Oral hygiene and periodontal disease in Victorian nursing homes

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1 Original article Oral hygiene and periodontal disease in Victorian nursing homes Matthew S. Hopcraft 1, Michael V. Morgan 1, Julie G. Satur 1, F.A. Clive Wright 2 and Ivan B. Darby 1 1 Cooperative Research Centre for Oral Health Sciences, School of Dental Science, The University of Melbourne, Vic., Australia; 2 Centre for Oral Health Strategy, NSW Health, Westmead, New South Wales, Australia doi: /j x Oral hygiene and periodontal disease in Victorian nursing homes Objective: To investigate oral hygiene and periodontal disease in residents of Victoria nursing homes. Background: The Australian population is ageing with a growing proportion of elderly Australians living in nursing homes. With declining edentulism rates, periodontal disease is becoming more prevalent in this population. Materials and methods: A total of 275 dentate residents from 31 Victorian nursing homes had a questionnaire and clinical examination using the Visual Plaque Index and a modified Community Periodontal Index. Results: Self-reported oral hygiene habits of residents were poor, with less than one-third of residents cleaning their teeth twice daily or more. Periodontal health was found to be extremely poor, and the prevalence of 4 mm+ periodontal pockets was 35.6%, with 10.2% having 6 mm+ pockets. Logistic regression found that age, gender, number of teeth present and oral hygiene were all strongly associated with the prevalence of 4 mm+ periodontal pockets. Conclusion: Poor oral hygiene and the presence of significant plaque and calculus were common findings in this study. Periodontal diseases are a significant problem for residents in nursing homes. Addressing this health issue will require improved training for carers and better access to appropriate dental services. Keywords: nursing homes, residential aged care facilities, periodontal disease, oral health. Accepted 8 September 2010 Introduction The Australian population is ageing, and by 2051 there will be 7.3 million people aged 65 + years representing one-quarter of the population 1. In 2006, there were people aged 65 + years living in Australian nursing homes, with approximately people entering permanent residential care each year 2,3. There has been a continual shift towards a requirement for high care needs, with 68% of older permanent residents having this level of need in 2006, up from 61% in 2001, with nearly all having multiple care needs 4. There has also been an increase in the complete length of stay in permanent nursing homes between and , from to weeks 5. In Australia, edentulism rates in nursing homes have declined from 80 to 90% in the 1970s and 1980s to around 50% by 2002, with dentate residents now having on average 12 teeth present 6 9. This improvement in health was described by Joshi et al. 10 as an adverse consequence of success, with improvements in tooth retention in a growing ageing population leading to more teeth at risk and therefore perversely a higher prevalence of oral diseases. Older people with more teeth and consequently more oral disease are now placing further demands on the dental care system. In the Australian population, the prevalence of periodontal disease, defined as at least one site with a periodontal pocket depth of 4 mm or more, is currently estimated as 19.8% (26% for people aged 75 + years) 11. More than 86% of people aged 55 + years have at least one site with 2 mm+ gingival recession of 2 mm+, which has important implication for root caries. e220

2 Periodontal disease in nursing homes e221 Periodontal disease is prevalent in nursing homes, with mild moderate loss of periodontal attachment common, although more severe disease reported in only a small proportion of residents 6,9. Large amounts of plaque, calculus and debris accumulation are the norm and poor oral hygiene is commonly reported as a consequence of residents being functionally dependent, medically compromised, cognitively impaired and behaviourally difficult 6,9. In a general health sense, periodontal diseases are significant due to links with systemic problems, including cardiovascular disease, atherosclerosis and stroke Periodontal diseases are a recognised and well-documented complication of diabetes, with evidence based on epidemiological data and animal model studies that explain the pathophysiology 16. Diabetics, particularly for those with poorly controlled diabetes, are at risk of developing advanced periodontitis For residents with poor oral health, aspiration pneumonia and bacteraemia are also of concern 20. Dental caries, the presence of cariogenic bacteria and periodontal pathogens, smoking and diabetes have been identified as potentially significant risk factors for aspiration pneumonia in the elderly 21,22. Pneumonia is reported as one of the leading causes of infection requiring hospitalisation for residents, with 33 per 1000 residents per year requiring this approach, and also one of the leading causes of mortality for nursing homes residents, accounting for 26 44% of all deaths, with acute mortality rates of 5 40% per episode 23,24. Since oral bacteria and plaque are significant risk factors for periodontal disease which have implications for other systemic conditions, it is essential that residents of nursing homes have access to good oral hygiene care and appropriate oral health care services. It is therefore vital to identify the extent of oral health disorders in nursing homes. The aim of this study was to assess oral hygiene and periodontal disease in Victorian nursing home residents. Methods Using a list of all nursing homes in Victoria, 26 metropolitan Melbourne nursing homes were randomly selected to participate in the project 25. Five nursing homes from regional and rural Victoria that were within two hours drive of Melbourne were also selected to participate in the study. An information pack outlining the nature of the research project was sent to the Director of Nursing at selected nursing homes, and follow-up information was provided by the principal researcher if required. All 31 selected nursing homes agreed to participate in the study, and they varied in size from 20 to 91 residents. Plain Language Statements and Consent Forms were provided to the Director of Nursing to distribute to their residents and legal guardians. For those who wished to participate, a medical history form was also provided. Residents who consented to participate in the project were examined by an experienced dentist who has previously been calibrated in epidemiological studies. The dental examination was conducted using a plane mouth mirror, periodontal probe and sickle probe, with lighting provided by a headlamp. The medical history was assessed prior to the dental examination, to determine, among other things, if antibiotic prophylaxis against infective endocarditis would be required, and no periodontal probing was undertaken for subjects considered at risk of infective endocarditis. There was a total of 1345 residents eligible for examination, and a total of 510 residents from 31 nursing homes consented and were able to have a dental examination, of which 275 were dentate and included in the present study. The dental examinations were conducted between May 2005 and June If residents were unable to be examined at the initial visit due to behavioural problems, examinations were scheduled for a subsequent visit, with a number of approaches used to assist compliance. If after three unsuccessful attempts at examination no further appointments were made. Socio-demographic, medical and dental history data (including tooth brushing habits) was collected via questionnaire, either from the resident or from a family member or staff where cognitive impairment or language problems were an issue. Where possible, medical history information was validated from resident medical and pharmacology charts. Presence or absence of plaque was scored using the Turesky modification of the Quigley-Hein Visual Plaque Index (VPI), six buccal surfaces assessed 26. Plaque was assessed using the following criteria: 0 no plaque; 1 separate flecks of plaque at gingival margin; 2 thin (1 mm) continuous band at gingival margin; 3 band >1 mm but <1/3 of tooth; 4 1/3 to 2/3 of tooth; 5 >2/3 of tooth. Periodontal disease was assessed using a modified Community Periodontal Index (CPI) 27. Three surface of each index tooth in each sextant were assessed, and at each site, recession, probing depth, presence of calculus, and presence of bleeding after probing were scored. The categories were:

3 e222 M. S. Hopcraft et al. 0 healthy; 1 bleeding on probing; 2 calculus; mm periodontal probing depth; 4 6 mm+ periodontal probing depth. The prevalence of gingivitis was assessed as the number of subjects with a CPI score of 1 or more. Similarly, the prevalence of periodontal disease was determined as those with a CPI score of 3 or more (4 mm+ periodontal pocket depths at one or more sites in the mouth). Ethical approval was obtained from The University of Melbourne Human Research Ethics Committee and Dental Health Services Victoria Human Research Ethics Committee, and informed consent was obtained from all participants. Statistical analysis was conducted using SPSS Table 1 Socio-demographic and medical characteristics by age group (%). Age group <75 years years 85 + years Total (n = (n = 60) (n = 101) (n = 102) 263) Male (a) Female Melbourne Regional Victoria Time since admitted 12 months months months months Don t know Time since last dental visit 12 months months months months Don t know Number of chronic medical conditions (b) < Number of medications (c) < Diagnosed dementia (d) History of stroke Diagnosed diabetes Pensioner Concession Card (e) Private Health Insurance (f) (a) v 2 = 52.44, p < 0.001; (b) v 2 = 20.69, p < 0.001; (c) v 2 = 12.91, p = 0.012; (d) v 2 = 16.42, p < 0.001; (e) v 2 = 6.23, p = 0.035; (f) v 2 = 6.45, p = Results The majority of the sample population were living in metropolitan Melbourne nursing homes, with only 16.7% living in regional and rural Victoria (Table 1). Females comprised nearly two-thirds of the sample population, and were significantly older than male residents. More than half of the residents had lived more for than 2 years in a nursing home, and only one-quarter had visited a dentist in the past 2 years. Residents were medically compromised and taking multiple medications. Just over 38% had a diagnosed dementia and 14.1% had a history of stroke. The majority of residents had a Government Concession Card and were eligible for public dental care, and one-quarter had private health insurance. Less than one-third of residents were cleaning their teeth twice daily or more, and half of the residents reporting cleaning their teeth only once per day (Table 2). One-third of residents reported receiving some assistance cleaning their teeth, with no differences between male and female residents. Significantly more residents with dementia required assistance with their oral hygiene care. Oral hygiene of residents was poor, with more than one-quarter of residents having plaque covering more than one-third of at least one index tooth, with index teeth generally representative of all teeth present in the mouth (Fig. 1). There were no residents in the sample who were assessed as having no visible plaque on all index teeth. Table 2 Oral hygiene care by sex and dementia status (%) (n = 245). Male (n = 85) Female (n = 160) Dementia (n = 84) No dementia (n = 152) Frequency of teeth cleaning Twice daily or more Once daily Several times a week Less than once a week Hardly ever Never Assistance needed cleaning teeth Yes some (a) Yes total No (a) v 2 = 22.72, p <0.001.

4 Periodontal disease in nursing homes e223 (a) (b) (c) (d) Figure 1 Examples of residents with varying VPI scores (plaque covering (a) 1-mm band at gingival margin; (b) <1/3 of tooth; (c) <2/3 of tooth; and (d) >2/3 of tooth). Table 3 Visual plaque scores (%). Plaque scores < Thin band <1/3 tooth >1/3 tooth <75 years years years Male Female Melbourne (a) Regional Periodontal disease <4 mm pocket (b) mm+ pocket <6 mm pocket (c) mm+ pocket Dementia No dementia Stroke No stroke Frequency of brushing (d) Twice daily or more Once daily Less than once per day Assistance brushing (e) No assistance brushing teeth present teeth present teeth present teeth present (a) v 2 = 9.39, p = 0.009; (b) v 2 = 23.28, p < 0.001; (c) v 2 = 14.43, p = 0.001; (d) v 2 = 18.28, p = 0.001; (e) v 2 = 9.02, p = Older residents appeared to have less visible plaque than younger residents, although this was not statistically significant (Table 3). However, younger residents were significantly less likely to be brushing their teeth at least once daily, with only 68.4% of residents aged <75 years brushing at least once daily, compared with 84.4% of residents aged years and 89.9% of residents aged 85 + years (v 2 = 19.26, p = 0.004). Residents with dementia displayed poorer oral hygiene than residents without dementia, although this difference was not statistically significant. Poor oral hygiene was associated with periodontal disease, assistance with tooth brushing and frequency of tooth brushing. There was also a strong association between the frequency of tooth brushing and the level of assistance required by residents with their oral hygiene, with nearly half of the residents who did not require assistance cleaning their teeth twice daily, while only 8.7% of residents who required some or total assistance were having their teeth cleaned twice daily, and 29.3% were having their teeth cleaned only several times per week or less (v 2 = 43.50, p < 0.001). Overall, periodontal health was also extremely poor, with no dentate residents assessed as having healthy periodontal tissues and more than half of the residents having calculus present. The prevalence of periodontal disease (periodontal probing depths of 4 mm+) was 35.6%, with moderate severe disease (periodontal probing depths of 6 mm+) present in 10.2% of the sample population. The prevalence of periodontitis increased from 20.6% in residents aged <64 years to 45.7% for residents aged years, then declined to 14.3%

5 e224 M. S. Hopcraft et al. Table 4 Percentage of people with 4 mm+ and 6 mm+ periodontal pocket depths. 4 mm+ pockets 6 mm+ pockets Age <75 years 30.9 (a) years years Sex Male 43.4 (b) 14.5 Female Melbourne 38.3 (c) 10.4 Rural Diagnosed dementia No dementia History of stroke No stroke Diagnosed diabetes No diabetes Time since admitted 12 months months months months Frequency of teeth cleaning Twice daily or more (d) Once daily Less than once daily Assistance needed cleaning teeth No Yes some Yes total (a) v 2 = 8.11, p = 0.017; (b) v 2 = 3.27, p = 0.048; (c) v 2 = 3.50, p = 0.043; (d) v 2 = 6.59, p = for residents aged 95 + years, although these older residents had fewer teeth present than the younger residents (Table 4). When controlling for the number of teeth present, it was the number of teeth rather than the age of the resident that was related to the prevalence of periodontitis, with more teeth present increasing the likelihood of periodontitis being present. Frequency of brushing was associated with having 6 mm+ periodontal pockets. There was a strong association between oral hygiene status and periodontal disease, with subjects with the poorest periodontal health also displaying the poorest oral hygiene (Fig. 2) (v 2 = 35.17, p < 0.001). Logistic regression found that age, gender, number of teeth present and oral hygiene were all strongly associated with the prevalence of 4 mm+ periodontal pockets (Table 5) although no associations were found with 6 mm+ periodontal pockets. Discussion In the present study, the prevalence of periodontal disease was estimated using a partial mouth index, rather than a full mouth examination of clinical attachment loss. However, it has been reported that the CPI is a reliable index for estimating the prevalence of periodontal disease in a population group 28. Numerous studies have demonstrated poor oral health and oral hygiene of residents in nursing homes, and linked this to low levels of oral health knowledge of the carers and nursing staff Figure 2 Visual plaque index by Community Periodontal Index.

6 Periodontal disease in nursing homes e225 Table 5 Logistic regression factors associated with having 4 mm+ periodontal pockets. Odds ratio p-value 95% CI Lower Upper Age <74 years years years Female 1 Male Rural 1 Melbourne Diagnosed diabetes Dementia Teeth present <9 teeth teeth teeth Plaque Index Thin band of plaque 1 <1/3 of tooth 4.68 < >1/3 of tooth Hosmer and Lemeshow test v 2 = 9.06, p = 0.337; Nagelkerke R 2 = responsible for the daily care of residents Inadequate knowledge of oral and dental problems and the ineffective provision of oral hygiene care may be related to the fact that oral care is often not taught in nurse training or given a high priority 37. Previous studies have also shown that self-dependent residents had better oral hygiene than more dependent residents, suggesting that staff responsible for oral hygiene care did not have sufficient training to ensure good oral hygiene 36. Nursing staff generally find oral care to be one of the most undesirable tasks, and barriers include lack of time, uncooperative residents and oral malodour Oral hygiene of dentate residents in the present study was poor, mirroring findings of other studies, where high levels of plaque and debris are common findings 6. In a study of dentate residents in Britain, only 31% of residents were able to clean their mouths twice daily, and these residents had significantly lower Plaque Index and Gingival Index scores than residents who cleaned less frequently 41. Residents who requested help cleaning their teeth also had poorer oral hygiene, which is supported by the findings from the present study. Younger residents had significantly more teeth than older residents and a trend to poorer oral hygiene, suggesting an association between the number of teeth and ability to maintain oral cleanliness. Older residents were significantly more likely to have their teeth brushed at least once daily, and this would appear to be the most significant factor in this disparity in oral hygiene across the age spectrum. It was not possible to determine whether older residents had their teeth brushed more frequently than younger residents because they were perceived by the carer staff to have greater oral hygiene needs, or because they were indeed more functionally dependent. However, older residents were in general more medically compromised and more likely to suffer from dementia, and as such were more likely to be dependent on carers for the provision of oral hygiene care. Oral hygiene was strongly associated with the frequency of tooth brushing, and this in turn was associated with the need for assistance with oral hygiene. Although cognitive and physical impairments are likely to impact on the provision of oral hygiene care 6, only residents with dementia were more likely to require assistance with oral hygiene. Residents who required assistance with oral hygiene were significantly less likely to have their teeth brushed twice daily, suggesting that carers either did not have the time or inclination to undertake adequate oral care for these residents. This association between plaque and frequency of tooth brushing is particularly important given the links between plaque-related periodontal diseases and chronic medical conditions such as coronary diseases, stroke and aspiration pneumonia. These findings strongly emphasise the need for regular oral hygiene care for residents, whether this is total, assisted or simply encouraged (depending on the cognitive and physical capabilities of the resident) in order to minimise co-morbidity associated with increased plaque accumulation and an increased bio-burden. Periodontal diseases were ubiquitous amongst nursing home residents in the present study, and were predominantly mild in nature. More than one-third of residents had periodontitis defined as at least one site with a periodontal pocket greater than 4 mm, and the remainder had gingivitis in at least one site. The prevalence of periodontitis in the present study was higher than that reported in the general Australian population, where 23.7% of people aged years and 26.0% of people aged 75 + years had 4 mm+ periodontal pocket depths 11. However, this is a lower prevalence of periodontal disease than has been reported in other studies. The Helsinki Ageing Study conducted in on subjects aged years found 54%

7 e226 M. S. Hopcraft et al. were dentate with a mean of 14.4 teeth present, almost identical figures to the present study, although they were home-dwelling rather than institutionalised elderly 42. Healthy periodontal tissues were found in only 7% of subjects, with 46% having periodontal pocket depths of 4 mm or more (11% with 6 mm+ pocket depths). Females had more healthy periodontal sites, and fewer deeper pockets than males. There was not a clear association between age and the prevalence of periodontitis, and it appeared to be more related to the number of teeth present than the age of the resident. The number of teeth present may influence oral hygiene, with more natural teeth resulting in a greater plaque burden and hence more periodontal disease. This is consistent with a study of Norwegian nursing home residents, where there was a 50% increase in prevalence of periodontal disease over a 16-year period when edentulism declined from 71 to 43% and the number of teeth increased from 10.7 to The corollary of declining edentulism rates is reinforced with this finding 10. If there is indeed an association between an increasing number of teeth and increased risk of periodontal disease, then this presents a major challenge in the future, with edentulism rates projected to decline significantly in Australia. Although there appeared to be a relationship between frequency of tooth brushing and severe periodontal disease (presence of pocket depths of 6 mm+), this was not the case for periodontal pockets of 4 mm+, suggesting that more severe periodontal disease was associated with lack of regular oral hygiene care. The role of oral hygiene in the progression of periodontitis has become more controversial recently. A number of studies have demonstrated the importance of patient compliance with adequate oral hygiene measures in managing periodontal disease and reducing the rate of tooth loss, although some of the more recent literature questions this link 43. Merchant et al. 44 argue that other factors such as genetic susceptibility, may play a larger role in the aetiology of periodontitis that oral hygiene. A systematic review of the literature also failed to find significant support for the role of poor oral hygiene as a major aetiological factor in periodontitis progression 45. MacEntee 46 believes that tooth loss due to periodontitis amongst the elderly is unusual, however he argues that plaque continues to cause chronic marginal gingivitis which is endemic in this population. This finding is supported by the results of the current study where all dentate residents showed some signs of periodontal disease including gingival bleeding and inflammation, presence of calculus and periodontal attachment loss. Professional mechanical plaque removal has been shown to be effective in the treatment of periodontal disease, including the reduction of dento-gingival plaque, gingival bleeding/inflammation and probing depths, and the maintenance of attachment levels 47. Although the majority of subjects had been in residential care for more than 2 years, only 10.9% had a dental visit in the previous 12 months, and less than 1% indicated that their last dental visit was for professional cleaning of their teeth. Therefore, it seems likely that this combination of lack of professional cleaning, coupled with lack of adequate daily oral hygiene care (performed by the residents themselves or by carers), is having a significant impact on the prevalence of periodontal diseases and the presence of considerable plaque and calculus deposits. It would appear that there is an important role for dental professionals to play in the oral health of nursing home residents, both in the education of carers to assist with the provision of daily oral hygiene care, and in regular professional cleaning. However, previous research has demonstrated a reluctance by dentists to provide treatment to nursing home residents 48,49. Conclusions Poor oral hygiene and the presence of significant amounts of plaque and calculus were common findings for dentate residents of Victorian nursing homes. More than one-third of residents had 4 mm+ periodontal pockets, with the prevalence of periodontitis strongly associated with the number of teeth present and oral hygiene. With edentulism rates decreasing in the elderly, periodontal disease will become a growing problem for residents in nursing homes, and it is important that carers are trained sufficiently to manage the daily oral hygiene of residents, and appropriate dental services are available for residents to access. Acknowledgements The research described in this paper was supported by the Victorian Department of Human Services and the Cooperative Research Centre for Oral Health Sciences (CRC-OHS). The CRC-OHS s activities are funded by the Australian Government s Cooperative Research Centres program.

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