Within the increasing older Australian population, there is a significant group at very high risk for developing complex oral diseases and dental problems—institutionalised older adults in Australian residential care facilities. There are abundant general health, functional, cognitive, social and financial problems among this group of high-risk older adults. These problems are associated not only with their development of oral diseases, such as dental caries, but with the many barriers they encounter to accessing adequate dental care. In the Australian residential aged care community, it is the carers who play an essential role in the delivery of oral hygiene care and the maintenance of residents' oral health. Better integration of carers into oral hygiene care delivery and the timely identification of oral health problems are essential in improving residents' access to and equity in oral health.
This study investigated the role of carers in Australian residential care facilities in maintaining adequate oral health for residents, and improving their timely referral and access to dental professionals. Three aspects of best practice were used in this research. The first was to assist participating facilities to develop comprehensive and appropriate oral and dental care policies and procedures, in accordance with Commonwealth Residential Aged Care Standards. The second was to train carers to use an Oral Health Assessment Tool (OHAT), a modified version of the Kayser-Jones Brief Oral Health Status Examination (BOHSE) (Kayser-Jones et al. 1995). The study then assessed the reliability and validity of carers' use of the tool in monitoring and assessing residents' oral health. The third was to use an Oral Hygiene Care Plan (OHCP) developed as part of an evidence-based oral health protocol for carers of dependent older adults (Blanco & Chalmers 2001).
The aims of this study were to:
- establish best practice oral health policies and procedures for participating residential care facilities, in accordance with the Commonwealth Residential Aged Care Oral and Dental Standard 2.15
- trial, over a 6-month period, the use by carers of an Oral Health Assessment Tool in randomly selected Australian residential care facilities, in conjunction with residents' 3-monthly care plan reviews
- trial, over a 6-month period, the use by carers of an Oral Hygiene Care Plan in Australian residential care facilities, in conjunction with residents' 3-monthly care plan reviews
- test the reliability and validity of carers' use of the Oral Health Assessment Tool over a 6-month period in Australian residential care facilities.
A total of 21 residential care facilities in New South Wales, Victoria and South Australia completed this study. Approval was obtained from the appropriate administrators/directors of nursing at each residential care facility and, where required, by the Human Research Ethics Committee for any affiliated Regional Health Organisations. Of the 534 residents who participated at baseline, 455 completed the three study phases. Thus, a complete data set was collected for these 455 residents comprising: OHATs at baseline, 3 months and 6 months; two OHAT reliability exams at 3 months; and OHCPs at baseline, 3 months and 6 months. Mean age of the 455 participating residents was 82.1 years. Of the residents participating, 56.5% had a diagnosed dementia, 88.9% were in Residential Care Services (RCS) 1-4 and 68.7% had resided at the facility for more than 12 months. A questionnaire concerning each facility's dental policies and procedures was completed at baseline and at the end of the study. All facilities improved their scores on this questionnaire over the study period.
Mean total OHAT scores decreased significantly from the baseline score over the study period from 2.71 at baseline to 2.5 at 3 months and 2.4 at 6 months. There were no significant differences in category scores. The highest mean scores were for natural teeth, followed by dentures and oral cleanliness.
OHAT reliability was analysed both for an individual carer (intra-examiner) and between carers (inter-examiner) for each participating resident. Intra-examiner percentage agreement for individual categories ranged from 74.4% for oral cleanliness to 93.9% for dental pain and 96.6% for referral to a dentist. Intra-examiner Kappa statistics were in the moderate range (0.51-0.60) for lips, saliva, oral cleanliness and referral to a dentist. All other categories had an intra-examiner Kappa statistic in the range of 0.61-0.80, indicating substantial agreement. The Pearson correlation coefficient for intra-examiner total OHAT score was 0.78, and all intra-examiner analyses were statistically significant.
Inter-examiner percentage agreement for individual categories ranged from 72.6% for oral cleanliness to 92.6% for dental pain and 96.8% for referral to a dentist. Inter-examiner Kappa statistics were in the moderate range (0.48-0.60) for lips, tongue, gums, saliva, oral cleanliness and referral to a dentist. All other categories had an inter-examiner Kappa statistic in the range of 0.61-0.80, indicating substantial agreement. The Pearson correlation coefficient for inter-examiner total OHAT score was 0.74, and all inter-examiner analyses were statistically significant. These intra- and inter-carer reliability scores were similar or higher than previous studies with the Kayser-Jones BOHSE. However, ongoing problematic categories were saliva, oral cleanliness and dental pain, which require further research.
Percentage agreement and Pearson correlation analyses were completed between individual OHAT categories and associated dental examination findings (using standardised assessments and indices) for 21 residents. There was complete agreement on scoring for the lips. Natural teeth, dentures and tongue had the highest significant correlations and high percentage agreements, and the gums also had a significant but lower correlation. Non-significant and low correlations and percentage agreements were evident for saliva, oral cleanliness and dental pain.