Original article
Oral health and dental care in aged care facilities in New South Wales, Australia. Part 3 concordance between residents’ perceptions and a professional dental examination Bettine C Webb1, Terry Whittle1 and Eli Schwarz2 1
Faculty of Dentistry, The University of Sydney, Sydney, NSW, Portland, OR, USA
Australia; 2School of Dentistry, Oregon Health & Science University,
Gerodontology 2015; doi:10.1111/ger.12170 Oral health and dental care in aged care facilities in New South Wales, Australia. Part 3 concordance between residents’ perceptions and a professional dental examination Objectives: To determine the perceptions of dental care held by the residents in aged care facilities (ACFs) in New South Wales (NSW) and to compare these perceptions with clinical observations. Background: No specific data exist relating to NSW residents’ perceptions of dental care compared with a clinical examination. Planning for appropriate oral health programs in ACFs necessitate such data. Materials and methods: Four Area Health Services of Sydney and 25 low care ACFs were selected from which representative residents were sampled who completed a survey and underwent a basic dental examination. Results: Of the subjects (25 males, 96 females), 76.9% had never received a dental visit as entering the ACF; 14.1% suffered from dental pain; 69.4% wore dentures and of these 18.3% required assistance in cleaning. Dentures were cleaned twice/day in 54.9% of cases. Natural teeth were reported present in 71.9% of residents, and 85.1% did not require assistance in cleaning. Appropriate dental care facilities and dry mouth were most frequent problems highlighted. Clinical examinations showed that 69% were denture wearers; oral hygiene and denture hygiene were considered good in 15.7% of cases. A high level of concordance existed between self-reports and examination. Conclusions: Increased awareness about oral health across leadership, caregivers and residents with appropriate dental health education and dedicated space within facilities would provide a much needed improvement for addressing oral health issues of the ACF residents. This might be the right time to plan for the future challenges that will need to be met by the NSW care system. Keywords: dental care, dental examination, denture hygiene, nursing homes. Accepted 19 October 2014
Introduction There is relatively little information about the self-perception of oral health among residents of aged care facilities (ACFs) and how it relates to a professional dental examination. Residents (average age on entry, 83.2 years) in Australian ACFs are part of the generation that grew up before fluoridation of the public water supplies and have experienced a different level of dental care, but increasing proportions still have their natural teeth1. Sanders et al.2 have reported that today’s elders had historically high rates of extraction prior to the 1950s that have not been experienced
by subsequent cohorts. According to Australian Dental Association (ADA) research, 60% of residents in 1979 had no natural teeth (edentulous), by 1988, it had decreased to 44%. Within 10 years, it is predicted to drop to 20%1. In a previous paper, ACF Directors of Nursing (DONs) reported that approximately 41% of residents in New South Wales (NSW) ACFs still possessed natural teeth.3 Care of natural teeth in older adults is more complex than care of dentures. As associations between poor oral health and cardio-vascular problems, diabetes and periodontal disease have been identified4–7 emphasis must be placed on informed preventive oral health care provided
© 2015 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd
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by dental professionals and caregivers of ACF residents. Kandelman7 commented that improved oral health would lead to better general health and indirectly to an improved quality of life (QoL). According to Kiyak8, oral health was perceived by residents in ACFs to be less important than general physical health. Gooch and Berkey9 observed that there was a wide discrepancy between the objective (observed by the dental professional) and the subjective (perceived by the elders) need for dental care. Heyes and Robinson10 have mentioned the low perception of dental need held by aged persons who perceive dental problems as part of the ageing process. In a study conducted in Brazil, by Barbosa et al.11 edentulous patients had limited awareness of prosthetic hygiene and maintenance and it was concluded that inadequate denture care instructions were given by the dentist. A Swedish study conducted by Einarson12 reported that oral health can negatively or positively affect a person’s sense of well-being, in other words their QoL. Colussi13 carried out a study to compare the self-perceived prosthetic needs of elders with those observed by a professional examiner according to WHO diagnosis criteria and found that the need for a prosthesis according to dental professionals differed from the perceptions held by elderly patients. Stoller14 conducted a study in which the preferences and priorities that patients use in making dental treatment decisions were demonstrated. Reed et al.15 in evaluating the outcome of oral health promotion programmes stressed that it is critical to measure the individuals’ perceptions of oral health conditions, that is the oral health-related QoL as well as the clinical needs of residents. Although overseas studies showed that there was a need to improve residents’ oral health, there was a paucity of information relating to residents’ perceptions of good dental health. According to Vigild16, residents have expectations and demands of oral care and she asks to what extent are these being met? MacEntee17 stated that residents accept poor oral health because they are not aware of the condition or they do not wish to disturb busy staff. De Visschere et al.18 spoke of the residents as an ‘at-risk population’ prone to nursing home-acquired pneumonia because of the accumulation of dental and denture plaque. They concluded that the oral hygiene of residents was poor and suggested that an improved QoL for residents could result from adequate oral hygiene and oral health services. Walker and Kiyak19 in a study of frail older adults in day centres found
that the provision of dental care enhanced their lives. Berkey et al.20 reported a lack of resident interest in dental care among the elders in Colorado ACFs. Wardh et al.21 also indicated that the residents in Swedish ACFs were not concerned about their oral health. Galan22 studied a sample of 170 Canadian residents and found that a lack of perceived need (88%) was the primary reason why dental care was not sought more frequently. Vigild23 in her study of ACFs in Denmark spoke of the ‘realistic treatment need’ when considering residents’ perceived need and demand for dental treatment, in other words the mental and physical health of each individual should be taken into account. Lee et al.24 demonstrated that individuals’ subjective perceptions of their oral health status had a greater impact on their health-related QoL than the clinical disease of dentulous or edentulous. Kiyak25 reported that dentists are often faced with dental problems in elders that are closely associated with the patients’ other diseases or emotional problems. She advocated placing more emphasis on providing better dental services to elders and reported that many frail elders can benefit through preventive oral health education in an ACF. There are few comparable studies in Australia, and the main investigations were carried out by Chalmers26 and colleagues in South Australia. They observed that with increasing severity of cognitive impairment, residents required more assistance with oral hygiene care and gave staff more difficulties with the provision of this care. In Western Australia, Paley27 addressed the resident perception of financial constraint and reported that residents were discouraged by the perceived high costs of dental care, thus hindering regular check-ups and appropriate treatment. The same researcher28 conducted a study, which investigated resident and family caregiver perceptions of oral health care and found that regular oral care, assessment and treatment were perceived as limited. Vowles29 in a survey of ACFs in South Australia reported that 13% of residents were unable to eat satisfactorily, and 16% were dissatisfied with their appearance. Homan’s30 study of residents at Mt. Olivet, Brisbane, revealed that one-half reported functional problems, and one in ten was concerned about appearance. An Australian study by Peel and Wilson31 showed that, contrary to general belief, frail older people proved to be excellent participants in research provided the process was carefully planned. From the literature reviewed, it was
© 2015 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd
Dental care in NSW aged care facilities
apparent that there was little information concerning resident perception of dental needs in Australian ACFs compared to similar studies overseas, and in NSW, which comprises around onethird of the country’s population and includes the population centre of Sydney, there were no specific data relating to residents’ perceptions of dental care compared with a clinical examination. A comprehensive study was carried out to investigate the oral health and the dental care situation in a sample of ACFs in NSW addressing oral health and dental care issues from the point of view of chief administrators, caregivers and residents of which the two first have been reported.3,32 The aims of this study were to document the dental needs as perceived by residents in Sydney metropolitan ACFs; to explore the oral health situation among these residents by a dental examination; and to examine to what extent there was concordance between residents’ perception of selected oral variables and the examination carried out by a dental professional.
Materials and methods The protocol of this study was approved by The University of Sydney Human Ethics Committee. A copy of the resident survey and resident clinical examination form can be obtained by writing to the corresponding author. The responsibility for Aged Care and Population Ageing including funding and services for residential as well as home care rests with the Australian Government (now Department of Social Services, previously the Department of Health and Ageing).33 To ensure that the growth in the number of aged care places available across Australia matches the growth in the aged population, the Australian Government’s planning framework determines annually the type(s) and distribution of places to be made available. A distinction is made between residential high care places and low care places (mostly based on dependency and need for assistance).33 Due to the need in this study for residents to be able to respond to a survey, the sampling frame only included low care facilities. A two-stage cluster sampling process was used to select four of the eight Area Health Services in NSW (Northern Sydney/Central Coast, South Eastern Sydney/Illawarra, Sydney South West, and Sydney West). Subsequently, twentyfive low care ACFs were randomly selected from these Area Health Services from a list of facilities with a target of participants of 120 residents, which were randomly selected by the facilities.
3
Telephone calls were made to the participating ACFs explaining the aim of the research and requesting permission to approach male and female residents to complete the survey. Of those agreeing to participate, approximately two male and two female residents who were not cognitively impaired and could read and understand English were selected and given the participant information sheet and consent form to complete. All participants were informed of complete information confidentiality and that they could withdraw from the study without penalty. Contact details were given should they wish to ask questions or make a complaint. A 24-item survey instrument for residents was developed from results of our previous research on the perceptions of DONs and caregivers in NSW ACFs and from past literature23,27,34. The questions, designed for ease of comprehension and an appropriate level of language, comprised general information about the resident, information on the resident’s self- and facility-delivered oral care, and limitations to that care. Resident oral health needs were determined using the Community Periodontal Index of Treatment Needs (CPITN) endorsed by the World Health Organisation (WHO) and the Federation Dentaire Internationale (FDI) to examine the mouth in sextants35. A clinical examination was conducted to provide more information on the resident’s oral health status. It consisted of a simple observation of the number of natural teeth, whether complete dentures or partial dentures were used, the general hygiene of the oral cavity including periodontal and gingival conditions based on Silness and Loe’s36 plaque index (modified as no WHO probe was used), halitosis, mucosal lesions and dry mouth as described by Scully and Cawson.37 No treatment or consultation was provided. Participating residents were placed in separate rooms to complete the survey and undergo the brief clinical examination. The method of recruitment reduced coercion as no resident was approached while on their own to participate or without staff supervision. All questionnaires and dental pro forma were marked with an identification code, which ensured their confidentiality. The information relating to the codes was kept in a secure location and not available to anyone other than the investigators. The direct method of collecting data was chosen in preference to postal surveys as it was considered more acceptable to older people and would yield higher response rates and less non-response bias.31
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Data from the returned survey and clinical examinations were transferred to Excel spreadsheet and analysed by SPSS for Windows v.20 (IBM Corp., Armonk, NY) with results reported as percentages and appropriate non-parametric statistics applied as indicated in the tables.
Results Residents’ responses Surveys were collected from 121 residents as illustrated in Table 1 with 25 male and 96 female respondents with an age range of 46–107 years and with more than half aged 85 years and older. There was no statistical difference between males and females with regard to age distribution. The ratio of males to females was 1:3.84, consistent with a previous assessment by DONs of a ratio of 1:3.453. The length of time for a resident to stay in an aged care facility ranged from 3 months to 41 years with a mean of 3.7 years. Residents (93.4%) had their teeth checked on entry to a facility, but this was part of the general assessment by ACF staff. To the question ‘when was your last dental appointment?’ answers ranged from a minimum of 0.25 year to a maximum of 50 years. Dental visits varied from once a year (76.9%) to more than once a year (17.4%). The predominant reason for visiting a dentist was problem related (60.3%), whereas check-ups were lower at 39.7%. In answer to the question ‘who does your dental treatment?’ 24.8% of residents said facility dentist, 14.1% own dentist and 44.6% said no treatment was required. When asked if they had dental pain 86% of residents answered ‘no’.
However, those who answered ‘yes’ could not give location of pain. Denture wearing was reported by 68.6% of residents, and dentures were worn from a minimum of 0.01 year to a maximum of 80 years. Responses about dentures revealed that 51.2% of residents removed their dentures at night, only 12.2% had their dentures labelled and 17.1% complained of moving dentures during speech or eating. Figure 1 shows the percentage of residents requiring assistance in cleaning their dentures and the number of times cleaned per day compared to similar data for residents with natural teeth. The data indicate that requiring assistance to clean and the number of times cleaned is similar between denture wearers and those with natural teeth. However, residents with natural teeth reported much higher rates of not having their teeth cleaned than those with dentures. The barriers to dental care as perceived by the residents are presented in Table 2 ranked by order of highest percentage of barriers that occurred often. The residents perceived lack of a suitable environment for dental examination and treatment (55%) as a priority barrier as were their medical problems (51%). Transportation was the fourth most often occurring barrier to dental care (31%) and may be linked to the perceived unwillingness of dental personnel to visit (25%) the ACFs. The medical problems as reported by residents as affecting the delivery of good dental care are listed in Table 3 with perceived dry mouth as the most important (almost half of the respondents) and a wide variety of general chronic ailments ranked lower.
Cleaning
100
Table 1 Selected demographical characteristics of the study population. Male
b
Female
Total
80
Denture
Natural
70
Age group
N
%
N
%
N
%
0.05). Table 5 relates selected clinical findings according to the same stratification by tooth status. Twothirds of the subjects wore dentures overall (69.4%), which was strongly associated with the remaining number of teeth (p < 0.001). Dry mouth was found in around half of the subjects, but with a significantly higher proportion among the edentate than any of the dentate groups. The need for prophylaxis and the presence of dental caries was only analysed in the eighty-eight dentate subjects with almost eight of 10 subjects needing prophylaxis due to plaque or calculus. No significant difference was found in the level of oral hygiene between the denture wearers and those with natural teeth, and the majority was found to have a fair level of oral hygiene. Overall, a third had dental caries, but significantly more subjects in the 10–19 teeth group had caries in need of treatment compared to the other two groups. Concordance between residents’ perception and clinical examination The final analysis addresses whether study subjects and the dental examiner were in agreement as to the subjects’ dental status. Three factors were selected for analysis, denture wearing, presence of natural teeth, and perception and examination of dry mouth. As illustrated in Table 6 both denture wearing and existence of natural teeth reached a very high level of agreement as indicated by a measure of concordance (Kendall’s Tau with p < 0.001). Slightly lower, but still a significantly concordant, level was reached between subjects’ perceptions and clinical findings of dry mouth.
Discussion The overriding aims of the investigation into the conditions for oral health and dental care in NSW aged care facilities were to approach the issues from the perspectives of chief administrators3, caregivers32, who are in contact with residents on a daily basis and residents themselves. With the present findings, a considerable amount of additional information has become available to consider possible ways to improve oral health care in ACFs. The high level of agreement between subjects’ perceptions of their own situation and the clinical examination indicates that residents are aware of some aspects of their dental care situation, even though they may be dependent on
© 2015 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd
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Table 4 Study population according to gender and age group stratified by tooth status. Tooth status Edentate Population characteristic Genderns Female Male Age groupns 0.05.
Table 5 Study population according to selected oral health characteristics as recorded during clinical examination stratified by tooth status. Tooth status Edentate Population characteristic Dentures*** No denture Denture Total Dry mouth** Yes No Total Prohylaxisns Required Not required Total Caries** Yes No Total
1–9 teeth
10–19 teeth
20+ teeth
Total
N
%
N
%
N
%
N
%
N
%
1 32 33
3.0 97.0 100
3 28 31
9.7 90.3 100
13 18 31
41.9 58.1 100
20 6 26
76.9 23.1 100
37 84 121
30.6 69.4 100
10 23 33
30.3 69.7 100
16 15 31
51.6 48.4 100
21 10 31
67.7 32.3 100
11 15 26
42.3 57.7 100
58 63 121
47.9 52.1 100
– – –
– – –
22 9 31
71.0 29.0 100
27 4 31
87.1 12.9 100
21 5 26
80.8 19.2 100
70 18 88
79.5 20.5 100
– – –
– – –
6 25 31
19.4 80.6 100
15 16 31
48.4 51.6 100
7 19 26
26.9 73.9 100
28 60 88
31.8 68.2 100
Outcome of a Pearson two-sided chi-square test: nsshowed no statistical significance with p > 0.05; **p < 0.05; ***p < 0.001. –, Indicates that the characteristic is not applicable due to edentulousness.
assistance with dental visits and daily oral hygiene activities. It is significant that residents considered lack of a suitable room with dental equipment and trained staff as a priority barrier to dental care, which agrees with the findings of Paley28. Barriers to maintaining oral care included mobility issues; lack of interest from dental professionals; long waiting times for Government dental care; lack of co-operation from family; lack of co-operation
from staff; ill-fitting dentures or poor dental work; resident non-compliance; resident unable to communicate oral problems and financial concerns.(Paley27). The findings showed that residents reported having various medical conditions (Table 3) and most reported that they had multiple medical conditions. This may be related to the rather high proportion of subjects’ complaints of dry mouth corroborated by the clinical examination. Although medications were not surveyed in
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Dental care in NSW aged care facilities
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Table 6 Concordance between the dental clinical examination and the study participants’ own assessment of (a) presence of dentures; (b) presence of remaining natural teeth; and (c) perceived dry mouth. Note, all percentages are calculated as percentage of total. Condition as assessed by clinical examination Dentures (a) Dentures present as assessed by subjects*
No denture N % of total
Yes denture N % of total
Total N
% of total
No Yes Total
36 1 37
2 82 84
38 62 121
31.4 68.6 100
29.8 0.8 30.6 Edentate
1.6 67.8 69.4 Dentate
Total
Teeth (b) Natural teeth remaining as assessed by subjects†
N
% of total
N
% of total
N
% of total
No Yes Total
33 0 33
27.3 0.0 27.3
1 87 88
0.8 71.9 72.7
34 87 121
28.1 71.9 100
Dry mouth (c) Dry mouth as perceived by subjects‡ No Yes Total
No dry mouth
Yes dry mouth
Total
N
% of total
N
% of total
N
% of total
57 6 63
47.1 5.0 52.1
9 49 58
7.4 40.5 47.9
66 55 121
54.5 45.5 100
Kendall’s Tau = *0.942, †0.981, ‡0.752; p < 0.001.
this research other reports have consistently found that multiple chronic conditions in elders are closely related to polypharmacy and its related side effects, such as dry mouth.38 Kandelman7 stated that there is good evidence that dry mouth negatively affects oral function and QoL. This may also be a factor in the finding of dental caries being present in a third of the subjects, which may not have reached the stage of ‘problem’ yet. However, no observational test for dry mouth was conducted. Mucosal lesions were observed in 21.7% of residents, and this figure included denture stomatitis lesions. Half of the residents reported that they removed their dentures at night thus eliminating one of the potential causes of multifactorial denture stomatitis, although this was not measured in the current study. Maupome et al.6 identified the associations between chronic systemic health conditions and oral health conditions of residents living in ACFs. Walker19 also conducted a similar study and suggested that providing basic dental care to frail elders may contribute to their well-being. In a review of the interrelationship between poor oral health of older people and their general health, Kandelman found that available scientific evidence was particularly strong for a direct relationship between diabetes and periodontal disease7.
It is noteworthy that although residents claimed to clean their dentures/teeth twice per day, the denture/oral hygiene was only fair and in some cases very poor. This suggests that the technique of cleaning could be inadequate, and it could be speculated that physical constraints and lack of dental health education contributed to this situation. The survey revealed that just over half of the residents did not clean their natural teeth at all, and they sought treatment for problems rather than have regular check-ups. Again, it could be speculated that these residents did not perceive a need to clean their natural teeth and they would wait for a problem to develop rather than have check-ups. In short, they regarded their dental condition as urgent only when pain alerted them to seek attention. This is in agreement with a study conducted by Ettinger et al.39 who found that the main reason residents did not accept dental care was the lack of perception of need. Heyes and Robinson10 explained that this low perception of need may be due to residents’ belief that dental problems were an inevitable consequence of ageing. It was also interesting that in our previous report3 the Directors of Nursing reported 41% of residents to have natural teeth yet in this study around 73% of residents retained natural teeth. Thus, there may be a lack of recognition on the
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part of the ACF leadership of the true nature of the oral health situation among residents. Similarly, daily caregivers reported that not enough time was allocated for cleaning of teeth and dentures, which they further elaborated with the need for further training in a range of oral healthrelated issues32. The trend for older persons to retain their natural teeth is supported by King40 who stated that it is projected that only about 20% of elderly Australians will be edentulous by 2019. Gooch9 indicated that younger cohorts of elders had greater educational and financial resources and decreased edentulousness in comparison with previous cohorts while Antoun et al.41 predicted an increase in the dentate institutionalised older population over the next few decades. The association between good dental/oral health and good general health needs to be emphasised. It is suggested that a special room be allocated in every ACF for dental assessment and treatment, and this is in agreement with suggestions by Paley28. Positively, the residents themselves have drawn attention to the need for a dedicated space for this purpose, while 86% of residents reported not having toothache and 86.9% reported no bleeding from gingivae when brushing natural teeth. Negatively, only 12.2% of residents had their dentures labelled, 60.3% sought dental treatment in response to a dental problem, and 52.3% did not clean their natural teeth at all. Limitations of the study Generalisability. The study was limited to survey low care facilities in order to include elders who would be able to respond to a survey. Thus, residents in high care facilities, who might exhibit more serious medical and mental conditions, might also reflect a more serious oral health situation, which was not captured here. Across all ACFs, the total need for oral health outreach and preventive approaches might be bigger. Even though many of the findings in this study are consistent with studies elsewhere no claim is made for generalisability beyond NSW. Selection bias. The sampling plan intended to include both leadership, caregivers and residents in this study. Thus, the selection of elderly participants was part of the larger study across a number of aged care facilities, which had already accepted to participate in the study. With the support of the facility, it was not perceived to be a big problem to enlist the study participants for the survey and the ensuing oral examination.
Recall bias. One of the most usual concerns around surveys, especially with elders, who may exhibit memory challenges, is the extent to which the responses are indeed correct. The survey limited the amount of recall, which was requested and focused more on what the respondents perceived about their present situation. Further, the analysis of concordance with the clinical examiner helped to demonstrate that respondents had a realistic perception on selected concrete factors in relation to their oral health. This may suggest that the perception of elders in this type of environment can be taken into account as part of a care plan. In conclusion, this study found that elderly residents in ACFs in NSW have reached a high age and a considerable proportion have retained their natural teeth, but that around two-thirds of them have dentures as well. The elders are aware of some aspects of their oral health such as their retained teeth, denture wearing and perceived dry mouth. On these variables, the study found a high level of concordance with a professional dental examination. Subjects seemed to be less aware in other areas, such as the need for oral hygiene or restorative treatment or less accepting of the need to do something as demonstrated by elders waiting for a problem to arise rather than seeking a dental check-up. The present report taken together with the two preceding ones on DONs and caregivers provides a picture of a sector of the social services where increased awareness about oral health across leadership, caregivers and residents with appropriate dental health education and dedicated space within facilities would provide a much needed improvement for addressing oral health issues of the ACF residents. Considering that future cohorts of residents will increasingly reflect patterns as seen in this study with even more teeth and complex medical situations this might be the right time to plan for the future challenges that will need to be met by the NSW care system.
Acknowledgments Thanks are due to The University of Sydney Human Research Ethics Committee for their approval to conduct this study, to the Australian Prosthodontic Society (NSW) for financial support, to all Residents, Directors of Nursing/Managers of ACFs who participated in this research and to Dr. Antonio Lee for reading this article and offering helpful advice.
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Dental care in NSW aged care facilities
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population. Acta Odontol Scand 2009; 67: 85–93. Colussi CF, De Freitas SFT, Calvo MCM. The prosthetic need WHO index: a comparison between selfperception and professional assessment in an elderly population. Gerodontology 2009; 26: 187–92. Stoller EP, Pyle MA, Perzynski AT. Priorities for oral health goals in a sample of older adults. Spec Care Dent 2004; 24: 220–8. Reed R, Broder HL, Jenkins G, Spivack E, Janal MN. Oral health promotion among older persons and their care providers in a nursing home facility. Gerodontology 2006; 23: 73–8. Vigild M. National survey of oral health care in Danish nursing homes. Gerodontics 1986; 2: 186–9. MacEntee MI, Thorne S, Kazanjian A. Conflicting priorities: oral health in long term care. Spec Care Dentist 1999; 19: 164–72. De Visschere LM, Grooten L, Theuniers G, Vanobbergen JN. Oral hygiene of elderly people in long-term institutions – a cross-sectional study. Gerodontology 2006; 23: 195–204. Walker RJ, Kiyak HA. The impact of providing dental services to frail older adults: Perceptions of elders in adult day health centers. Spec Care Dentist 2007; 27: 139–43. Berkey DB, Call RL, Gordon SR, Berkey KG. Barriers influencing dental care in long term care facilities. Gerodontics 1988; 4: 315–9. Wardh I, Berggren U, Andersson L, , Sorensen S. Assessments of oral health care independent older persons in nursing facilities. Acta Odontol Scand 2002; 60: 330–6. Galan D, Breex M, Heath MR. Oral health status of a population of community dwelling older Canadians. Gerodontology 1995; 12: 41–8. Vigild M. Oral health in institutionalized elderly. Tandlaegebladet 1990; 94: 169–94. Lee I-C, Shieh T-Y, Yang Y-H, Tsai C-C, Wang K-H. Individuals’ perception of oral health and its impact on the health-related quality of life. J Oral Rehabil 2007; 34: 79– 87. Kiyak HA. Psychosocial factors in dental needs of the elderly. Spec Care Dent 1981; 1: 22–30. Chalmers JM, Hodge C, Fuss JM, Spencer AJ, Carter KD. The prevalence and experience of oral diseases
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in Adelaide nursing home residents. Aust Dent J 2002; 4: 123–30. 27. Paley GA, Slack-Smith L, O’Grady MJ. Aged care staff perspectives on oral care for residents: Western Australia. Gerodontology 2004; 21: 146–54. 28. Paley GA, Slack-Smith L, O’Grady M. Oral health issues in aged care facilities in Western Australia: resident and family caregiver views. Gerodontology 2009; 26: 97– 104. 29. Vowles NJ, Watson BI, Dahi BJ. The needs of the homebound and institutionalized in South Australia, 1977. Aust Dent J 1979; 24: 114–20. 30. Homan BT, Lam B, Larsen RG. The oral needs and demands of a geriatric population at Mt. Olivet, Brisbane, 1986. Aust Dent J 1988; 33: 424–32. 31. Peel NM, Wilson C. Frail older people as participants in research. Educ Gerontol 2008; 34: 407–17. 32. Webb BC, Whittle T, Schwarz E. Provision of dental care in aged care facilities NSW Australia – Part 2 as perceived by the carers (care providers). Gerodontology 2013; 32: doi:10.1111/ger.12103. 33. Department of Social Services 2012– 13 Report on the operation of the Aged Care Act 1997. Available at: www.health.gov.au/internet/main/ publishing.nsf/Content/ageingreports-acarep.htm (last accessed 1 April 2014). 34. Chalmers JM, Carter KD, Spencer AJ. Caries incidence and increments in Adelaide nursing home residents. Spec Care Dentist 2005; 25: 96–105. 35. Lindhe J. Clinical periodontology and implant dentistry. In: Papapanou PN, Lindhe J eds., Chapter 2 Epidemiology of Periodontal Disease. Copenhagen: Munksgaard, 1997: 72– 8. 36. Lindhe J. Clinical periodontology and implant dentistry. In: Papapanou PN, Lindhe J eds, Chapter 2 Epidemiology of Periodontal Disease. Copenhagen: Munksgaard, 1997: 82– 94. 37. Scully C, Cawson RA. Oral disease. In: Major Salivary Gland Disease. London: Churchill Livingstone, 1999: 141. 38. van der Putten GJ, de Baat C, De Visschere L, Schols J. Poor oral health, a potential new geriatric syndrome. Gerodontology 2014; 31 (Suppl. 1): 17–24.
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39. Ettinger RL, Beck JD, Miller JA, Jakobsen J. Dental service use by older people living in long-term care facilities. Spec Care Dentist 1988; 8: 178–83. 40. King PL. Oral health needs of the elderly. NSW Public Health Bull 1999; 10 (8): 96–97. 41. Antoun JS, Adsett LA, Goldsmith SM, Thomson WM. The oral
health of older people: general dental practitioners’ beliefs and treatment experience. Spec Care Dent 2008; 28: 2–7.
Correspondence to: Dr Bettine Constance Webb, Honorary Senior Lecturer, Jaw Function and Orofacial Pain
Research Unit, Level 2, Westmead Centre for Oral Health, Darcy Road, Westmead, NSW 2145, Australia. Tel.: 612 9845 7734 Fax: 612 9633 2893 E-mail: bettine.webb@sydney. edu.au
© 2015 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd
Oral health and dental care in aged care facilities in New South Wales, Australia. Part 3 concordance between residents’ perceptions and a professional dental examination Bettine C Webb1, Terry Whittle1 and Eli Schwarz2 1
Faculty of Dentistry, The University of Sydney, Sydney, NSW, Portland, OR, USA
Australia; 2School of Dentistry, Oregon Health & Science University,
Gerodontology 2015; doi:10.1111/ger.12170 Oral health and dental care in aged care facilities in New South Wales, Australia. Part 3 concordance between residents’ perceptions and a professional dental examination Objectives: To determine the perceptions of dental care held by the residents in aged care facilities (ACFs) in New South Wales (NSW) and to compare these perceptions with clinical observations. Background: No specific data exist relating to NSW residents’ perceptions of dental care compared with a clinical examination. Planning for appropriate oral health programs in ACFs necessitate such data. Materials and methods: Four Area Health Services of Sydney and 25 low care ACFs were selected from which representative residents were sampled who completed a survey and underwent a basic dental examination. Results: Of the subjects (25 males, 96 females), 76.9% had never received a dental visit as entering the ACF; 14.1% suffered from dental pain; 69.4% wore dentures and of these 18.3% required assistance in cleaning. Dentures were cleaned twice/day in 54.9% of cases. Natural teeth were reported present in 71.9% of residents, and 85.1% did not require assistance in cleaning. Appropriate dental care facilities and dry mouth were most frequent problems highlighted. Clinical examinations showed that 69% were denture wearers; oral hygiene and denture hygiene were considered good in 15.7% of cases. A high level of concordance existed between self-reports and examination. Conclusions: Increased awareness about oral health across leadership, caregivers and residents with appropriate dental health education and dedicated space within facilities would provide a much needed improvement for addressing oral health issues of the ACF residents. This might be the right time to plan for the future challenges that will need to be met by the NSW care system. Keywords: dental care, dental examination, denture hygiene, nursing homes. Accepted 19 October 2014
Introduction There is relatively little information about the self-perception of oral health among residents of aged care facilities (ACFs) and how it relates to a professional dental examination. Residents (average age on entry, 83.2 years) in Australian ACFs are part of the generation that grew up before fluoridation of the public water supplies and have experienced a different level of dental care, but increasing proportions still have their natural teeth1. Sanders et al.2 have reported that today’s elders had historically high rates of extraction prior to the 1950s that have not been experienced
by subsequent cohorts. According to Australian Dental Association (ADA) research, 60% of residents in 1979 had no natural teeth (edentulous), by 1988, it had decreased to 44%. Within 10 years, it is predicted to drop to 20%1. In a previous paper, ACF Directors of Nursing (DONs) reported that approximately 41% of residents in New South Wales (NSW) ACFs still possessed natural teeth.3 Care of natural teeth in older adults is more complex than care of dentures. As associations between poor oral health and cardio-vascular problems, diabetes and periodontal disease have been identified4–7 emphasis must be placed on informed preventive oral health care provided
© 2015 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd
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by dental professionals and caregivers of ACF residents. Kandelman7 commented that improved oral health would lead to better general health and indirectly to an improved quality of life (QoL). According to Kiyak8, oral health was perceived by residents in ACFs to be less important than general physical health. Gooch and Berkey9 observed that there was a wide discrepancy between the objective (observed by the dental professional) and the subjective (perceived by the elders) need for dental care. Heyes and Robinson10 have mentioned the low perception of dental need held by aged persons who perceive dental problems as part of the ageing process. In a study conducted in Brazil, by Barbosa et al.11 edentulous patients had limited awareness of prosthetic hygiene and maintenance and it was concluded that inadequate denture care instructions were given by the dentist. A Swedish study conducted by Einarson12 reported that oral health can negatively or positively affect a person’s sense of well-being, in other words their QoL. Colussi13 carried out a study to compare the self-perceived prosthetic needs of elders with those observed by a professional examiner according to WHO diagnosis criteria and found that the need for a prosthesis according to dental professionals differed from the perceptions held by elderly patients. Stoller14 conducted a study in which the preferences and priorities that patients use in making dental treatment decisions were demonstrated. Reed et al.15 in evaluating the outcome of oral health promotion programmes stressed that it is critical to measure the individuals’ perceptions of oral health conditions, that is the oral health-related QoL as well as the clinical needs of residents. Although overseas studies showed that there was a need to improve residents’ oral health, there was a paucity of information relating to residents’ perceptions of good dental health. According to Vigild16, residents have expectations and demands of oral care and she asks to what extent are these being met? MacEntee17 stated that residents accept poor oral health because they are not aware of the condition or they do not wish to disturb busy staff. De Visschere et al.18 spoke of the residents as an ‘at-risk population’ prone to nursing home-acquired pneumonia because of the accumulation of dental and denture plaque. They concluded that the oral hygiene of residents was poor and suggested that an improved QoL for residents could result from adequate oral hygiene and oral health services. Walker and Kiyak19 in a study of frail older adults in day centres found
that the provision of dental care enhanced their lives. Berkey et al.20 reported a lack of resident interest in dental care among the elders in Colorado ACFs. Wardh et al.21 also indicated that the residents in Swedish ACFs were not concerned about their oral health. Galan22 studied a sample of 170 Canadian residents and found that a lack of perceived need (88%) was the primary reason why dental care was not sought more frequently. Vigild23 in her study of ACFs in Denmark spoke of the ‘realistic treatment need’ when considering residents’ perceived need and demand for dental treatment, in other words the mental and physical health of each individual should be taken into account. Lee et al.24 demonstrated that individuals’ subjective perceptions of their oral health status had a greater impact on their health-related QoL than the clinical disease of dentulous or edentulous. Kiyak25 reported that dentists are often faced with dental problems in elders that are closely associated with the patients’ other diseases or emotional problems. She advocated placing more emphasis on providing better dental services to elders and reported that many frail elders can benefit through preventive oral health education in an ACF. There are few comparable studies in Australia, and the main investigations were carried out by Chalmers26 and colleagues in South Australia. They observed that with increasing severity of cognitive impairment, residents required more assistance with oral hygiene care and gave staff more difficulties with the provision of this care. In Western Australia, Paley27 addressed the resident perception of financial constraint and reported that residents were discouraged by the perceived high costs of dental care, thus hindering regular check-ups and appropriate treatment. The same researcher28 conducted a study, which investigated resident and family caregiver perceptions of oral health care and found that regular oral care, assessment and treatment were perceived as limited. Vowles29 in a survey of ACFs in South Australia reported that 13% of residents were unable to eat satisfactorily, and 16% were dissatisfied with their appearance. Homan’s30 study of residents at Mt. Olivet, Brisbane, revealed that one-half reported functional problems, and one in ten was concerned about appearance. An Australian study by Peel and Wilson31 showed that, contrary to general belief, frail older people proved to be excellent participants in research provided the process was carefully planned. From the literature reviewed, it was
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Dental care in NSW aged care facilities
apparent that there was little information concerning resident perception of dental needs in Australian ACFs compared to similar studies overseas, and in NSW, which comprises around onethird of the country’s population and includes the population centre of Sydney, there were no specific data relating to residents’ perceptions of dental care compared with a clinical examination. A comprehensive study was carried out to investigate the oral health and the dental care situation in a sample of ACFs in NSW addressing oral health and dental care issues from the point of view of chief administrators, caregivers and residents of which the two first have been reported.3,32 The aims of this study were to document the dental needs as perceived by residents in Sydney metropolitan ACFs; to explore the oral health situation among these residents by a dental examination; and to examine to what extent there was concordance between residents’ perception of selected oral variables and the examination carried out by a dental professional.
Materials and methods The protocol of this study was approved by The University of Sydney Human Ethics Committee. A copy of the resident survey and resident clinical examination form can be obtained by writing to the corresponding author. The responsibility for Aged Care and Population Ageing including funding and services for residential as well as home care rests with the Australian Government (now Department of Social Services, previously the Department of Health and Ageing).33 To ensure that the growth in the number of aged care places available across Australia matches the growth in the aged population, the Australian Government’s planning framework determines annually the type(s) and distribution of places to be made available. A distinction is made between residential high care places and low care places (mostly based on dependency and need for assistance).33 Due to the need in this study for residents to be able to respond to a survey, the sampling frame only included low care facilities. A two-stage cluster sampling process was used to select four of the eight Area Health Services in NSW (Northern Sydney/Central Coast, South Eastern Sydney/Illawarra, Sydney South West, and Sydney West). Subsequently, twentyfive low care ACFs were randomly selected from these Area Health Services from a list of facilities with a target of participants of 120 residents, which were randomly selected by the facilities.
3
Telephone calls were made to the participating ACFs explaining the aim of the research and requesting permission to approach male and female residents to complete the survey. Of those agreeing to participate, approximately two male and two female residents who were not cognitively impaired and could read and understand English were selected and given the participant information sheet and consent form to complete. All participants were informed of complete information confidentiality and that they could withdraw from the study without penalty. Contact details were given should they wish to ask questions or make a complaint. A 24-item survey instrument for residents was developed from results of our previous research on the perceptions of DONs and caregivers in NSW ACFs and from past literature23,27,34. The questions, designed for ease of comprehension and an appropriate level of language, comprised general information about the resident, information on the resident’s self- and facility-delivered oral care, and limitations to that care. Resident oral health needs were determined using the Community Periodontal Index of Treatment Needs (CPITN) endorsed by the World Health Organisation (WHO) and the Federation Dentaire Internationale (FDI) to examine the mouth in sextants35. A clinical examination was conducted to provide more information on the resident’s oral health status. It consisted of a simple observation of the number of natural teeth, whether complete dentures or partial dentures were used, the general hygiene of the oral cavity including periodontal and gingival conditions based on Silness and Loe’s36 plaque index (modified as no WHO probe was used), halitosis, mucosal lesions and dry mouth as described by Scully and Cawson.37 No treatment or consultation was provided. Participating residents were placed in separate rooms to complete the survey and undergo the brief clinical examination. The method of recruitment reduced coercion as no resident was approached while on their own to participate or without staff supervision. All questionnaires and dental pro forma were marked with an identification code, which ensured their confidentiality. The information relating to the codes was kept in a secure location and not available to anyone other than the investigators. The direct method of collecting data was chosen in preference to postal surveys as it was considered more acceptable to older people and would yield higher response rates and less non-response bias.31
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Data from the returned survey and clinical examinations were transferred to Excel spreadsheet and analysed by SPSS for Windows v.20 (IBM Corp., Armonk, NY) with results reported as percentages and appropriate non-parametric statistics applied as indicated in the tables.
Results Residents’ responses Surveys were collected from 121 residents as illustrated in Table 1 with 25 male and 96 female respondents with an age range of 46–107 years and with more than half aged 85 years and older. There was no statistical difference between males and females with regard to age distribution. The ratio of males to females was 1:3.84, consistent with a previous assessment by DONs of a ratio of 1:3.453. The length of time for a resident to stay in an aged care facility ranged from 3 months to 41 years with a mean of 3.7 years. Residents (93.4%) had their teeth checked on entry to a facility, but this was part of the general assessment by ACF staff. To the question ‘when was your last dental appointment?’ answers ranged from a minimum of 0.25 year to a maximum of 50 years. Dental visits varied from once a year (76.9%) to more than once a year (17.4%). The predominant reason for visiting a dentist was problem related (60.3%), whereas check-ups were lower at 39.7%. In answer to the question ‘who does your dental treatment?’ 24.8% of residents said facility dentist, 14.1% own dentist and 44.6% said no treatment was required. When asked if they had dental pain 86% of residents answered ‘no’.
However, those who answered ‘yes’ could not give location of pain. Denture wearing was reported by 68.6% of residents, and dentures were worn from a minimum of 0.01 year to a maximum of 80 years. Responses about dentures revealed that 51.2% of residents removed their dentures at night, only 12.2% had their dentures labelled and 17.1% complained of moving dentures during speech or eating. Figure 1 shows the percentage of residents requiring assistance in cleaning their dentures and the number of times cleaned per day compared to similar data for residents with natural teeth. The data indicate that requiring assistance to clean and the number of times cleaned is similar between denture wearers and those with natural teeth. However, residents with natural teeth reported much higher rates of not having their teeth cleaned than those with dentures. The barriers to dental care as perceived by the residents are presented in Table 2 ranked by order of highest percentage of barriers that occurred often. The residents perceived lack of a suitable environment for dental examination and treatment (55%) as a priority barrier as were their medical problems (51%). Transportation was the fourth most often occurring barrier to dental care (31%) and may be linked to the perceived unwillingness of dental personnel to visit (25%) the ACFs. The medical problems as reported by residents as affecting the delivery of good dental care are listed in Table 3 with perceived dry mouth as the most important (almost half of the respondents) and a wide variety of general chronic ailments ranked lower.
Cleaning
100
Table 1 Selected demographical characteristics of the study population. Male
b
Female
Total
80
Denture
Natural
70
Age group
N
%
N
%
N
%
0.05). Table 5 relates selected clinical findings according to the same stratification by tooth status. Twothirds of the subjects wore dentures overall (69.4%), which was strongly associated with the remaining number of teeth (p < 0.001). Dry mouth was found in around half of the subjects, but with a significantly higher proportion among the edentate than any of the dentate groups. The need for prophylaxis and the presence of dental caries was only analysed in the eighty-eight dentate subjects with almost eight of 10 subjects needing prophylaxis due to plaque or calculus. No significant difference was found in the level of oral hygiene between the denture wearers and those with natural teeth, and the majority was found to have a fair level of oral hygiene. Overall, a third had dental caries, but significantly more subjects in the 10–19 teeth group had caries in need of treatment compared to the other two groups. Concordance between residents’ perception and clinical examination The final analysis addresses whether study subjects and the dental examiner were in agreement as to the subjects’ dental status. Three factors were selected for analysis, denture wearing, presence of natural teeth, and perception and examination of dry mouth. As illustrated in Table 6 both denture wearing and existence of natural teeth reached a very high level of agreement as indicated by a measure of concordance (Kendall’s Tau with p < 0.001). Slightly lower, but still a significantly concordant, level was reached between subjects’ perceptions and clinical findings of dry mouth.
Discussion The overriding aims of the investigation into the conditions for oral health and dental care in NSW aged care facilities were to approach the issues from the perspectives of chief administrators3, caregivers32, who are in contact with residents on a daily basis and residents themselves. With the present findings, a considerable amount of additional information has become available to consider possible ways to improve oral health care in ACFs. The high level of agreement between subjects’ perceptions of their own situation and the clinical examination indicates that residents are aware of some aspects of their dental care situation, even though they may be dependent on
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Table 4 Study population according to gender and age group stratified by tooth status. Tooth status Edentate Population characteristic Genderns Female Male Age groupns 0.05.
Table 5 Study population according to selected oral health characteristics as recorded during clinical examination stratified by tooth status. Tooth status Edentate Population characteristic Dentures*** No denture Denture Total Dry mouth** Yes No Total Prohylaxisns Required Not required Total Caries** Yes No Total
1–9 teeth
10–19 teeth
20+ teeth
Total
N
%
N
%
N
%
N
%
N
%
1 32 33
3.0 97.0 100
3 28 31
9.7 90.3 100
13 18 31
41.9 58.1 100
20 6 26
76.9 23.1 100
37 84 121
30.6 69.4 100
10 23 33
30.3 69.7 100
16 15 31
51.6 48.4 100
21 10 31
67.7 32.3 100
11 15 26
42.3 57.7 100
58 63 121
47.9 52.1 100
– – –
– – –
22 9 31
71.0 29.0 100
27 4 31
87.1 12.9 100
21 5 26
80.8 19.2 100
70 18 88
79.5 20.5 100
– – –
– – –
6 25 31
19.4 80.6 100
15 16 31
48.4 51.6 100
7 19 26
26.9 73.9 100
28 60 88
31.8 68.2 100
Outcome of a Pearson two-sided chi-square test: nsshowed no statistical significance with p > 0.05; **p < 0.05; ***p < 0.001. –, Indicates that the characteristic is not applicable due to edentulousness.
assistance with dental visits and daily oral hygiene activities. It is significant that residents considered lack of a suitable room with dental equipment and trained staff as a priority barrier to dental care, which agrees with the findings of Paley28. Barriers to maintaining oral care included mobility issues; lack of interest from dental professionals; long waiting times for Government dental care; lack of co-operation from family; lack of co-operation
from staff; ill-fitting dentures or poor dental work; resident non-compliance; resident unable to communicate oral problems and financial concerns.(Paley27). The findings showed that residents reported having various medical conditions (Table 3) and most reported that they had multiple medical conditions. This may be related to the rather high proportion of subjects’ complaints of dry mouth corroborated by the clinical examination. Although medications were not surveyed in
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Dental care in NSW aged care facilities
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Table 6 Concordance between the dental clinical examination and the study participants’ own assessment of (a) presence of dentures; (b) presence of remaining natural teeth; and (c) perceived dry mouth. Note, all percentages are calculated as percentage of total. Condition as assessed by clinical examination Dentures (a) Dentures present as assessed by subjects*
No denture N % of total
Yes denture N % of total
Total N
% of total
No Yes Total
36 1 37
2 82 84
38 62 121
31.4 68.6 100
29.8 0.8 30.6 Edentate
1.6 67.8 69.4 Dentate
Total
Teeth (b) Natural teeth remaining as assessed by subjects†
N
% of total
N
% of total
N
% of total
No Yes Total
33 0 33
27.3 0.0 27.3
1 87 88
0.8 71.9 72.7
34 87 121
28.1 71.9 100
Dry mouth (c) Dry mouth as perceived by subjects‡ No Yes Total
No dry mouth
Yes dry mouth
Total
N
% of total
N
% of total
N
% of total
57 6 63
47.1 5.0 52.1
9 49 58
7.4 40.5 47.9
66 55 121
54.5 45.5 100
Kendall’s Tau = *0.942, †0.981, ‡0.752; p < 0.001.
this research other reports have consistently found that multiple chronic conditions in elders are closely related to polypharmacy and its related side effects, such as dry mouth.38 Kandelman7 stated that there is good evidence that dry mouth negatively affects oral function and QoL. This may also be a factor in the finding of dental caries being present in a third of the subjects, which may not have reached the stage of ‘problem’ yet. However, no observational test for dry mouth was conducted. Mucosal lesions were observed in 21.7% of residents, and this figure included denture stomatitis lesions. Half of the residents reported that they removed their dentures at night thus eliminating one of the potential causes of multifactorial denture stomatitis, although this was not measured in the current study. Maupome et al.6 identified the associations between chronic systemic health conditions and oral health conditions of residents living in ACFs. Walker19 also conducted a similar study and suggested that providing basic dental care to frail elders may contribute to their well-being. In a review of the interrelationship between poor oral health of older people and their general health, Kandelman found that available scientific evidence was particularly strong for a direct relationship between diabetes and periodontal disease7.
It is noteworthy that although residents claimed to clean their dentures/teeth twice per day, the denture/oral hygiene was only fair and in some cases very poor. This suggests that the technique of cleaning could be inadequate, and it could be speculated that physical constraints and lack of dental health education contributed to this situation. The survey revealed that just over half of the residents did not clean their natural teeth at all, and they sought treatment for problems rather than have regular check-ups. Again, it could be speculated that these residents did not perceive a need to clean their natural teeth and they would wait for a problem to develop rather than have check-ups. In short, they regarded their dental condition as urgent only when pain alerted them to seek attention. This is in agreement with a study conducted by Ettinger et al.39 who found that the main reason residents did not accept dental care was the lack of perception of need. Heyes and Robinson10 explained that this low perception of need may be due to residents’ belief that dental problems were an inevitable consequence of ageing. It was also interesting that in our previous report3 the Directors of Nursing reported 41% of residents to have natural teeth yet in this study around 73% of residents retained natural teeth. Thus, there may be a lack of recognition on the
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part of the ACF leadership of the true nature of the oral health situation among residents. Similarly, daily caregivers reported that not enough time was allocated for cleaning of teeth and dentures, which they further elaborated with the need for further training in a range of oral healthrelated issues32. The trend for older persons to retain their natural teeth is supported by King40 who stated that it is projected that only about 20% of elderly Australians will be edentulous by 2019. Gooch9 indicated that younger cohorts of elders had greater educational and financial resources and decreased edentulousness in comparison with previous cohorts while Antoun et al.41 predicted an increase in the dentate institutionalised older population over the next few decades. The association between good dental/oral health and good general health needs to be emphasised. It is suggested that a special room be allocated in every ACF for dental assessment and treatment, and this is in agreement with suggestions by Paley28. Positively, the residents themselves have drawn attention to the need for a dedicated space for this purpose, while 86% of residents reported not having toothache and 86.9% reported no bleeding from gingivae when brushing natural teeth. Negatively, only 12.2% of residents had their dentures labelled, 60.3% sought dental treatment in response to a dental problem, and 52.3% did not clean their natural teeth at all. Limitations of the study Generalisability. The study was limited to survey low care facilities in order to include elders who would be able to respond to a survey. Thus, residents in high care facilities, who might exhibit more serious medical and mental conditions, might also reflect a more serious oral health situation, which was not captured here. Across all ACFs, the total need for oral health outreach and preventive approaches might be bigger. Even though many of the findings in this study are consistent with studies elsewhere no claim is made for generalisability beyond NSW. Selection bias. The sampling plan intended to include both leadership, caregivers and residents in this study. Thus, the selection of elderly participants was part of the larger study across a number of aged care facilities, which had already accepted to participate in the study. With the support of the facility, it was not perceived to be a big problem to enlist the study participants for the survey and the ensuing oral examination.
Recall bias. One of the most usual concerns around surveys, especially with elders, who may exhibit memory challenges, is the extent to which the responses are indeed correct. The survey limited the amount of recall, which was requested and focused more on what the respondents perceived about their present situation. Further, the analysis of concordance with the clinical examiner helped to demonstrate that respondents had a realistic perception on selected concrete factors in relation to their oral health. This may suggest that the perception of elders in this type of environment can be taken into account as part of a care plan. In conclusion, this study found that elderly residents in ACFs in NSW have reached a high age and a considerable proportion have retained their natural teeth, but that around two-thirds of them have dentures as well. The elders are aware of some aspects of their oral health such as their retained teeth, denture wearing and perceived dry mouth. On these variables, the study found a high level of concordance with a professional dental examination. Subjects seemed to be less aware in other areas, such as the need for oral hygiene or restorative treatment or less accepting of the need to do something as demonstrated by elders waiting for a problem to arise rather than seeking a dental check-up. The present report taken together with the two preceding ones on DONs and caregivers provides a picture of a sector of the social services where increased awareness about oral health across leadership, caregivers and residents with appropriate dental health education and dedicated space within facilities would provide a much needed improvement for addressing oral health issues of the ACF residents. Considering that future cohorts of residents will increasingly reflect patterns as seen in this study with even more teeth and complex medical situations this might be the right time to plan for the future challenges that will need to be met by the NSW care system.
Acknowledgments Thanks are due to The University of Sydney Human Research Ethics Committee for their approval to conduct this study, to the Australian Prosthodontic Society (NSW) for financial support, to all Residents, Directors of Nursing/Managers of ACFs who participated in this research and to Dr. Antonio Lee for reading this article and offering helpful advice.
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Dental care in NSW aged care facilities
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Correspondence to: Dr Bettine Constance Webb, Honorary Senior Lecturer, Jaw Function and Orofacial Pain
Research Unit, Level 2, Westmead Centre for Oral Health, Darcy Road, Westmead, NSW 2145, Australia. Tel.: 612 9845 7734 Fax: 612 9633 2893 E-mail: bettine.webb@sydney. edu.au
© 2015 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd
