Samenvatting

Summary Introduction Daily oral care for older people is important, to obtain and maintain good functional oral health. Nursing staff is involved in the daily oral care and/ or the monitoring of oral health and hygiene, depending on the level of care support that older people need. Yet, the oral health and hygiene of older people is often below standard. The overall aim of this thesis was to contribute to the improvement of daily oral care for older people and the knowledge and attitude of nursing staff towards oral health (care) of older people, in both nursing homes and home care nursing. The studies in this thesis aim to improve oral health of older people and support in daily oral care of nursing staff, including monitoring of oral health and adequate dental triage. Part 1 – implementation of oral care in nursing homes In Chapter 2A and B, the effects of implementation of oral care improvement programs in nursing homes were systematically overviewed, in a systematic review published in 2013 and in 2024 with additional evidence collected from material published between 2011 and 2023. The aim of these studies was to gain insights in implementation strategies used to promote or improve oral health care for older people in long term care facilities, to explore their effectiveness, to uncover strategy content in behavioral change techniques, to report differences between the current results and those of 2013. Sixteen studies were included in 2024 and 20 studies previously in 2013. All studies of both reviews used knowledge as implementation strategy. In the review of 2013 knowledge was most often combined with self-efficacy and facilitation of behavior, and intention, awareness and attitude were strategies also used and/ or combined. Implementation positively affected knowledge and attitude of nursing staff, however the oral health of older people did not necessarily improve. In the review of 2013 more studies using combined oral health measurements were effective, than in the current review. Meta-analyses on plaque showed that oral care implementations are effective; for denture plaque the effects are larger and may thus have more clinical value, than for plaque on natural teeth. Attitudes, perceptions, and perceived barriers and facilitators among nursing home staff and the actual oral care in nursing homes were studied, in Chapter 3. Our mixed methods study in which 21 nursing homes participated, reported on a) the results of 409 questionnaires completed by nursing staff members and managers; b) 14 focus group interviews with nursing staff. Attitude was not a barrier in this study. Oral care was not performed according to guidelines. Nursing staff reported a lack of products, even though toothbrushes are available. The most frequently mentioned barriers were lack of support of dental staff, oral care for clients with cognitive impairment, and a lack of education. Facilitators for improvement could be; more (practical) education combined with tailored advice from internal dental staff. Part 2 – Oral care in home care nursing Chapters 4 and 5 are studies performed in the home care nursing setting, evaluating the implementation of an Oral Care Program. Oral health care in the setting of home care nursing was not embedded yet, while more older people are frail and home-dwelling and in need of oral care support. Formal home care nurses may have an important role in (support of) daily oral care. Our Oral Care Program for community dwelling older people targeted home care nurses and older people’s oral health and hygiene. It was our aim to evaluate the impact of the implementation of an Oral Care Program on home care nurses’ attitudes and knowledge about oral health (care) and the impact on older people’s oral health. Questionnaires at baseline and after 6 months for home care nurses showed an improved knowledge and attitude and the Oral Care Program fitted well in their working routines. For older people, implementation was measured at baseline and after 3 months with the Oral Health Assessment Tool and a questionnaire about oral (self) care. The oral health of older people improved significantly after 3 months and people with full dentures benefited the most form the Oral Care Program. . A qualitative evaluation of the impact of the Oral Care Program included eight older people, nine home-care nurses and three dental hygienists. Thematic analysis was used to group all codes in nine main themes. The Oral Care Program was experienced as mostly positive and the educational sessions had led to more awareness of oral care in home care nurses, but should be repeated regularly. Personalized oral care plans for older people were experienced positively, however, instigating oral care behavior changes appeared to be difficult. The level of collaboration between dental hygienists and home care nurses varied between the teams, but lead to a positive experience from both sides. Part 3 – Dental assessment instruments and triage by non-dental care professionals Chapters 6 and 7 report a systematic review of oral health assessment instruments for use by non-dental health care professionals and the validation of a Simplified Oral Indicator for dental triage in home care nursing. Regular dental check-up visits are necessary for prevention and early diagnosis of oral problems. Older people tend to disregard their oral health check-up visits. Home care nurses are closely related to these older people and could possibly encourage their older clients to seek dental care (again). Home care nurses may actively refer older people to dental care professionals, or make an oral assessment in an older person, when needed. Assessments to inspect the oral cavity have been designed for non-dental healthcare professionals, like nurses. In Chapter 6 it was our aim to systematically review and evaluate the content and the measurement properties of oral health assessments for use by non-dental healthcare professionals in assessing older peoples’ oral health. The measurement properties (validity/reliability) of instruments used in 18 studies included, were evaluated on their methodological quality using ‘’The Consensus-based Standards for the selection of health Measurement Instruments’’ (COSMIN) checklist. Most studies showed poor methodological quality on some of their measurement properties. In total eight oral health assessments were found: the Revised Oral Assessment Guide (ROAG); the Minimum Data Set (MDS), with oral health component; the Oral Health Assessment Tool (OHAT); The Holistic Reliable Oral Assessment Tool (THROAT); Dental Hygiene Registration (DHR); Mucosal Plaque Score (MPS); The Brief Oral Health Screening Examination (BOHSE) and the Oral Assessment Sheet (OAS). Most frequently assessed items were: lips, mucosa membrane, tongue, gums, teeth, denture, saliva, and oral hygiene. The OHAT and ROAG are most complete in their included oral health items and are of best methodological quality in combination with positive quality criteria on their measurement properties. In Chapter 7 it was our aim to explore the identification of older people in need of dental consultation, with a Simplified Oral Indicator (SOI) performed by home care nurses and with the Geriatric Oral Health Assessment Index (GOHAI) completed by older people themselves, compared with the Oral Health Assessment Tool (OHAT), performed by dental hygienists. The data of 141 older people was analyzed and showed low sensitivity and specificity of the Simplified Oral Indicator - Oral Health Assessment Tool (respectively 0.45 and 0.64). The home care nurses using the Simplified Oral Indicator scored only few older people as ‘red’, while only 11 older people did not need a dental referral according to the Oral Health Assessment Tool. The Simplified Oral Indicator is currently not sensitive enough to identify older people in need of dental consultation. The Geriatric Oral Health Assessment Index by older people themselves was no addition in dental triage. Conclusions The different studies in this thesis have shown that oral care for older people in nursing homes and home care nursing can be improved by implementing oral care programs, using different implementation strategies, targeting older people and nursing staff. Effects of oral care improvement programs generally show a positive impact on knowledge and attitude of nursing staff. The implementation of our Oral Care program showed an improved oral health of older people, but did not improve support of oral care by home care nurses. Tailored oral care plans for older people, continuous education about oral care for nursing staff and the availability of dental professionals, like dental hygienists, can be of added value in nursing care. More research is needed to support nursing staff in dental triage; currently existing assessment instruments are scarcely studied and our Simplified Oral Indicator was not sensitive enough to properly refer older people. Yet, the majority of older people in our Oral Care Program, did not regularly visit a dentist anymore. The studies in this thesis have shown that implementations of oral care improvement programs primarily impact the oral health and hygiene of denture wearing older people and it is our advice to continue these implementations. To provide better access to oral health care and improve older people’s oral health and hygiene, while they are community-dwelling, a long term collaboration between home care nursing teams and dental care professionals in their working area should be established. Therefore, future implementations in nursing care should focus on older people with natural teeth and encourage older people to visit dental care professionals regularly. Recently developed oral care guidelines for nursing homes should be implemented carefully and with regard to nursing staff and older people’s oral care routines, to improve daily oral care for frail older people.