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Review

Effect of oral health education programs for caregivers on oralhygiene of the elderly: A systemic review and meta-analysis

Tze-Fang Wang a ,*, Chiu-Mieh Huang a , Chyuan Chou b , Shu Yu aa School of Nursing, National Yang Ming University, Taipei, Taiwanb Bloomberg School of Public Health, Johns Hopkins University, D.D.S., Dr.PH., USA

What is already known about the topic?

Poor oral health in the elderly is associated withmalnutrition, cognitive decline, and a higher risk forcardiovascular disease and infectious respiratory dis-eases.

Various oral health education programs have beenpresented to nursing personnel with anticipation thatthe elderly may benet from caregivers’ improvedexpertise in personal hygiene procedures.

Regarding the improvement of oral health of the elderly,many studies reported conicting conclusions of theseoral health education programs on caregivers.

What this paper adds

This meta-analysis analysis, involving 602 elders, foundthat the percentage of elderly with normal oral mucosa,with no visible plaque, and with no detectable denture

International Journal of Nursing Studies 52 (2015) 1090–1096

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Article history:Received 22 July 2014Received in revised form 26 January 2015Accepted 28 January 2015

Keywords:Meta-analysisOral hygieneDental health educationCaregiversElderlyDental hygiene

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Objectives: To evaluate the effects of oral health education for caregivers on the oral healthstatus of the elderly.Design: A systematic review and meta-analysis.Data sources: The Medline, EMBASE, Cochrane Library (CENTRAL), PsycINFO, CINAHLweresearched up to September, 2014.Review methods: Randomized controlled trials or comparative before-and-after studiesinvolving an oral health education program for caregivers of the elderly ( 65 years old)were identied by two independent reviewers. Primary outcome was the percentage of patients with normal mucosa in the oral cavity. The secondary outcomes were thepercentage of patients with no visible plaque and the percentage of patients withoutdenture stomatitis.Results: A total of vestudies, involving602 elders, metthe eligible criteria forinclusion in

the meta-analysis. It was found that the percentage of residents with normal oral mucosa(odds ratio (OR) = 1.81, P = 0.027), no visible plaque (OR = 1.54, P = 0 .001), and nodetectable denture stomatitis (OR = 2.89, P < 0.001) signicantly increased after the groupwas treated by caregivers who had received a recent oral health education program.Conclusions: The systemic review and meta-analysis found limited evidence that oralhealth education for caregivers may be effective for improving the oral health of theelderly.

2015 Elsevier Ltd. All rights reserved.

Abbreviations: CI, condence interval; OR, odds ratio; RCT, random-ized clinical trial.

* Corresponding author. School of Nursing, National Yang MingUniversity, No. 155, Section 2, Li-Nong Street, Shi-Pai, Taipei 112, Taiwan.Tel.: +886 2 28267000x7907; fax: +886 2 28202487.

E-mail address: fang@ym.edu.tw (T.-F. Wang).

Contents lists available at ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

http://dx.doi.org/10.1016/j.ijnurstu.2015.01.0150020-7489/ 2015 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.ijnurstu.2015.01.015http://dx.doi.org/10.1016/j.ijnurstu.2015.01.015http://dx.doi.org/10.1016/j.ijnurstu.2015.01.015http://dx.doi.org/10.1016/j.ijnurstu.2015.01.015http://dx.doi.org/10.1016/j.ijnurstu.2015.01.015http://dx.doi.org/10.1016/j.ijnurstu.2015.01.015http://dx.doi.org/10.1016/j.ijnurstu.2015.01.015http://dx.doi.org/10.1016/j.ijnurstu.2015.01.015http://dx.doi.org/10.1016/j.ijnurstu.2015.01.015http://dx.doi.org/10.1016/j.ijnurstu.2015.01.015http://dx.doi.org/10.1016/j.ijnurstu.2015.01.015http://dx.doi.org/10.1016/j.ijnurstu.2015.01.015http://dx.doi.org/10.1016/j.ijnurstu.2015.01.015http://dx.doi.org/10.1016/j.ijnurstu.2015.01.015http://dx.doi.org/10.1016/j.ijnurstu.2015.01.015mailto:fang@ym.edu.twmailto:fang@ym.edu.twhttp://www.sciencedirect.com/science/journal/00207489http://dx.doi.org/10.1016/j.ijnurstu.2015.01.015http://dx.doi.org/10.1016/j.ijnurstu.2015.01.015http://www.sciencedirect.com/science/journal/00207489mailto:fang@ym.edu.twhttp://dx.doi.org/10.1016/j.ijnurstu.2015.01.015http://crossmark.crossref.org/dialog/?doi=10.1016/j.ijnurstu.2015.01.015&domain=pdfhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.ijnurstu.2015.01.015&domain=pdf

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stomatitis all signicantly increased after the group wastreated by caregivers who had received a recent oralhealth education program.

An oral health education for caregivers may signicantlyimprove the oral health of the elderly.

1. Introduction

The prevalence of elderly who lacked dental careranged from approximately 17% in France (Herr et al.,2013 ) to > 63% in institutionalized elderly in Spain(Cornejo et al., 2013 ), 82% in nursing home residents inCanada (Chen et al., 2013 ), and > 90% in homeboundelderly in the USA (Gluzman et al., 2013 ). Poor oral healthin the elderly is associated with malnutrition, cognitivedecline, and a higher risk for cardiovascular disease andinfectious respiratory diseases, including pneumonia(Adachi et al., 2007; Awano et al., 2008; Juthani-Mehtaet al., 2013 ).In fact, oral bacteria were the major pathogensin 15% of cases of community acquired pneumonia(Yamasaki et al., 2013 ). The ability of elders to maintainadequate oral health may be reduced by cognitive decline,reduced hand function (Padilha et al., 2007 ), sarcopenia(Walls, 2014 ), and loss of autonomy. Since poor oral healthmay exert a negative impact on the general health of theelderly and increase the cost of their care, effectivemethods that improve the oral health of elders iswarranted.

A promising approach is the education of the caregiversfor the elderly. Various oral health education programshave been presented to nursing personnel with anticipa-tion that patients may benet from caregivers’ improvedexpertise in personal hygiene procedures. Many studiesevaluated the effectiveness of the educational program onthe improvement of knowledge, attitude, and perception of caregivers (Khanagar et al., 2014; Paulsson et al., 1998;Reed et al., 2006 ). These programs produced conictingconclusions regarding oral health, level of knowledge,benets over time (Brand et al., 2013; Sjogren et al., 2010 ),and attitudes toward dental issues of elderly (Isakssonet al., 2000; Kullberg et al., 2009; Reed et al., 2006; Simonset al., 2000 ). Therefore, we conducted a meta-analysis toevaluate the effects of oral health education of thecaregivers on the oral health status of the residents.

2. Materials and methods

2.1. Search strategy

The systematic review and meta-analysis was con-ducted in accordance with Preferred Reporting Items forSystematic Reviews and Meta-Analyses (PRISMA) guide-lines (Liberati et al., 2009 ). The Medline, EMBASE, CochraneLibrary (CENTRAL), PsycINFO, CINAHL were searched forthe keywords, ‘‘(frail OR aging OR aged OR dementia OR elderly OR older OR elder OR institutionalization) AND(dental OR oral) AND health AND (education OR Promo-tion) AND (nurses OR caregivers OR nurse OR caregiver)’’for articles published up to September, 2014. The selectioncriteria were for research articles on one or more oral

health

education

program(s)

for

caregivers

of

the

elderly( 65 years old). The elderly were living in the community,

assisted living facilities, nursing homes, or other institu-tions. Additional inclusion criteria for the full meta-analysis were (a) a primary research article, (b) effectsof oral educational program for caregivers on the oralhealth of the elderly, and (c) randomized controlled trialsor comparative before-and-after studies that evaluated theelders’ oral health after the caregivers’ completion of

educational

program.

Exclusion

criteria

were

(a)

caregiversof younger groups (< 65 yrs) or (b) educational interven-tions for only the patients. Non-English articles wereexcluded.

2.2. Data extraction

Two independent reviewers identied studies by thesearch strategy. If the eligibility of a study was notunanimous, a third reviewer was consulted. The reviewersnoted the reference (rst author, year published, journalcitation) and compiled the following data from the includedstudies: study design, participants’ demographics (age and

gender),

number

of

participants

before-and-after

healtheducation program, protocol of education program, durationof follow up period, and primary and secondary outcomes.

2.3. Assessment of quality of study

The two reviewers assessed the quality of the publica-tion by using Newcastle-Ottawa Scale (Wells et al., 2006 )to score across three categories: selection of study groups(four questions), comparability of study groups (twoquestions), and ascertainment of the outcome of interest(three questions). While most questions had a score of 1,separate points were awarded for controlling for age and

sex

(maximum,

2

points).

2.4. Outcome measures

The different studies had used different scales tomeasure abnormalities in mucosa, plaque, and denturestomatitis. Because each scale included one common grade– the identication of normal mucosa (Table 1), theprimary outcome was the percentage of patients withnormal mucosa in the oral cavity. Normal mucosa wasdened as no inammation, no erythema, no swelling, no

Table 1

Comparison

of

the

scales

for

evaluating

normal

mucosa..

Study Scale for evaluating oralmucosa

Referencefor scale

Portellaet al. (2013)

1: normal appearance2: mild inammation3: moderate inammation4: severe inammation

Henriksenet al. (1999)

Boczkoet al. (2009)

1: normal2–4: abnormalities inincreasing severity

Nicolet al. (2005)

Absent or present of mucosal disease

Isakssonet al. (2000)

1: normal appearance2: mild inammation3: moderate inammation4: severe inammation

Henriksenet al. (1999)

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atrophy, no ulceration or lesions on oral mucosa andgingival (Henriksen et al., 1999 ). The secondary outcomeswere the percentage of patients with no visible plaque andthe percentage of patients without denture stomatitissince the scales in all articles had used these categories.

2.5. Statistical analysis

The effect of the health education on the caregivers wasevaluated by assessing the improvement in the elders’dental hygiene: the percentages of patients with normalmucosa, no visible dental plaque rate, and lack of denturestomatitis before-and-after health education program. Ax

2 -based test of homogeneity was performed and theinconsistency index (I 2 ) and Q statistics were determined.If an I 2 of < 25% indicated that the studies werehomogeneous, the xed-effects models (Mantel-Haenszelmethod) were utilized. If an I 2 of > 50% or > 75% indicatedthat the trials were heterogeneous or highly heteroge-neous, respectively, a random-effects model (DerSimo-

nian–Laird

method)

was

utilized.

Otherwise,

pooledsummary statistics (odds ratio (OR) and corresponding95% condence interval (C.I.)) were shown for theindividual studies. Pooled OR (95% CI.) were calculatedand a 2-sided P value < 0.05 was considered to indicatestatistical signicance.

The primary outcome was considered for the sensitivityanalysis which utilized the leave-one-out approach.However, the publication bias was not performed due tothe small number of selected studies (Sutton et al., 2000 ).All statistical analyses were performed using the statisticalsoftware Comprehensive Meta-Analysis, version 2.0 (Bio-stat, Englewood, NJ, USA).

3. Results

3.1. Literature search

A total of 570 articles remained after removingduplicates. Screening of titles and abstracts resulted inremoval of 553 articles that were irrelevant to this meta-analysis.

Full text review of the 17 articles indicated that vestudies met the inclusion criteria (Fig. 1) (Boczko et al.,2009; Frenkel et al., 2001; Isaksson et al., 2000; Nicol et al.,2005; Portella et al., 2013 ). Four of the twelve excluded

studies

did

not

provide

quantitative

data

of

the

outcome

of interest (Kullberg et al., 2010; MacEntee et al., 2007;Simons et al., 2000; Sjogren et al., 2010 ). Four studies(Frenkel et al., 2002; Gammack and Pulisetty, 2009;Khanagar et al., 2014; Reed et al., 2006 ) did not evaluatethe oral health of the elderly. Two articles described the

Fig. 1. Flow chart for study selection.

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effects of an educational program on oral health providedto the elderly, not to the caregivers (Little et al., 1997;Persson et al., 1998 ) and two articles were review articles(Watt and Marinho 2005 ; Stein and Henry, 2009 ). The veincluded studies reported the effect of the caregivers’ oralhealth education on the oral health status of 602 combinedelderly residents (Boczko et al., 2009; Frenkel et al., 2001;

Isaksson

et

al.,

2000;

Nicol

et

al.,

2005;

Portella

et

al.,

2013 ).

3.2. Study characteristics and quality assessment

The characteristics and quality assessment of the veincluded studies are summarized in Table 2. The educa-tional programs given to caregivers covered oral health,oral hygiene, dental diseases, common risk factors, and oralhygiene instruction. Four of the ve educational programsincluded demonstrations of proper oral care and aninteractive instructional period (Boczko et al., 2009;Frenkel et al., 2001; Nicol et al., 2005; Portella et al.,2013 ) using models and manikins. The program in the

Broczko

et

al.

study

also

included

discussions

on

over-looked patients and residents with behavior problems(Boczko et al., 2009 ). The program in the Nicol study (Nicolet al., 2005 ) also included discussion time between thecaregivers and residents to discuss common oral condi-tions and oral health challenges of the residents. Theteachers of the programs ranged from a professor anddental students (Portella et al., 2013 ), two speech languagepathologists (Boczko et al., 2009 ), dentist and/or dentalhygienists (Isaksson et al., 2000; Nicol et al., 2005 ), or ahealth promoter trained in dental and oral care (Frenkel

et al., 2001 ). The length of the educational program rangedfrom 1 h (Boczko et al., 2009 ) to 4 h (Isaksson et al., 2000 ).According to Newcastle-Ottawa Scale, four studies (Boczkoet al., 2009; Isaksson et al., 2000; Nicol et al., 2005; Portellaet al., 2013 ) provided pre and post oral health evaluationsof the patients by the educated caregivers and wereconsidered moderate quality. The Frenkel et al. study

(Frenkel

et

al.,

2001 )

used

a

randomized

clinical

trial

(RCT)design and had a higher quality assessment.

3.3. Study outcomes

Fig. 2A shows the forest plot of the primary outcome –percentage of normal mucosa of the residents evaluatedbefore-and-after the caregivers had received healtheducation program – by using pooled summary odds ratio(OR) statistics with 95% CI. The Frenkel et al. (2001) studydid not provide numerical information on oral mucosa.Finally, four studies (Boczko et al., 2009; Isaksson et al.,2000; Nicol et al., 2005; Portella et al., 2013 ) involving 401

residents

were

included

in

the

meta-analysis.

The

hetero-geneity test (Q = 20.92, I 2 = 85.7%, P < 0.001) indicated theuse of the random effect model. The pooled summarystatistics were observed as OR = 1.81 (95% CI. = [1.07,3.05]). Thus, the percentage of residents’ normal mucosasignicantly increased by 81% after the caregivers im-proved delivery of oral care due to the health educationprogram (P = 0.027).

Sensitivity analysis implied that the direction andmagnitude of pooled estimates might be affected by that(Boczko et al. 2009 ) study (Fig. 2B). Thus, we excluded it

Table 2Patients’ demographics, characteristics and quality assessment of the ve studies.

Study name (year) Type of study

Number of patients Age (yrs) Female (%) Education program Follow-up (months) Qualityassessment *

Baseline Follow up

Portella et al.(2013)

Pre-post 80 55 80, 59.2% 71.7 Dental professor and studentsgave 2 h lecture on oral and bodyhygiene, video w/instructionsand Q & A.

12 5

Boczko et al.(2009)

Pre-post 112 104 NA NA Two speech languagepathologists gave a 1 hr PPpresentation on oral hygiene,good oral care, risk factors,difcult patients, and demo onoral care.

NA 5

Nicol et al.(2005)

Pre-post 39 31 84 (35–99) a 82.1 Dentist and dental hygienistgave 90 min training programDVD, and demos on oral health,oral hygiene and care withdemos.

18 5

Frenkel et al.(2001)

RCT 201 155 84.9 (8.2) b 81.1 Health promoter gave 1 hrsession on oral health, hygiene,and staff had practice session onmanikins

6 NA

Isaksson et al.(2000)

Pre-post 170 158 84.6 (51–99) c 70 Specially trained dentalhygienists gave single, four-hoursession on healthy oral cavity

3–4 5

NA, not available; RCT: randomized controlled trial.a Data are displayed as median (range).b Data are displayed as mean (standard deviation).c

Data are displayed as mean (range)* Assessed independently by 2 of the authors using the Newcastle-Ottawa Scale.

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(Boczko et al., 2009 ) from the meta-analysis. The result

indicated

that

the

percentage

of

the

residents’

normalmucosa after caregivers’ health education program signi-cantly increased by 2.29 times compared to the baselinenormal mucosa measurements obtained prior to care-givers’ educational program (P < 0.001).

Fig. 3 shows the forest plot of secondary outcomes –percentage of elderly with no visible plaque and withoutdenture stomatitis – by using pooled summary statistics of OR with 95% CI. before-and-after the caregivers’ health

education. Only two studies, Isaksson et al. (2000) and

Portella

et

al.

(2013) , had

complete

information

on

dentalplaque of a combined 250 residents before-and-after thecaregivers’ health education. A xed effect model was usedaccording to the heterogeneity test (Q = 0.86, I 2 = 0%,P = 0.352). The OR = 1.54 (95% CI. = [1.19, 2.00]) indicatedthat the percentage of no visible plaque in the residentswas signicantly higher after the caregiver received oralhealth education than that before the caregivers’ education(P = 0.001) (Fig. 3A).

Fig. 2. The results of primary outcome, the rate of normal mucosa before-and-after health education program. (A) Forest plot, (B) Sensitivity analysis for theinuence of each individual study on pooled estimate by the means of leave-one-out, (C) The result of forest plot in which Boczko et al. (2009) was excluded.

Fig.

3.

Forest

plot

of

secondary

outcomes.

(A)

Percentage

of

patients

with

no

visible

plaque,

the

percentage

of

elderly

residents

with

no

visible

plaque

and

(B)the percentage of patients without denture stomatitis, the rate of patients without denture stomatitis.

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Two studies (Frenkel et al., 2001; Nicol et al., 2005 )presented the denture stomatitis before-and-after thecaregivers’ health education program of a combined 240residents. A random effect model was used according tothe heterogeneity test (Q = 3.73, I 2 = 73.2%, P = 0.053). Fig. 3B indicated a signicant increase in the percentage of elderly without denture stomatitis after the caregivers had

received

the

health

education

program

(OR

=

2.89,

95%

CI.[1.64, 5.10], P < 0.001).

4. Discussion

We had hypothesized that providing oral healtheducation to the nursing personnel would increase theirknowledge and improve their attitudes toward oral healthcare of the elders in their units and improve not onlydelivery of oral health care but ultimately improve the oralhealth of the 602 residents. Taken together, these studies(Boczko et al., 2009; Frenkel et al., 2001; Isaksson et al.,2000; Nicol et al., 2005; Portella et al., 2013 ) showed that

the

percentage

of

residents

with

normal

oral

mucosa,

novisible plaque, and no detectable denture stomatitissignicantly increased after the group was treated bycaregivers who had received a recent oral health educationprogram.

Instruction on oral health care, its associations withinfectious disease, and other degenerative diseases canimprove the attitude of the caregivers toward theimportance of oral health of the elderly residents (Kullberget al., 2009 ). Repeated oral health education programs forthe caregivers improved the oral health of the elderlyresidents at least in some facilities (Kullberg et al., 2010 ), inagreement with the results of this meta-analysis. Further-

more,

improved

oral

health

of

elderly

residents

helpedreduce the incidence of pneumonia (Kullberg et al., 2010 ).However, several studies that investigated the effect of anoral health education program for the caretakers did notobserve a signicant improvement in the oral health statusof the elderly residents (Gammack and Pulisetty, 2009;MacEntee et al., 2007; Simons et al., 2000 ) whereas otherstudies did observe an improvement (Boczko et al., 2009;Frenkel et al., 2001; Isaksson et al., 2000; Kullberg et al.,2009; Nicol et al., 2005; Portella et al., 2013 ). Sjogren et al.(2010) indicated that a single oral health education of thecaregivers yearly was insufcient to improve the oralhealth status of the residents after 1.5 yrs. Possible reasons

for

the

lack

of

a

signicant

impact

of

the

caregivers’training on the oral health status of the elderly residentsmay include relatively good oral health status of residentsat baseline (MacEntee et al., 2007 ), less sensitive measure-ment scales for the oral health assessments (Gammack andPulisetty, 2009 ), too small a sample size to detect a 20%difference (MacEntee et al., 2007 ), short presentationwithout adequate training or theory of improved oralhealth care (Gammack and Pulisetty, 2009 ), insufcienttime due to competing personal care duties (Gammack andPulisetty, 2009; Reed et al., 2006; Simons et al., 2000 ),inadequate stafng intensity at facility (Gammack andPulisetty, 2009; Reed et al., 2006; Simons et al., 2000 ),

insufcient

supplies

for

oral

health

care

(Coleman,

2005 ),the Hawthorne effect on the facilities and staff (MacEntee

et al., 2007 ), and a relatively high turnover of staff at thefacility between the pre and post training assessments(Simons et al., 2000 ). Multiple oral health educationsessions augmented the oral health knowledge andpractical oral hygiene procedures of the caregivers (Reedet al., 2006 ), but some facilities hesitated to provide theextra time for staff training due to workload (Simons et al.,

2000 ).The limitations of this meta-analysis included that moststudies were not randomized clinical trials but insteadprovided pre and post assessments of the oral health of theelderly residents who had received care from caregiverstrained in an oral health program. Although these studieswere deemed to be of only moderate quality, theadvantage of the pre and post measurements is thepotential to reduce the inter-patient variability. A secondlimitation was that the different studies used differentscales to measure abnormalities in the muscosa whichmade comparison of studies difcult, similar to Watt andMarinho (2005) . However, all studies listed the percentage

of

patients

with

normal

mucosa

which

facilitated

compar-ison between studies. Similarly, all studies used thepercentage of patients with no plaque and the percentageof patients without denture stomatitis. A third limitationwas that publication bias could not be adequately assesseddue to the small number of studies. While ve studiesinvolving 602 elderly residents may be considered arelatively small sample size for meta-analysis, the resultssuggest that an oral health education program forcaregivers can improve the oral hygiene of the elderly.

In conclusion, this systematic review and meta-analysisfound limited evidence that oral health education forcaregivers may be effective for improving the oral health of

the

elderly.

Conict of interest

None declared.

Funding

No external funding.

Acknowledgments

We thank MedcomAsia and K. Molnar-Kimber, Ph.D. foreditorial assistance, which was funded by the authors.

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