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Aging & Mental Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/camh20
Improving oral health of institutionalized older people with diagnosed dementia a
a
a
a
Andreas Zenthöfer , Tomas Cabrera , Peter Rammelsberg & Alexander Jochen Hassel a
Department of Prosthodontics, Dental School, University of Heidelberg, Heidelberg, Germany Published online: 13 Feb 2015.
Click for updates To cite this article: Andreas Zenthöfer, Tomas Cabrera, Peter Rammelsberg & Alexander Jochen Hassel (2015): Improving oral health of institutionalized older people with diagnosed dementia, Aging & Mental Health, DOI: 10.1080/13607863.2015.1008986 To link to this article: http://dx.doi.org/10.1080/13607863.2015.1008986
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Aging & Mental Health, 2015 http://dx.doi.org/10.1080/13607863.2015.1008986
Improving oral health of institutionalized older people with diagnosed dementia Andreas Zenth€ ofer*, Tomas Cabrera, Peter Rammelsberg and Alexander Jochen Hassel Department of Prosthodontics, Dental School, University of Heidelberg, Heidelberg, Germany
Downloaded by [University of Birmingham] at 05:34 20 March 2015
(Received 18 August 2014; accepted 3 January 2015) Objective: Previous research has revealed poor oral hygiene and health among older people suffering from dementia. To evaluate the oral health and denture hygiene of older people with and without dementia, six months after carer have followed a dental education programme. Method: Ninety-three older people living in four long-term care homes in south-western Germany were included in this longitudinal cohort study. All participants were allocated into two groups on basis of the medical dementia diagnosis extracted from the medical records in the care documentation: suffering from dementia (n D 33) or not (n D 60). For each participant plaque control record, gingival bleeding index (GBI), community periodontal index of treatment needs (CPITN), and denture hygiene index (DHI) were assessed at baseline and six months after carer have followed a dental education programme, and after use of ultrasonic devices for denture cleaning. Differences between all target variables from baseline to follow-up, and between participants with and without dementia, were evaluated by bivariate and multivariate testing. Results: In bivariate testing, participants with dementia had a significantly lower DHI (p < 0.001), a lower GBI (p < 0.05), and a lower CPITN (p < 0.01) at follow-up. In participants without dementia, only for DHI (p < 0.001) a significant improvement was observed. In multivariate analyses, the significant association could not be reproduced (p > 0.05). Conclusions: Use of ultrasonic baths can be a successful means for improving denture hygiene among older people in long-term care with and without dementia. Education for carer in order to improve oral hygiene, however, seems to be of minor significance and to be more effective for people with dementia. Keywords: older people; dementia; oral health; oral hygiene; intervention
Introduction Oral health of older people A demographic shift to a larger proportion of people 65 years old and above is occurring in nearly all developed countries. This increases the risk of becoming dependent on care. In Germany, for example, approximately 2.5 million people are in need of care and 743,000 are living in stationary long-term care (Statistisches Bundesamt, 2011). For dependent older people, a variety of oral problems have been reported in the literature (Furuta et al., 2013; Komulainen et al., 2014) and the oral health of the institutionalized aged people seems to be even poorer (Chalmers, Carter & Spencer, 2005; Matthews et al., 2012; McMillan, Wong, Lo, & Allen, 2003; Montal, Tramini, Triay, & Valcarcel, 2006). Older people suffer from a variety of diseases, and frequently take drugs which can affect oral health (Leal et al., 2010; Porter, Scully, & Hegarty, 2004; Scannapieco et al. 1998). Cognitive and motor disabilities are, furthermore, highly prevalent among long-term care residents (Friedlander, Norman, Mahler, Norman, & Yagiela, 2006; Grossberg, 2003; Neissen, 2000). A few studies have investigated the relationships between dementia and oral health. Previous research acknowledged worse oral hygiene among aged people with dementia compared with healthy subjects. The same has been confirmed for oral health (Rejnefelt, Andersson and Renvert, 2006). Primarily, more caries and
greater prevalence of gingival and periodontal inflammation have been reported for this group (Ribeiro, Costa, Ambrosano, & Garcia, 2012; Syrj€al€a et al., 2012). In summary, oral problems are partially a result of barriers to dental services and changed self-perception of oral health in the context of multimorbidity, as acknowledged by Fiske, Griffiths, Jamieson, and Manger (2000). Because reduced cognitive functioning frequently results in greater levels of dependency, including for oral care, carer are of crucial importance in maintaining oral health (Adams, 1999; Fiske et al., 2000; Nitschke, M€uller, & Hopfenm€ uller, 2001). Nevertheless, there is evidence that carer lack knowledge of the specific oral hygiene requirements of older people, or do not have the time needed for adequate oral care (Adams, 1999; Fiske et al., 2000). Unfortunately, the oral hygiene of older people with dementia is sometimes complicated by affective and uncooperative behaviour (Mahoney et al., 1999).
Attempts to improve oral health To improve the oral hygiene and health of long-term care residents, the effects of different types of intervention have been studied. Most interventions have focused on improvement of the oral condition of healthy or mildly cognitively impaired older people. A few studies have revealed the positive effects of residents’ education in
*Corresponding author. Email: [email protected] Ó 2015 Taylor & Francis
Downloaded by [University of Birmingham] at 05:34 20 March 2015
2
A. Zenth€ ofer et al.
teeth-brushing techniques or critical self-estimation of oral condition (Komulainen et al., 2014; Ribeiro et al., 2009; Zenth€ ofer et al., 2013). Others have attempted to reduce oral shortcomings by educating care staff (Frenkel, Harvey, & Newcombe, 2001; Isaksson, Paulsson, Fridlund, & Nederfors, 2000; Zenth€ ofer et al., 2013). It has been shown that carer’ improved knowledge leads to less plaque (Frenkel et al., 2001; Portella et al., 2013; Zenth€ ofer et al., 2013) and reduced mucosal (Isaksson et al., 2000) and gingival inflammation (Zenth€ ofer et al., 2013) among care dependents. Other investigations evaluating the effects of education of carer revealed lower prevalence of denture stomatitis, and improved denture hygiene (Nicol, Petrina Sweeney, McHugh, & Bagg, 2005). It has also been demonstrated that professional teeth cleaning can achieve reduction of oral pathogens, for example candida, the prevalence of febrile diseases, and fatal pneumonia (Adachi et al, 2002; Ueda, Toyosato, & Nomura, 2003). Reports of intervention programmes among the most compromised older people, especially those with dementia, are rare. The few available studies of severely compromised older people found no or only small positive effects of intervention programmes on the improvement of oral hygiene and health (de Visschere, de Baat, Schols, Deschepper, & Vanobbergen, 2011; van der Putten et al., 2013) and denture plaque (van der Putten et al., 2013). It, therefore, remains unclear whether it is possible to improve oral and denture hygiene among institutionalized older people suffering from dementia by training care staff in oral health issues.
Purpose of this study The purpose of this study was, therefore, to evaluate the oral health and denture hygiene of elderly people with and without dementia six months after their carer had followed a dental education programme.
Method Participants The study was approved by the ethics committee of the University of Heidelberg (no. S-002/2012). Participants were recruited from four long-term care homes located in Mannheim, a city of 350,000 inhabitants in south-western Germany. Inclusion criteria required that participants or if the participants were not sui legis their legal guardians gave informed consent. It was also required that participants did not plan to leave their care home during the six months of the study period. At baseline, 93 participants agreed to participate and were enrolled in the study.
Study procedure A detailed study flowchart is presented in Figure 1. Participants were assigned to two groups on the basis of the medical dementia diagnosis extracted from the medical records in the care documentation: 33 participants were
categorized as ‘suffering from dementia’, all others as ‘healthy’ (n D 60). For all participants, dental examinations were performed at baseline and six months after intervention. Examinations included assessment of oral hygiene, denture hygiene, and periodontal health. Plaque control record (PCR; O’Leary, Drake, & Naylor, 1972) and gingival bleeding index (GBI; Ainamo and Bay, 1975) were used as indicators of oral hygiene. Denture hygiene was evaluated by using the denture hygiene index (DHI; Wefers et al., 1999). The community periodontal index of treatment needs (CPITN; Ainamo et al., 1982) was used to assess periodontal condition. All dental examinations were performed by two dentists experienced in epidemiologic surveys. To assess reliability, 15 participants of the sample were independently studied twice by both examiners. For all indices, inter-rater agreement was calculated by using Cronbach’s alpha; this reached a level > 0.9, which is indicative of excellent agreement. Additionally, socio-demographic data was administered. Further, participants’ cognitive ability was tested by using the mini mental state examination (MMSE, 0 30 points) administered by three psychologists (Folstein, Folstein, & McHugh et al., 1975). Intervention The intervention was intended to improve carer’ knowledge of oral hygiene and oral health among older people. All formal full-time carer in the four long-term care homes in the study were, therefore, asked to participate in a two-day oral health training programme. No honorary carer which frequently have irregular working times were targeted in the intervention with the intention to reach comparable study conditions regarding care routines. This training programme was offered separately to each participating long-term care home. It was intended that at least one carer from each ward of the homes attended the training. Forty-eight employees passed the training. The training included a theoretical part on specific approaches to improving oral hygiene, primarily of dependent seniors suffering from dementia. A PowerPoint presentation was used for the theoretical lecture. Initially, an overview of age-associated changes of the oral cavity and oral diseases was given. Carers were taught feasible brushing techniques, and handling of tooth and interdental space brushes, tooth pastes, and mouth rinses. In this context, a film was also shown to the carer. To improve carer’ capability of estimation of oral health, an assessment tool for the evaluation of oral conditions by dental laypersons, the revised oral assessment guide (ROAG; Hassel et al., 2008), was introduced to carer. In addition, dental demonstration models were used to practise oral care and handling of different kinds of removable denture. In an attempt to improve denture hygiene, two ultrasonic devices (Sonorex Super RK 31H; Bandelin GmbH; Berlin; Germany) were supplied to each long-term care home. As pointed out by Shay (2000), ultrasonic devices are rarely used for denture cleaning, because of high cost and lack of consumer information; they are, however,
Aging & Mental Health
3
Downloaded by [University of Birmingham] at 05:34 20 March 2015
and dementia/non-dementia (on basis of the medical dementia diagnosis) as independent variables. The level for local statistical significance was set to alpha < 0.05.
Figure 1. Participants’ flowchart.
recommended by the authors for use in care homes. Caregivers were educated in handling of the devices. During the study period, the ultrasonic appliances were used by the carer in accordance with the manufacturer’s instructions. As cleaning agent, soapy water, only, was recommended to the carer. With regard to hygiene requirements, each denture wearer received his own acrylic insert for the ultrasonic bath. The second part of the training was practical. Caregivers were asked to suggest residents for whom oral care was a problem. First, the care home staff being trained were instructed in how to evaluate oral hygiene and health by using the ROAG. Second, they performed oral care by themselves. They were also trained in the removal of dentures and mechanical cleaning of the dentures by using denture brushes. Practical exercises were supervised by a dentist who gave feedback and advice. Finally, an information brochure containing all the content of the training course was distributed to all carer. Statistical analysis Data analysis was performed by using SPSS 19.0 (IBM Corporation, NY, USA). The target variables PCR, GBI, CPITN, and DHI were compared between baseline and follow-up investigation by the use of t-tests. In addition to bivariate testing, linear regression models for changes of the target variables between baseline and follow-up (dependent variables) were compiled, with age, gender,
Results Of the 93 residents included in this study, five died, one left a home, and two decided during the six-month study period they no longer wished to participate (response to follow-up: 89.5%). Thus, complete records for 85 participants were used for longitudinal evaluation. Most of the population at baseline (n D 93) was female (n D 60, 65%). Ages of participants ranged from 54 to 107 years (mean 82.9, SD 9.9). Participants had a mean of 6.6 (SD 3.7) comorbidities and the number of drugs taken frequently was 7.1 (SD 3.6). Of the sample, 40% were edentulous and 72% wore some type of denture. Mean number of missing teeth was 20.5 (SD 8.7). Some 36% of the participants suffered from medically diagnosed dementia. Mean MMSE among the total study population was 15.3 (SD 9.5). Participants suffering from dementia, or not, had a mean MMSE of 10.9 (SD 9.5) and 17.7 (SD 8.6), respectively, which was significantly different (p < 0.001). Oral health at baseline as measured by GBI was significantly worse in participants with diagnosed dementia compared to those without (p < 0.05). All other baseline characteristics were comparable (p > 0.05). See Table 1 for details. Over the six-month study period, mean PCR decreased by 5.1% (SD 23.7%), GBI decreased by 1.2% (SD 30.6%), and DHI decreased by 30% (SD 30.8%) among the study group. CPITN improved by a mean of 0.2 (SD 0.7) units. DHI (p < 0.001), GBI (p < 0.05), and CPITN (p < 0.01) in participants suffering from dementia improved significantly; however, PCR did not show any significant improvement at follow-up (p > 0.05). Detailed results are presented in Table 2. The improvements of oral health indices found in bivariate analysis faded in the multivariate models when confounded with age, gender, and dental baseline indices. Linear regression analysis revealed no significant association with age, gender, or suffering, or not, from dementia; the baseline level was, however, significantly associated with changes in the indices (Tables 3 6). This suggested that participants with the worst baseline conditions profited most from the intervention. Discussion Denture hygiene improved substantially over the sixmonth period following the instructions for the carer and the implementation of the ultrasonic bathes. People with the worst denture hygiene at baseline improved most from the intervention. It must be stressed that participants with and without dementia profited both from the intervention. This is clinically relevant because previous research confirmed strong associations between denture plaque and the incidence of pneumonia. Therefore, plaque reduction reduces this risk for pneumonia (Adachi et al., 2002). It can be concluded that the use of ultrasonic devices by
4
A. Zenth€ ofer et al.
Table 1. Participants’ characteristics at baseline (n D 93). Dementia group (n D 33) Age, mean (SD)a Gender, frequency (%)b Female Male No. frequently taken drugs, mean (SD)a No. diseasesa MMSE scorea Gingival bleeding (GBI), mean (SD)a Plaque (PCR), mean (SD)a Denture hygiene (DHI), mean (SD)a Community periodontal index of treatment needs (CPITN), mean (SD)a Missing teeth, mean (SD)a a
Downloaded by [University of Birmingham] at 05:34 20 March 2015
b
Non-dementia group (n D 60)
Total cohort
81.7 (9.0)
83.4 (10.4)
82.8 (9.9)
19 (57.6) 14 (42.4) 7.0 (3.4) 6.3 (3.6) 10.9 (9.5) 52.1 (29.2) 89.3 (12.6) 86.1 (20.1) 3.3 (0.6)
41 (68.3) 19 (31.7) 7.1 (3.8) 6.8 (3.8) 17.7 (8.6) 38.1 (20.1) 80.3 (23.0) 84.6 (13.3) 3.1 (0.6)
60 (64.5) 23 (35.5) 7.1 (3.6) 6.6 (3.7) 15.3 (9.5) 42.6 (24.1) 83.2 (20.5) 85.1 (15.7) 3.2 (0.6)
20.5 (9.2)
20.5 (8.5)
20.5 (8.7)
Unpaired t-test: p < 0.05; p < 0.001. Chi-square test: p < 0.05; p < 0.001.
Table 2. Target variables at baseline and at six-month follow-up. Baseline (n D 93) Gingival bleeding index (GBI) Dementia Non-dementia Plaque control record (PCR) Dementia Non-dementia Community periodontal index (CPITN) Dementia Non-dementia Denture hygiene index (DHI) Dementia Non-dementia
Six-month follow-up (n D 85)
52.1 (29.2) 38.1 (20.1)
37.7 (24.5) 42.6 (28.6)
89.3 (12.6) 80.3 (23.0)
80.4 (21.0) 76.1 (25.7)
3.3 (0.6) 3.1 (0.6)
3.0 (0.7) 2.9 (0.6)
86.1 (20.1) 84.6 (13.3)
55.3 (35.1) 55.0 (27.2)
Note: Unpaired t-test: p < 0.05; p < 0.01; p < 0.001 between baseline and follow-up.
Table 3. Linear regression model for changes of gingival bleeding index (GBI) as dependent variable (n D 50). Confounder Age Female Dementia Baseline GBI
Regression
95% CI
p-value
0.2 ¡11.0 ¡13.9 ¡0.6
¡0.6, 1.0 ¡28.8, 6.8 ¡31.6, 3.9 ¡0.9, ¡0.2
0.692 0.218 0.122
Aging & Mental Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/camh20
Improving oral health of institutionalized older people with diagnosed dementia a
a
a
a
Andreas Zenthöfer , Tomas Cabrera , Peter Rammelsberg & Alexander Jochen Hassel a
Department of Prosthodontics, Dental School, University of Heidelberg, Heidelberg, Germany Published online: 13 Feb 2015.
Click for updates To cite this article: Andreas Zenthöfer, Tomas Cabrera, Peter Rammelsberg & Alexander Jochen Hassel (2015): Improving oral health of institutionalized older people with diagnosed dementia, Aging & Mental Health, DOI: 10.1080/13607863.2015.1008986 To link to this article: http://dx.doi.org/10.1080/13607863.2015.1008986
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Aging & Mental Health, 2015 http://dx.doi.org/10.1080/13607863.2015.1008986
Improving oral health of institutionalized older people with diagnosed dementia Andreas Zenth€ ofer*, Tomas Cabrera, Peter Rammelsberg and Alexander Jochen Hassel Department of Prosthodontics, Dental School, University of Heidelberg, Heidelberg, Germany
Downloaded by [University of Birmingham] at 05:34 20 March 2015
(Received 18 August 2014; accepted 3 January 2015) Objective: Previous research has revealed poor oral hygiene and health among older people suffering from dementia. To evaluate the oral health and denture hygiene of older people with and without dementia, six months after carer have followed a dental education programme. Method: Ninety-three older people living in four long-term care homes in south-western Germany were included in this longitudinal cohort study. All participants were allocated into two groups on basis of the medical dementia diagnosis extracted from the medical records in the care documentation: suffering from dementia (n D 33) or not (n D 60). For each participant plaque control record, gingival bleeding index (GBI), community periodontal index of treatment needs (CPITN), and denture hygiene index (DHI) were assessed at baseline and six months after carer have followed a dental education programme, and after use of ultrasonic devices for denture cleaning. Differences between all target variables from baseline to follow-up, and between participants with and without dementia, were evaluated by bivariate and multivariate testing. Results: In bivariate testing, participants with dementia had a significantly lower DHI (p < 0.001), a lower GBI (p < 0.05), and a lower CPITN (p < 0.01) at follow-up. In participants without dementia, only for DHI (p < 0.001) a significant improvement was observed. In multivariate analyses, the significant association could not be reproduced (p > 0.05). Conclusions: Use of ultrasonic baths can be a successful means for improving denture hygiene among older people in long-term care with and without dementia. Education for carer in order to improve oral hygiene, however, seems to be of minor significance and to be more effective for people with dementia. Keywords: older people; dementia; oral health; oral hygiene; intervention
Introduction Oral health of older people A demographic shift to a larger proportion of people 65 years old and above is occurring in nearly all developed countries. This increases the risk of becoming dependent on care. In Germany, for example, approximately 2.5 million people are in need of care and 743,000 are living in stationary long-term care (Statistisches Bundesamt, 2011). For dependent older people, a variety of oral problems have been reported in the literature (Furuta et al., 2013; Komulainen et al., 2014) and the oral health of the institutionalized aged people seems to be even poorer (Chalmers, Carter & Spencer, 2005; Matthews et al., 2012; McMillan, Wong, Lo, & Allen, 2003; Montal, Tramini, Triay, & Valcarcel, 2006). Older people suffer from a variety of diseases, and frequently take drugs which can affect oral health (Leal et al., 2010; Porter, Scully, & Hegarty, 2004; Scannapieco et al. 1998). Cognitive and motor disabilities are, furthermore, highly prevalent among long-term care residents (Friedlander, Norman, Mahler, Norman, & Yagiela, 2006; Grossberg, 2003; Neissen, 2000). A few studies have investigated the relationships between dementia and oral health. Previous research acknowledged worse oral hygiene among aged people with dementia compared with healthy subjects. The same has been confirmed for oral health (Rejnefelt, Andersson and Renvert, 2006). Primarily, more caries and
greater prevalence of gingival and periodontal inflammation have been reported for this group (Ribeiro, Costa, Ambrosano, & Garcia, 2012; Syrj€al€a et al., 2012). In summary, oral problems are partially a result of barriers to dental services and changed self-perception of oral health in the context of multimorbidity, as acknowledged by Fiske, Griffiths, Jamieson, and Manger (2000). Because reduced cognitive functioning frequently results in greater levels of dependency, including for oral care, carer are of crucial importance in maintaining oral health (Adams, 1999; Fiske et al., 2000; Nitschke, M€uller, & Hopfenm€ uller, 2001). Nevertheless, there is evidence that carer lack knowledge of the specific oral hygiene requirements of older people, or do not have the time needed for adequate oral care (Adams, 1999; Fiske et al., 2000). Unfortunately, the oral hygiene of older people with dementia is sometimes complicated by affective and uncooperative behaviour (Mahoney et al., 1999).
Attempts to improve oral health To improve the oral hygiene and health of long-term care residents, the effects of different types of intervention have been studied. Most interventions have focused on improvement of the oral condition of healthy or mildly cognitively impaired older people. A few studies have revealed the positive effects of residents’ education in
*Corresponding author. Email: [email protected] Ó 2015 Taylor & Francis
Downloaded by [University of Birmingham] at 05:34 20 March 2015
2
A. Zenth€ ofer et al.
teeth-brushing techniques or critical self-estimation of oral condition (Komulainen et al., 2014; Ribeiro et al., 2009; Zenth€ ofer et al., 2013). Others have attempted to reduce oral shortcomings by educating care staff (Frenkel, Harvey, & Newcombe, 2001; Isaksson, Paulsson, Fridlund, & Nederfors, 2000; Zenth€ ofer et al., 2013). It has been shown that carer’ improved knowledge leads to less plaque (Frenkel et al., 2001; Portella et al., 2013; Zenth€ ofer et al., 2013) and reduced mucosal (Isaksson et al., 2000) and gingival inflammation (Zenth€ ofer et al., 2013) among care dependents. Other investigations evaluating the effects of education of carer revealed lower prevalence of denture stomatitis, and improved denture hygiene (Nicol, Petrina Sweeney, McHugh, & Bagg, 2005). It has also been demonstrated that professional teeth cleaning can achieve reduction of oral pathogens, for example candida, the prevalence of febrile diseases, and fatal pneumonia (Adachi et al, 2002; Ueda, Toyosato, & Nomura, 2003). Reports of intervention programmes among the most compromised older people, especially those with dementia, are rare. The few available studies of severely compromised older people found no or only small positive effects of intervention programmes on the improvement of oral hygiene and health (de Visschere, de Baat, Schols, Deschepper, & Vanobbergen, 2011; van der Putten et al., 2013) and denture plaque (van der Putten et al., 2013). It, therefore, remains unclear whether it is possible to improve oral and denture hygiene among institutionalized older people suffering from dementia by training care staff in oral health issues.
Purpose of this study The purpose of this study was, therefore, to evaluate the oral health and denture hygiene of elderly people with and without dementia six months after their carer had followed a dental education programme.
Method Participants The study was approved by the ethics committee of the University of Heidelberg (no. S-002/2012). Participants were recruited from four long-term care homes located in Mannheim, a city of 350,000 inhabitants in south-western Germany. Inclusion criteria required that participants or if the participants were not sui legis their legal guardians gave informed consent. It was also required that participants did not plan to leave their care home during the six months of the study period. At baseline, 93 participants agreed to participate and were enrolled in the study.
Study procedure A detailed study flowchart is presented in Figure 1. Participants were assigned to two groups on the basis of the medical dementia diagnosis extracted from the medical records in the care documentation: 33 participants were
categorized as ‘suffering from dementia’, all others as ‘healthy’ (n D 60). For all participants, dental examinations were performed at baseline and six months after intervention. Examinations included assessment of oral hygiene, denture hygiene, and periodontal health. Plaque control record (PCR; O’Leary, Drake, & Naylor, 1972) and gingival bleeding index (GBI; Ainamo and Bay, 1975) were used as indicators of oral hygiene. Denture hygiene was evaluated by using the denture hygiene index (DHI; Wefers et al., 1999). The community periodontal index of treatment needs (CPITN; Ainamo et al., 1982) was used to assess periodontal condition. All dental examinations were performed by two dentists experienced in epidemiologic surveys. To assess reliability, 15 participants of the sample were independently studied twice by both examiners. For all indices, inter-rater agreement was calculated by using Cronbach’s alpha; this reached a level > 0.9, which is indicative of excellent agreement. Additionally, socio-demographic data was administered. Further, participants’ cognitive ability was tested by using the mini mental state examination (MMSE, 0 30 points) administered by three psychologists (Folstein, Folstein, & McHugh et al., 1975). Intervention The intervention was intended to improve carer’ knowledge of oral hygiene and oral health among older people. All formal full-time carer in the four long-term care homes in the study were, therefore, asked to participate in a two-day oral health training programme. No honorary carer which frequently have irregular working times were targeted in the intervention with the intention to reach comparable study conditions regarding care routines. This training programme was offered separately to each participating long-term care home. It was intended that at least one carer from each ward of the homes attended the training. Forty-eight employees passed the training. The training included a theoretical part on specific approaches to improving oral hygiene, primarily of dependent seniors suffering from dementia. A PowerPoint presentation was used for the theoretical lecture. Initially, an overview of age-associated changes of the oral cavity and oral diseases was given. Carers were taught feasible brushing techniques, and handling of tooth and interdental space brushes, tooth pastes, and mouth rinses. In this context, a film was also shown to the carer. To improve carer’ capability of estimation of oral health, an assessment tool for the evaluation of oral conditions by dental laypersons, the revised oral assessment guide (ROAG; Hassel et al., 2008), was introduced to carer. In addition, dental demonstration models were used to practise oral care and handling of different kinds of removable denture. In an attempt to improve denture hygiene, two ultrasonic devices (Sonorex Super RK 31H; Bandelin GmbH; Berlin; Germany) were supplied to each long-term care home. As pointed out by Shay (2000), ultrasonic devices are rarely used for denture cleaning, because of high cost and lack of consumer information; they are, however,
Aging & Mental Health
3
Downloaded by [University of Birmingham] at 05:34 20 March 2015
and dementia/non-dementia (on basis of the medical dementia diagnosis) as independent variables. The level for local statistical significance was set to alpha < 0.05.
Figure 1. Participants’ flowchart.
recommended by the authors for use in care homes. Caregivers were educated in handling of the devices. During the study period, the ultrasonic appliances were used by the carer in accordance with the manufacturer’s instructions. As cleaning agent, soapy water, only, was recommended to the carer. With regard to hygiene requirements, each denture wearer received his own acrylic insert for the ultrasonic bath. The second part of the training was practical. Caregivers were asked to suggest residents for whom oral care was a problem. First, the care home staff being trained were instructed in how to evaluate oral hygiene and health by using the ROAG. Second, they performed oral care by themselves. They were also trained in the removal of dentures and mechanical cleaning of the dentures by using denture brushes. Practical exercises were supervised by a dentist who gave feedback and advice. Finally, an information brochure containing all the content of the training course was distributed to all carer. Statistical analysis Data analysis was performed by using SPSS 19.0 (IBM Corporation, NY, USA). The target variables PCR, GBI, CPITN, and DHI were compared between baseline and follow-up investigation by the use of t-tests. In addition to bivariate testing, linear regression models for changes of the target variables between baseline and follow-up (dependent variables) were compiled, with age, gender,
Results Of the 93 residents included in this study, five died, one left a home, and two decided during the six-month study period they no longer wished to participate (response to follow-up: 89.5%). Thus, complete records for 85 participants were used for longitudinal evaluation. Most of the population at baseline (n D 93) was female (n D 60, 65%). Ages of participants ranged from 54 to 107 years (mean 82.9, SD 9.9). Participants had a mean of 6.6 (SD 3.7) comorbidities and the number of drugs taken frequently was 7.1 (SD 3.6). Of the sample, 40% were edentulous and 72% wore some type of denture. Mean number of missing teeth was 20.5 (SD 8.7). Some 36% of the participants suffered from medically diagnosed dementia. Mean MMSE among the total study population was 15.3 (SD 9.5). Participants suffering from dementia, or not, had a mean MMSE of 10.9 (SD 9.5) and 17.7 (SD 8.6), respectively, which was significantly different (p < 0.001). Oral health at baseline as measured by GBI was significantly worse in participants with diagnosed dementia compared to those without (p < 0.05). All other baseline characteristics were comparable (p > 0.05). See Table 1 for details. Over the six-month study period, mean PCR decreased by 5.1% (SD 23.7%), GBI decreased by 1.2% (SD 30.6%), and DHI decreased by 30% (SD 30.8%) among the study group. CPITN improved by a mean of 0.2 (SD 0.7) units. DHI (p < 0.001), GBI (p < 0.05), and CPITN (p < 0.01) in participants suffering from dementia improved significantly; however, PCR did not show any significant improvement at follow-up (p > 0.05). Detailed results are presented in Table 2. The improvements of oral health indices found in bivariate analysis faded in the multivariate models when confounded with age, gender, and dental baseline indices. Linear regression analysis revealed no significant association with age, gender, or suffering, or not, from dementia; the baseline level was, however, significantly associated with changes in the indices (Tables 3 6). This suggested that participants with the worst baseline conditions profited most from the intervention. Discussion Denture hygiene improved substantially over the sixmonth period following the instructions for the carer and the implementation of the ultrasonic bathes. People with the worst denture hygiene at baseline improved most from the intervention. It must be stressed that participants with and without dementia profited both from the intervention. This is clinically relevant because previous research confirmed strong associations between denture plaque and the incidence of pneumonia. Therefore, plaque reduction reduces this risk for pneumonia (Adachi et al., 2002). It can be concluded that the use of ultrasonic devices by
4
A. Zenth€ ofer et al.
Table 1. Participants’ characteristics at baseline (n D 93). Dementia group (n D 33) Age, mean (SD)a Gender, frequency (%)b Female Male No. frequently taken drugs, mean (SD)a No. diseasesa MMSE scorea Gingival bleeding (GBI), mean (SD)a Plaque (PCR), mean (SD)a Denture hygiene (DHI), mean (SD)a Community periodontal index of treatment needs (CPITN), mean (SD)a Missing teeth, mean (SD)a a
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b
Non-dementia group (n D 60)
Total cohort
81.7 (9.0)
83.4 (10.4)
82.8 (9.9)
19 (57.6) 14 (42.4) 7.0 (3.4) 6.3 (3.6) 10.9 (9.5) 52.1 (29.2) 89.3 (12.6) 86.1 (20.1) 3.3 (0.6)
41 (68.3) 19 (31.7) 7.1 (3.8) 6.8 (3.8) 17.7 (8.6) 38.1 (20.1) 80.3 (23.0) 84.6 (13.3) 3.1 (0.6)
60 (64.5) 23 (35.5) 7.1 (3.6) 6.6 (3.7) 15.3 (9.5) 42.6 (24.1) 83.2 (20.5) 85.1 (15.7) 3.2 (0.6)
20.5 (9.2)
20.5 (8.5)
20.5 (8.7)
Unpaired t-test: p < 0.05; p < 0.001. Chi-square test: p < 0.05; p < 0.001.
Table 2. Target variables at baseline and at six-month follow-up. Baseline (n D 93) Gingival bleeding index (GBI) Dementia Non-dementia Plaque control record (PCR) Dementia Non-dementia Community periodontal index (CPITN) Dementia Non-dementia Denture hygiene index (DHI) Dementia Non-dementia
Six-month follow-up (n D 85)
52.1 (29.2) 38.1 (20.1)
37.7 (24.5) 42.6 (28.6)
89.3 (12.6) 80.3 (23.0)
80.4 (21.0) 76.1 (25.7)
3.3 (0.6) 3.1 (0.6)
3.0 (0.7) 2.9 (0.6)
86.1 (20.1) 84.6 (13.3)
55.3 (35.1) 55.0 (27.2)
Note: Unpaired t-test: p < 0.05; p < 0.01; p < 0.001 between baseline and follow-up.
Table 3. Linear regression model for changes of gingival bleeding index (GBI) as dependent variable (n D 50). Confounder Age Female Dementia Baseline GBI
Regression
95% CI
p-value
0.2 ¡11.0 ¡13.9 ¡0.6
¡0.6, 1.0 ¡28.8, 6.8 ¡31.6, 3.9 ¡0.9, ¡0.2
0.692 0.218 0.122
