263.
Missing n = 572.
4.1. Oral health problems
Oral health problems related to the Teeth in terms of Coating or food debris locally were reported among 43.4% of the older persons, and Coating, food debris generally and broken teeth was reported among 16.5%. The proportion of oral health problems related to the Gums in terms of Swollen and reddened was 22.2% in the total sample and 23.7% in the women and 19.5% in the men. The proportion of Minor swallowing problems was 18.5% in the total sample with similar distributions among men and women (Table 3).
TABLE 3.
Oral health problems according to the revised Oral assessment guide‐Jönköping (ROAG‐J), in which scores of 2 and 3 indicate oral health problems
| Total sample, N = 4,024 | Women, N = 2,578 | Men, N = 1,446 | |
|---|---|---|---|
| N (%) | N (%) | N (%) | |
| Voice | |||
| 0 Not applicable | 149 (3.7) | 86 (3.3) | 63 (4.4) |
| 1 Normal | 3,213 (79.8) | 2,062 (80.0) | 1,151 (79.6) |
| 2 Dry, hoarse, cracking | 471 (11.7) | 304 (11.8) | 167 (11.5) |
| 3 Difficult to speak | 191 (4.7) | 126 (4.9) | 65 (4.5) |
| Lips | |||
| 1 smooth, light red, moist | 3,502 (87.0) | 2,208 (85.6) | 1,294 (89.5) |
| 2 Dry, cracked, sore corners of the mouth | 519 (12.9) | 368 (14.3) | 151 (10.4) |
| 3 Ulcerated, bleeding | 3 (0.1) | 2 (0.1) | 1 (0.1) |
| Mucous membrane | |||
| 1 Bright red, moist | 3,314 (82.4) | 2,118 (82.2) | 1,196 (82.7) |
| 2 Red, dry, or areas of discoloration, coating. | 673 (16.7) | 438 (17.0) | 235 (16.3) |
| 3 Wounds with or without bleeding, blisters | 37 (0.9) | 22 (0.9) | 15 (1.0) |
| Tongue | |||
| 1 Pink, moist with papillae | 3,364 (83.6) | 2,161 (83.8) | 1,203 (83.2) |
| 2 No papillae, red, dry, coating | 648 (16.1) | 405 (15.7) | 243 (16.8) |
| 3 Ulcers with or without bleeding, blistering | 12 (0.3) | 12 (0.5) | 0 (0.0) |
| Gums | |||
| 0 No gums, only mucosa | 188 (4.7) | 113 (4.4) | 75 (5.2) |
| 1 Light red and solid | 2,808 (69.8) | 1,773 (68.8) | 1,035 (71.6) |
| 2 Swollen and reddened | 894 (22.2) | 612 (23.7) | 282 (19.5) |
| 3 Spontaneous bleeding | 134 (3.3) | 80 (3.1) | 54 (3.7) |
| Teeth | |||
| 0 No natural teeth | 492 (12.2) | 305 (11.8) | 187 (12.9) |
| 1 Clean, no visible coating or food debris | 1,124 (27.9) | 768 (29.8) | 356 (24.6) |
| 2 Coating or food debris locally | 1,745 (43.4) | 1,120 (43.4) | 625 (43.2) |
| 3 Coating, food debris generally, broken teeth | 663 (16.5) | 385 (14.9) | 278 (19.2) |
| Dentures | |||
| 0 No prosthetics | 2,769 (68.8) | 1,750 (67.9) | 1,019 (70.5) |
| 1 Clean, functioning | 669 (16.6) | 464 (18.0) | 205 (14.2) |
| 2 Coating or food debris | 248 (6.2) | 157 (6.1) | 91 (6.3) |
| 3 Not used or malfunctioning | 338 (8.4) | 207 (8.0) | 131 (9.1) |
| Saliva | |||
| 1 Runs freely | 3,259 (81.0) | 2,065 (80.1) | 1,194 (82.6) |
| 2 Runs sluggishly | 731 (18.2) | 490 (19.0) | 241 (16.7) |
| 3 Does not run at all | 34 (0.8) | 23 (0.9) | 11 (0.8) |
| Swallowing related to pain and dry mouth | |||
| 0 Not applicable | 379 (9.4) | 234 (9.1) | 145 (10.0) |
| 1 Unimpeded swallowing | 2,609 (64.8) | 1,675 (65.0) | 934 (64.6) |
| 2 Minor swallowing problems | 745 (18.5) | 485 (18.8) | 260 (18.0) |
| 3 Pronounced swallowing problems | 291 (7.2) | 184 (7.1) | 107 (7.4) |
4.2. Causes for oral health problems
Of the investigated causes, Impaired ability to understand information and instructions was reported among 39.4%. Sore mouth at or between meals was significantly more common among women than men at 4.7% versus 3.2%. (Table 4).
TABLE 4.
Causes for oral health problems
| Total sample, N = 3,682 a | Women, N = 2,357 | Men, N = 1,325 | p‐values comparing women and men b | |
|---|---|---|---|---|
| N (%) | N (%) | N (%) | ||
| Sore mouth at or between meals | 153 (4.2) | 111 (4.7) | 42 (3.2) | .025 |
| Impaired hand/arm function or impaired general condition that complicates oral care | 723 (19.6) | 466 (19.8) | 257 (19.4) | .784 |
| Impaired function in the mouth and facial muscles | 273 (7.4) | 177 (7.5) | 96 (7.2) | .769 |
| Impaired sensation in the mouth | 101 (2.7) | 58 (2.5) | 43 (3.2) | .162 |
| Impaired ability to understand information and instructions | 1,449 (39.4) | 933 (39.6) | 516 (38.9) | .702 |
| Short intervals between meals | 242 (6.6) | 149 (6.3) | 93 (7.0) | .413 |
Missing n = 342.
Chi‐square test.
Bold value indicates significant difference.
4.3. Planned preventive interventions
The most frequent planned preventive interventions were Tooth brushing (planned for 56.2%) and Moisturizing the mouth (planned for 22.2%), while Local pain relief of the lips, mucous membranes and tongue were rarely planned. Consultation with a dentist when scoring 3 on any of the oral health assessments was planned for 9.7%, while 7.5% Resisted all preventive measures (Table 5).
TABLE 5.
Planned interventions grouped according to the revised Oral assessment guide‐Jönköping (ROAG‐J), n = 3,761 (263 missing)
| Interventions | Planned, N (%) |
|---|---|
| Voice | |
| Moisturizing the mouth | 835 (22.2) |
| Lips | |
| Lubricating the lips | 811 (21.6) |
| Local pain relief | 2 (0.1) |
| Mucous membrane | |
| Moisturizing | 636 (16.9) |
| Removal of scabs | 61 (1.6) |
| Local pain relief | 5 (0.1) |
| Tongue | |
| Cleaning of the tongue | 286 (7.6) |
| Moisturizing of the tongue | 515 (13.7) |
| Local pain relief of the tongue | 5 (0.1) |
| Gums, teeth, implants | |
| Information/training in oral health | 609 (16.2) |
| Toothbrushing | 2,113 (56.2) |
| Cleaning between teeth | 796 (21.2) |
| Moisturizing | 102 (2.7) |
| Fluoride | 343 (9.1) |
| Extra oral care | 42 (1.1) |
| Dentures | |
| Information/training in cleaning dentures | 130 (3.5) |
| Assistance with cleaning dentures | 465 (12.4) |
| Cleaning of remaining teeth and mucous membrane | 218 (5.8) |
| Saliva | |
| Moisturizing | 631 (16.8) |
| Swallowing related to pain and dry mouth | |
| Ease pain by moisturizing | 361 (9.6) |
| Other intervention – oral health | 484 (12.9) |
| Person resists all preventive measures | 281 (7.5) |
| Oral health palliative care | 46 (1.2) |
| Consultation with dentist when scoring 3 on any assessment | 363 (9.7) |
4.4. Correspondence between type of oral health problem and planned preventive interventions
Figure 1a–d illustrate the correspondence between the types of oral health problems and planned preventive interventions among older persons with different oral health problems according to the ROAG‐J. Fewer than half of the older persons with Problems related to the voice, lips and saliva and Swallowing problems related to pain and dry mouth had planned interventions related to these oral health problems, with the exception of Lubricating the lips, which was planned for 65.1% (Figure 1a). Figure 1b shows that not all older persons with problems related to Dentures, Tongue and Mucous membrane had planned interventions. Tooth brushing was the most common planned intervention for problems related to the Gums (72.0%) and Teeth (67.9%) (Figure 1c,d).
FIGURE 1.
(a) The correspondence between oral health problems (orange bars) related to voice (n = 609, missing n = 53), lips (n = 481, missing n = 41), saliva (n = 711, missing n = 54), and swallowing related to pain and dry mouth (n = 962, missing n = 74) and their respective planned preventive interventions (green bars) according to the ROAG‐J. (b) The correspondence between oral health problems (orange bars) related to dentures (n = 547, missing n = 39), tongue (n = 618, missing n = 42) and mucous membrane (n = 659, missing n = 51) and their respective planned preventive interventions (green bars) according to the ROAG‐J. (c) The correspondence between oral health problems (orange bar) related to gums (n = 972, missing n = 56) and planned preventive interventions (green bars) according to the ROAG‐J. (d) The correspondence between oral health problems (orange bar) related to teeth (n = 2,261, missing n = 147) and planned preventive interventions (green bars) according to the ROAG‐J
5. DISCUSSION
The current study shows that among older persons with assessed oral health problems, a large majority had planned preventive interventions, and approximately three quarters of these interventions were completed. However, there was a mismatch between type of oral health problem and preventive interventions. Common oral health problems were related to the Teeth. Impaired ability to understand information and instructions was the most common cause of oral health problems, and Tooth brushing was the most common planned intervention.
To the best of our knowledge, our study is the first to investigate the correspondence between specific oral health problems and associated planned preventive interventions according to ROAG‐J. While our study focused on correspondence between specific problems and associated interventions, a recent study by Bellander, Andersson, Wijk, et al. (2021) investigated longitudinal effect of preventive interventions according to ROAG‐J and found some improvements in oral health. Our results demonstrate inconsistency between risk and preventive interventions for oral health problems. Only two‐thirds of the older persons with identified risk for poor oral health related to the Teeth had Tooth brushing as a planned preventive intervention. On the one hand, it could be argued that all older persons would most likely benefit from such care, especially because tooth brushing after each meal and cleaning the dentures once a day can reduce the incidence of aspiration pneumonia among frail older persons (Manger et al., 2017; van der Maarel‐Wierink et al., 2013). On the other hand, this finding may reflect that the older persons brushed their own teeth and were not in need of assistance. Moreover, only 22.5% of the older persons having problems related to the Tongue had Cleaning of the tongue as a planned intervention, indicating that this intervention needs more emphasis because a recent review (Izumi & Akifusa, 2021) concluded that cleaning the tongue among older persons in nursing homes has a positive influence on swallowing and respiratory functions and prevents aspiration pneumonia. In the total sample, Cleaning of the tongue was planned for 7.6%, that is 286 of the older persons, while such intervention was planned for 22.5%, that is 139 of the 618 older persons with oral health problems specifically related to the Tongue. This may illustrate an example of a potential mismatch between oral health problems and planned interventions because it could have been expected that a larger proportion with oral health problems specifically related to the Tongue had Cleaning of the tongue as a planned intervention. Our results thus point towards a need to improve preventive nursing care among older persons about oral health problems. It can be assumed that a better match between type of risk and intervention would decrease the risk for oral health problems and improve quality of life among older persons because previous research has shown such associations (Lindmark et al., 2020; McGrath & Bedi, 1991; van de Rijt et al., 2021) and has shown that the promotion of oral hygiene is an essential basic part in nursing (Pipe et al., 2012).
Because lack of knowledge, education and training in providing oral care have been reported as reasons among nursing staff for not providing oral care for older persons (Wårdh et al., 2012), our results suggest that nursing programs need to clearly emphasize the importance of assisting older persons with their oral health. Moreover, educational interventions for nurses and assistant nurses in community care are vital in order to identify and act on oral health among older persons. Indeed, a wish for education about preventive oral health care has been raised by nursing staff and managers in nursing homes (Neziraj, Andersson, et al., 2021), which is in line with another recent study in which nursing staff expressed a need for more education and training in oral care despite the fact that the nursing staff reported being good at identifying oral health problems among older persons (Andersson & Persenius, 2021). Griffiths et al. (2021) developed an intervention integrating science and practice using a participatory research design for situations when different professionals are involved. One suggestion is to further develop or culturally adapt an existing intervention into a Swedish context and to involve older persons and their next of kin in the development of such an intervention. Another suggestion is to emphasize the importance of oral health basic nursing care in educational programs.
In line with earlier research based on Senior Alert (Rantzow et al., 2017), oral health problems related to the Teeth were the most common and were reported in more than 50% of the older persons in the current study. A majority of the older persons in the current study had at least one planned intervention, which also is in line with Rantzow et al. (2017) who reported similar results. In contrast to our results, which showed that Tooth brushing was the most common planned intervention (56.2%), this was planned only among 13.5% of the older persons in the study by Rantzow et al. (2017) in which Moistening of the mouth was the most common planned intervention. In our study, the proportion of both any and completed preventive interventions was smaller in home health care than in the other types of housing. This may indicate that preventive work is more challenging and requires other routines than in nursing homes where nursing staff are present more constantly.
Older persons' resistance has been raised as an important barrier to performing oral care (Hoben et al., 2017: Willumsen et al., 2012). In our study, resistance to preventive interventions was only reported among 7.5%, which is in line with Rantzow et al. who reported resistance among 4.8%, but contradicting Willumsen et al. (2012) who reported that almost half of the nurses encountered patients resisting help every day. A recent interview study (Koistinen et al., 2021) with older persons in short‐term care showed that they wanted to maintain control over their tooth brushing and that assistance was unthinkable at present but could be considered when not being able to do so themselves. It was also emphasized that many of the older persons had not visited dental care for many years due, for instance, to hospitalizations, declining health, and because the teeth were no longer a priority. Considering that poor oral health is associated with malnutrition (Lindroos et al., 2019; van Lancker et al., 2012) and aspiration pneumonia (van der Maarel‐Wierink et al., 2011) and has an impact on quality of life in older persons (Lindmark et al., 2020; McGrath & Bedi, 1991; van de Rijt et al., 2021), it seems important to offer regular dental care in municipal care. According to the ROAG‐J, a dentist should be consulted and offered when the older persons score a 3 on any assessment, but it is of course important to take the older person's autonomy into consideration because it may be that a dentist appointment is not desired. However, in our study, Consultation with dentist when scoring a 3 on any assessment was planned for 9.7% of the older persons, which is somewhat higher than in Rantzow et al. (2017) who reported 5.7%. This could be viewed as alarming and suggesting room for improvement, but another explanation could be that the older persons have simply declined the offered dentist appointment.
5.1. Limitations
A limitation is the lack of available medical data and scant background data in Senior Alert, which most likely would have added value to the interpretation of the results. Another weakness is the missing data for the different performed interventions. However, the missing data were handled according to the listwise deletion, that is, in analyses including intervention the complete cases were used (Kang, 2013). Another limitation may be that the included instructions were not fully adhered to by the registration professionals, which may be an explanation for the missing data. Although Senior Alert contains a clear care process, it could be that planned interventions do not reflect what is really being done in practice resulting in both under‐ and over‐reporting. A strength of the current study is that the sample size was rather large and represented older persons receiving different types of municipal care in a whole county in southern Sweden. Another strength may be that the risk assessments were made based on the validated ROAG‐J instrument (Senior Alert, 2021) and that the quality registry Senior Alert has a coverage of 73% (Senior Alert, 2019), which may indicate that the findings are generalizable for older persons receiving municipal care.
6. CONCLUSION
A large majority of older persons with assessed oral health problems had at least one planned preventive intervention, and approximately three quarters of these interventions were completed. Importantly, there seemed to be a mismatch between type of oral health problems and preventive interventions as not all older persons had a planned preventive intervention related to their specific oral health problem. Because oral health is an important element in nursing care, the current findings argue that there is room for improvement and suggest the need for educational interventions for nursing staff about the promotion of oral health.
ETHICAL APPROVAL
The study was ethically approved by the Regional Ethical Review Board, Lund, Sweden (2015‐484).
Axelsson, M. , Bahtsevani, C. , Neziraj, M. , Persson, K. , & Kumlien, C. (2023). A registry study of oral health problems and preventive interventions among older persons receiving municipal healthcare – PROSENIOR. Nursing Open, 10, 525–534. 10.1002/nop2.1318
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the national quality registry Senior Alert. The data are not publicly available due to privacy or ethical restrictions.
REFERENCES
- Andersson, M. , & Persenius, M. (2021). Good in providing oral care, but we could be better‐nursing staff identification of improvement areas in oral care. SAGE Open Nursing, 1, 1–8. 10.1177/23779608211045258 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Andersson, P. , Hallberg, I. R. , & Renvert, S. (2002). Inter‐rater reliability of an oral assessment guide for elderly patients residing in a rehabilitation ward. Special Care in Dentistry, 22(5), 181–186. [DOI] [PubMed] [Google Scholar]
- Bellander, L. , Andersson, P. , Nordvall, D. , & Hägglin, C. (2021). Oral health among older adults in nursing homes: A survey in a national quality register, the senior alert. Nursing Open, 8, 1262–1274. 10.1002/nop2.743 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Bellander, L. , Andersson, P. , Wijk, H. , & Hägglin, C. (2021). Oral assessment and preventive actions within the Swedish quality register senior alert: Impact on frail older Adults' Oral health in a longitudinal perspective. International Journal of Environmental Research and Public Health, 18, 13075. 10.3390/ijerph182413075 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Chiesi, F. , Grazzini, M. , Innocenti, M. , Giammarco, B. , Simoncini, E. , Garamella, G. , Zanobini, P. , Perra, C. , Baggiani, L. , Lorini, C. , & Bonaccorsi, G. (2019). Older people living in nursing homes: An Oral health screening survey in Florence, Italy. International Journal of Environmental Research and Public Health, 19(18), 3492. 10.3390/ijerph1618349 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Costello, T. , & Coyne, I. (2008). Nurses knowledge on mouth care practices. British Journal of Nursing, 17, 264–268. [DOI] [PubMed] [Google Scholar]
- Czwikla, J. , Herzberg, A. , Kapp, S. , Kloep, S. , Schmidt, A. , Rothgang, H. , Schwendicke, F. , & Hoffmann, F. (2021). Home care recipients have poorer oral health than nursing home residents: Results from two German studies. Journal of Dentistry, 107, 103607. 10.1016/j.jdent.2021.103607 [DOI] [PubMed] [Google Scholar]
- Edman, K. , & Wårdh, I. (2022). Oral health care beliefs among care personnel working with older people –follow‐up of oral care education provided by dental hygienists. International Journal of Dental Hygiene, 20, 241–248. 10.1111/idh.12588 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Edvinsson, J. , Rahm, M. , Trinks, A. , & Höglund, P. J. (2015). Senior alert: A quality registry to support a standardized, structured, and systematic preventive care process for older adults. Quality Management in Health Care, 24(2), 96–101. [DOI] [PubMed] [Google Scholar]
- Ek, K. , Browall, M. , Eriksson, M. , & Eriksson, I. (2018). Healthcare providers' experiences of assessing and performing oral care in older adults. International Journal of Older People Nursing, 13, e12189. 10.1111/opn.12189 [DOI] [PubMed] [Google Scholar]
- Forsell, M. , Sjögren, P. , & Johansson, O. (2009). Need of assistance with daily oral hygiene measures among nursing home resident elderly versus the actual assistance received from the staff. The Open Dentistry Journal, 3, 241–244. 10.2174/1874210600903010241 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Griffiths, A. W. , Devi, R. , Cheetham, B. , Heaton, L. , Randle, A. , Ellwood, A. , Douglas, G. V. A. , Csikar, J. , Vinall‐Collier, K. , Wright, J. , & Spilsbury, K. (2021). Maintaining and improving mouth care for care home residents: A participatory research project. International Journal of Older People Nursing, 16, e12394. 10.1111/opn.12394 [DOI] [PubMed] [Google Scholar]
- Hoben, M. , Clarke, A. , Huynh, K. T. , Kobagi, N. , Kent, A. , Hu, H. , Pereira, R. A. C. , Xiong, T. , Yu, K. , Xiang, H. , & Yoon, M. N. (2017). Barriers and facilitators in providing oral care to nursing home residents, from the perspective of care aides: A systematic review and meta‐analysis. International Journal of Nursing Studies, 73, 34–51. 10.1016/j.ijnurstu.2017.05.003 [DOI] [PubMed] [Google Scholar]
- Izumi, M. , & Akifusa, S. (2021). Tongue cleaning in the elderly and its role in the respiratory and swallowing functions: Benefits and medical perspectives. Journal of Oral Rehabilitation, 48, 1395–1403. 10.1111/joor.13266 [DOI] [PubMed] [Google Scholar]
- Kang, H. (2013). The prevention and handling of the missing data. Korean Journal of Anesthesiology, 64, 402–406. 10.4097/kjae.2013.64.5.402 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Kitson, A. , Conroy, T. , Wengstrom, Y. , Profetto‐McGrath, J. , & Robertson‐Malt, S. (2010). Defining the fundamentals of care. International Journal of Nursing Practice, 16, 423–434. [DOI] [PubMed] [Google Scholar]
- Koistinen, S. , Ståhlnacke, K. , Olai, L. , Ehrenberg, A. , & Carlsson, E. (2021). Older people's experiences of oral health and assisted daily oral care in short‐term facilities. BMC Geriatrics, 21, 388. 10.1186/s12877-021-02281-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- Lindmark, U. , Ernsth Bravell, M. , Johansson, L. , & Finkel, D. (2020). Oral health is essential for quality of life in older adults: A Swedish national quality register study. Gerodontology, 38, 191–198. 10.1111/ger.12514 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Lindroos, E. K. , Saarela, R. K. T. , Suominen, M. H. , Muurinen, S. , Soini, H. , Kautiainen, H. , & Pitkälä, K. H. (2019). Burden of oral symptoms and its associations with nutrition, well‐being, and survival among nursing home residents. Journal of the American Medical Directors Association, 20(5), 537–543. 10.1016/j.jamda.2018.10.025 [DOI] [PubMed] [Google Scholar]
- Manger, D. , Walshaw, M. , Fitzgerald, R. , Doughty, J. , Wanyonyi, K. L. , White, S. , & Gallagher, J. E. (2017). Evidence summary: The relationship between oral health and pulmonary disease. British Dental Journal, 222, 527–533. 10.1038/sj.bdj.2017.315 [DOI] [PubMed] [Google Scholar]
- McGrath, C. , & Bedi, R. (1991). The importance of oral health to older people's quality of life. Gerodontology, 16, 59–63. [DOI] [PubMed] [Google Scholar]
- McKenzie‐Green, B. , Giddings, L. S. , Buttle, L. , & Tahana, K. (2009). Older peoples' perceptions of oral health: ‘it's just not that simple’. International Journal of Dental Hygiene, 7, 31–38. [DOI] [PubMed] [Google Scholar]
- Neziraj, M. , Andersson, M. , Hellman, P. , Axelsson, M. , & Kumlien, C. (2021). Prevention of pressure ulcers, malnutrition, poor oral health and falls in nursing homes: A focus group study with nurse aides, registered nurses and managers. International Journal of Nursing Studies Advances, 3, 100056. 10.1016/j.ijnsa.2021.100056 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Neziraj, M. , Hellman, P. , Kumlien, C. , Andersson, M. , & Axelsson, M. (2021). Prevalence of risk for pressure ulcers, malnutrition, poor oral health and falls – A register study among older persons receiving municipal health care in southern Sweden. BMC Geriatrics, 21, 265. 10.1186/s12877-021-02205-x [DOI] [PMC free article] [PubMed] [Google Scholar]
- Oda, K. , Boyd, M. , Parsons, J. , & Smith, M. (2022). Integrating oral care into nursing practice in care homes. Nursing Older People, 22, 27–34. 10.7748/nop.2022.e1406 [DOI] [PubMed] [Google Scholar]
- Pipe, T. B. , Conolly, T. , Spahr, N. , Lendzion, N. , Buchda, V. , & Cisar, N. (2012). Bringing back the basics of nursing. Defining patient care essentials. Nursing Administration Quarterly, 36, 225–233. 10.1097/NAQ.0b013e31825afb3c [DOI] [PubMed] [Google Scholar]
- PROSENIOR . Prevention of falls, pressure ulcers, malnutrition and poor oral health in older persons in Skåne. Research project, Malmö University. https://mau.se/en/research/projects/prosenior/
- Rantzow, V. , Andersson, P. , & Lindmark, U. (2017). Occurrence of oral health problems and planned measures in dependent older people in nursing care. Journal of Clinical Nursing, 27, 4381–4389. 10.1111/jocn.14584 [DOI] [PubMed] [Google Scholar]
- Ribeiro, M. T. , Ferreira, R. C. , Vargas, A. M. , & Ferreira e Ferreira, E. (2014). Validity and reproducibility of the revised oral assessment guide applied by community health workers. Gerodontology, 31(2), 101–110. 10.1111/ger.12014 [DOI] [PubMed] [Google Scholar]
- Senior Alert . (2019). Annual report . https://plus.rjl.se/info_files/infosida40605/118_Senior_alert_Arsrapport_2019.pdf
- Senior Alert . (2021). Homepage . https://www.senioralert.se/english/
- Swedish Institute . (2021). Elderly care in Sweden . https://sweden.se/life/society/elderly‐care‐in‐sweden
- The Swedish Code of Statutes (SFS) . (2008). Patient data act . p. 355. https://www.riksdagen.se/sv/dokument‐lagar/dokument/svensk‐forfattningssamling/patientdatalag‐2008355_sfs‐2008‐355
- van de Rijt, L. J. M. , Feast, A. R. , Vickerstaff, V. , Sampson, E. L. , & Lobbezoo, F. (2021). Oral function and its association with nutrition and quality of life in nursing home residents with and without dementia: A cross‐sectional study. Gerodontology, 38, 404–413. 10.1111/ger.12535 [DOI] [PMC free article] [PubMed] [Google Scholar]
- van der Maarel‐Wierink, C. D. , Vanobbergen, J. N. O. , Bronkhorst, E. M. , Schols, J. M. G. A. , & de Baat, C. (2011). Risk factors for aspiration pneumonia in frail older people: A systematic literature review. Journal of the American Medical Directors Association, 12, 344–354. 10.1016/j.jamda.2010.12.099 [DOI] [PubMed] [Google Scholar]
- van der Maarel‐Wierink, C. D. , Vanobbergen, J. N. O. , Bronkhorst, E. M. , Schols, J. M. G. A. , & de Baat, C. (2013). Oral health care and aspiration pneumonia in frail older people: A systematic literature review. Gerodontology, 30, 3–9. 10.1111/j.1741-2358.2012.00637.x [DOI] [PubMed] [Google Scholar]
- van Lancker, A. , Verhaeghe, S. , Van Hecke, A. , Vanderwee, K. , Goossens, J. , & Beeckman, D. (2012). The association between malnutrition and oral health status in elderly in long‐term care facilities: A systematic review. International Journal of Nursing Studies, 49, 1568–1581. 10.1016/j.ijnurstu.2012.04.001 [DOI] [PubMed] [Google Scholar]
- von Elm, E. , Altman, D. G. , Egger, M. , Pocock, S. J. , Gøtzsche, P. C. , Vandenbroucke, J. P. , & STROBE Initiative . (2008). The strengthening the reporting of observational studies in epidemiology (STROBE) statement: Guidelines for reporting observational studies. Journal of Clinical Epidemiology, 61(4), 344–349. [DOI] [PubMed] [Google Scholar]
- Wårdh, I. , Jonsson, M. , & Wikström, M. (2012). Attitudes to and knowledge about oral health care among nursing home personnel–an area in need of improvement. Gerodontology, 29, e787–e792. [DOI] [PubMed] [Google Scholar]
- Welte, T. , Torres, A. , & Nathwani, D. (2012). Clinical and economic burden of community‐acquired pneumonia among adults in Europe. Thorax, 67, 71–79. [DOI] [PubMed] [Google Scholar]
- Willumsen, T. , Karlsen, L. , Næss, R. , & Bjørntvedt, S. (2012). Are the barriers to good oral hygiene in nursing homes within the nurses or the patients? Gerodontology, 29, e748–e755. 10.1111/j.1741-2358.2011.00554.x [DOI] [PubMed] [Google Scholar]
- Wong, M. F. F. , Ng, T. Y. Y. , & Leung, W. K. (2019). Oral health and its associated factors among older institutionalized residents ‐a systematic review. International Journal of Environmental Research and Public Health, 16, 4132. 10.3390/ijerph16214132 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Zenthöfer, A. , Rammelsberg, P. , Cabrera, T. , & Hassel, A. (2014). Increasing dependency of older people in nursing homes is associated with need for dental treatments. Neuropsychiatric Disease and Treatment, 10, 2285–2290. 10.2147/NDT.S71184 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available on request from the national quality registry Senior Alert. The data are not publicly available due to privacy or ethical restrictions.