Domiciliary Professional Oral Care for Dependent Older Adults

Care dependent older adults living in nursing homes have high rates of untreated rootcaries lesions (RCLs). RCLs, if left untreated could lead to pain, tooth loss,difficulties eating, and impacts on general health. An increasing number of researchpublications point to the association between poor oral health, respiratory tractinfections and aspiration pneumonia. Therefore, there is a need for prevention andeffective treatment among older adults, and especially those who are care dependent.When hospitalized or being care dependent, help with care often depends on others.However, nursing assisted oral care/help with oral hygiene, is a difficult task. Aneffective method for preventing and treating RCLs is to brush the teeth twice a day withhigh fluoride toothpaste containing 5000 ppm F ‐ . Toothpaste containing 5,000 ppm F ‐decreases the numbers of RCLs in comparison with ordinary toothpaste containing 1,100 ‐1,450 ppm F ‐ .Visits at a dental clinic decrease with age and especially with a dementia diagnosis. Forthat reason, the service domiciliary dental care (DDC), could be an option since DDCenables dental care at home (check‐ups, prophylaxis, simple tooth extractions, toothrestorations and prothesis adjustments) by dental personnel. DDC could be beneficial forthe older adults, due to not having to leave home.The effect of DDC on root caries development, has not yet been explored in care dependentolder adults.Objectives: The aim is to evaluate the effects of domiciliary professional cleaning forcare dependent home living older adults. Furthermore, to contribute to increasedknowledge for establishing oral health care recommendations about frequency and contentfor domiciliary preventive professional oral care in this patient group.The first hypothesis is that domiciliary professional cleaning will improve the oralhealth, as measured by; root caries development, gingival bleeding, plaque accumulationand oral mucosal status, compared with a control group that receives assisted oral careas usual.The second hypothesis is that domiciliary professional cleaning will improve the generalhealth status, as measured by; oral health related quality of life, number of antibiotictreatments and number of respiratory tract infections, compared with a control group thatreceives assisted oral care as usual.Study design: The project is designed as a randomized control trial (RCT), evaluatorblinded, with two parallel study arms for one year. Randomization will be performed atindividual level by a person not otherwise involved in the project.Data collection will be performed at baseline and at twelve months, by calibratedregistered dental hygienists (RDH) assisted by dental assistants. For the intervention,two additional dental assistants, will visit the study participants. Data analysis willbe presented at group level and dropouts will be handle according to per protocolanalysis.Description of the study population: Variables regarding cognitive functions byPfeiffer's test, age, gender, number of respiratory tract infections, oral hygiene habits(frequency of toothbrushing, performing oral hygiene routine by themself or nursingassisted oral care, frequency of interproximal cleaning), dental status (number of teeth,root tips, fillings, dental caries, missing teeth, implants) and drug intake (gatheredfrom responsible nurse) will be collected during baseline visit for descriptivemeasurements.The sample size is based on a power calculation (two‐tailed) for the primary effectvariable root caries, 63 individuals in each group are required. Due to high drop‐outrates previously reported in the study population, the sample will be increased by 25%.Accordingly, the number of participants will be n=158 (79 in each group).Data registration: ‐ Dental root caries lesions ‐ Gingival bleeding/Bleeding on probing (BoP) ‐ Oral hygiene ‐ Oral health related quality of life ‐ General health ‐ Oral microbiota: Collection of dental plaque and unstimulated saliva samples will beperformed single‐blinded in a subsample of 50 from the total study population. Topossibly elucidate the causes behind the oral health situation. The PhD‐student isresponsible for coding, adequate storage and the transport to the lab for analysis.Analysis of saliva samples will be performed at NGS at the appropriate corefacilities (SciLifeLabs) at Karolinska Institutet (Professor Belibasakis). Dentalplaque at Umeå University, Institute of Odontology, Clinical Oral MicrobiologyLaboratory (Dr. Anders Johansson). All samples will, after completion of the processat the lab (up to six months after collection), be destroyed.The participants are consecutively recruited during their annually oral healthassessments and sorted to intervention or control group after informed consent. All studyparticipants will, after baseline, start with fluoridated toothpaste ≥ 4000 part permillion (ppm) for brushing their teeth twice a day during the study period to establishan equivalent oral hygiene routine. For controlling the adherence to the toothpasteroutine, all participants will receive a litterbox to throw empty toothpaste tubes duringthe study period.Preliminary results: The previous study was a RCT ‐ study performed at nursing homesduring six months. The intervention group received monthly professional dental cleaning,oral hygiene information and instruction, by RDHs. The control group continued with oralcare as usual. Data collection was performed every third month. The analysis showed animprovement in both groups for gingival bleeding, mucosal score and root caries. Due toimprovement in both groups, the upcoming study will reduce the prophylactic visits toevery third month. Reducing visits is economical beneficial since delivering home care isoften more time consuming. Also, instead of having RDHs for the visits, we now engagedental assistants. Dental assistants have prophylactic training in their education and itis important that every profession have possibilities to fully take advantage of theircompetence.Significance: Oral diseases and especially dental root caries are common among olderadults and increase with age. Among care dependent older adults the amount of untreatedroot caries is high, causing (if left untreated) pain, tooth loss and impacts on generalhealth. An increasing number of research publications point to the association betweenpoor oral health, aspiration pneumonia and quality of life. For that reason, the need forprevention and effective treatments for root caries is important among older adults, andespecially those who need help with daily activities. For prevention, one simple andeffective method is to use fluoride toothpaste containing 5000 ppm NaF daily. Thecombination with this toothpaste and prophylactic/reminding home visits every third monthby a dental assistants, could be an effective method for preventing root caries in thispatient group.