O R I G I N A L R E S E A R C H

Effects of Domiciliary Professional Oral Care for
Care-Dependent Elderly in Nursing Homes – Oral
Hygiene, Gingival Bleeding, Root Caries and
Nursing Staff’s Oral Health Knowledge and
Attitudes

This article was published in the following Dove Press journal:
Clinical Interventions in Aging

Caroline
Girestam Croonquist1,2

Jesper Dalum 3

Pia Skott1,2

Petteri Sjögren4

Inger Wårdh2,3

Elisabeth Morén 3

1Folktandvården Stockholm AB,
Stockholm, Sweden; 2Academic Centre
Of Geriatric Dentistry, Stockholm,
Sweden; 3Department Of Dental
Medicine, Karolinska Institutet,
Huddinge, Sweden; 4Oral Care AB,
Stockholm, Sweden

Purpose: The primary aim was to describe the effects for nursing home residents of monthly
professional cleaning and individual oral hygiene instruction provided by registered dental
hygienists (RDHs), in comparison with daily oral care as usual. The secondary aim was to
study the knowledge and attitudes among nursing staff regarding oral health care and needs.
Patients and Methods: In this randomised controlled trial (RCT), 146 residents were
recruited from nine nursing homes in Regions of Stockholm and Sörmland and were
randomly assigned (on nursing home level) to either intervention group (I; n=72) or control
group (C; n=74). Group I received monthly professional cleaning, individual oral hygiene
instructions and information given by an RDH. Group C proceeded with daily oral care as
usual (self-performed or nursing staff-assisted). Oral health-related data was registered with
the mucosal-plaque score index (MPS), the modified sulcus bleeding index (MSB), and root
caries. The nursing staff’s attitudes and knowledge were analysed at baseline and at six-
month follow-up. Statistical analysis was performed by Fisher’s exact test and two-way
variance analysis (ANOVA).
Results: Improvements were seen in both Group I and Group C concerning MPS, MSB and
active root caries. The nursing staff working with participants in Group I showed significant
improvements regarding the Nursing Dental Coping Beliefs Scale (DCBS) in two of four
dimensions, oral health care beliefs (p=0.0331) and external locus of control (p=0.0017)
compared with those working with Group C. The knowledge-based questionnaire showed
improvement (p=0.05) in Group I compared with Group C.
Conclusion: Monthly professional oral care, combined with individual oral health care
instructions, seems to improve oral hygiene and may reduce root caries among nursing home
residents. This may also contribute to a more positive attitude regarding oral hygiene
measures among nursing home staff, as compared with daily oral care as usual.
Keywords: aged, residential facilities, nursing staff, dental care, attitude of health personnel,
oral health

Introduction
With an ageing population, the need for care support for dependent elderly
increases for the general public.1 Domiciliary dental care enables dental services
in the patients’ residences and offers the opportunity to provide regular check-ups,

Correspondence: Elisabeth Morén
Department Of Dental Medicine,
Karolinska Institutet, Box 4064, Huddinge
141 04, Sweden
Tel +46 70 165 88 03
Email [email protected]

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preventive measures and dental treatments to individuals
who experience difficulties attending a regular dental
clinic.2 The dental care performed at home by dental
personnel is rudimentary, with rather simple equipment
and treatments like scaling of calculus, tooth extractions,
tooth restorations, adjustments of dentures and plaque
removal.3 A study conducted by Wårdh et al (2012)3

regarding nursing staff’s knowledge and attitudes towards
oral health care showed that the majority of the nursing
staff believed that the residents would tell them when they
needed help with their daily oral hygiene. Furthermore, the
majority felt that performing assisted oral care (tooth-
brushing, interproximal tooth cleaning and/or cleaning of
prothesis) was a difficult task and 80% thought the greatest
obstacle was the non-cooperation from the residents.
Keboa et al (2019) presented, from a nursing staff per-
spective on performing assisted oral care, that challenges
lie in complicated teeth constructions, high workload,
resistance towards examine another person’s oral cavity/
mouth, and not wanting to performed assisted oral care.4

Residents at nursing homes may face difficulties visiting
a dental clinic,5 and a study by Muszalik et al (2015)6 of
patients visiting a geriatric clinic showed that elderly per-
sons often have difficulties participating in activities outside
their home environment. The major issues were the lack of
energy and the presence of pain. Today, elderly in devel-
oped countries retain their teeth at a higher age,7–9 but
ageing with increased morbidity and polypharmacy often
results in frailty and dependence on the care of others, all of
which increase the risk of deterioration of oral health and
susceptibility to developing oral diseases.10,11 The rela-
tively high number of natural teeth and complicated oral
prosthetic constructions (eg, bridges, crowns and oral
implants),7,12,16 together with progressing morbidity and
care dependence, necessitates that daily oral hygiene activ-
ities need to be maintained on a sufficient level, or even
intensified.7 The presence of oral health conditions can
cause pain, infections and nutritional difficulties.7,8 The
common condition oral dryness increases the risk of dental
caries, which can relatively rapidly lead to deterioration of
oral health.13,14 Additionally, it can cause a social handicap
since oral dryness can lead to difficulties speaking, chewing
and swallowing, impairment in tasting,14,15 and have
a negative impact on quality of life.14,16,17

Oral and general health are strongly related in older
individuals16,18 and maintained oral health among the
elderly has been related to retained general health.19,20

A study conducted by Hagglund et al (2019)12 showed

that the mortality risk observed over one year was signifi-
cantly higher in older individuals with poor oral health
than in those with good oral health. Furthermore, it has
been shown that intensified oral care interventions by
dental personnel may prevent approximately one in ten
deaths from healthcare-associated pneumonia (NNT
8.6–11).21 Both natural teeth and dentures may constitute
a reservoir for respiratory pathogens,22 and denture wear-
ing at night doubles the risk of healthcare-associated pneu-
monia in the oldest adults.23 Barbe et al (2019)24

concluded that professional cleaning performed by
a dental nurse every two weeks on residents living at
nursing homes maintained and improved the residents’
oral health. Furthermore, domiciliary dental care provides
the possibility of reaching individuals with, for example,
cognitive impairment and/or functional limitations.19,25

The primary aim of this study was to describe the
effects for nursing home residents of professional cleaning
and individual oral hygiene instruction provided by regis-
tered dental hygienists (RDHs), in comparison with daily
oral care as usual. The secondary aim was to study the
knowledge and attitudes among nursing staff regarding
oral health care and needs.

The hypothesis was that domiciliary prophylactic pro-
fessional oral care will improve oral health among partici-
pants in the intervention group, in comparison with
participants in a control group that receives daily oral
care as usual.

Materials and Methods
This evaluator-blinded RCT with an open-ended design
was performed at nine Swedish nursing homes. One hun-
dred and forty-six residents were recruited to participate in
the study; 72 were randomised to the intervention group
(Group I) and 74 to the control group (Group C).

Ethical Statement
The study was approved by the Ethics Committee in
Stockholm, Sweden (Number 2015/1641-31/2) and was
registered in ClinicalTrial.gov (Number NCT02669979).

Randomisation and Recruitment of the
Nursing Homes
Four nursing homes in Region Stockholm and five nursing
homes in Region Sörmland were recruited to the study.
Randomisation was performed at nursing home level.26

The nursing homes were chosen geographically (urban and

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rural areas) and were managed by both private companies
and municipalities. Approval from the head of the nursing
home was mandatory for inclusion in the study. After col-
lecting informed consent (for residents showing signs of
reduced cognitive function according to Pfeiffer-test,27

informed consent was required from either a relative or an
advocate), the randomisation of the nursing homes to either
Group I or Group C was decided by a computer-generated
sequence and administrated by a coded letter representing
each nursing home. The letter was opened by an RDH not
otherwise involved in the clinical examinations in the study.

The inclusion criteria were living in a nursing home,
=85 years of age, and at least ten remaining teeth including
dental implants. Exclusion criteria were having full den-
tures, edentulous, reduced cognitive function that made
cooperation impossible for examination and treatment by
RDHs, extreme dry mouth assessed by the mirror-sliding
friction test28 and ASA risk qualification of 4 or higher.29

The taking of antiplatelet drugs and anticoagulants was not
an exclusion criterion but was noted in the study protocol
during data collection.

Study Process
At baseline, participants in both study groups received
professional cleaning (tooth brushing, interproximal clean-
ing and scaling of supragingival calculus) performed by
three calibrated and blinded RDHs. Home care instructions
regarding oral hygiene were given verbally and in writing
to participants in both study groups and to nursing staff,
and fluoridated toothpaste, a soft toothbrush and interprox-
imal cleaning aids were given free of charge.

Intervention
The participants in Group I received monthly professional
cleaning, individual oral hygiene instructions and informa-
tion by RDHs (not otherwise involved in the oral exam-
ination and study protocol registration). The visiting time
was approximately 30 minutes.

Control
The participants in Group C received the same baseline
procedure as Group I and proceeded with daily oral care as
usual, performed either by themselves or assisted by nur-
sing staff, throughout the study, without any additional
visits or instructions by a study RDH.

Oral Examination and Study Protocol
Oral examination was performed by using a flashlight, mir-
ror and probe at baseline and the results were registered in
a study protocol (available on request) together with med-
ical history and medication use. Indexes used were the
mucosal-plaque score index (MPS),30 modified sulcus
bleeding index (MSB)31 and root caries. Oral mouth dry-
ness was measured by the participants’ subjective experi-
ences and the mirror-sliding friction test28 on the inside of
the buccal mucosa. Registrations according to the study
protocol were performed in both groups by the three cali-
brated RDHs at baseline, after three months and after six
months (Figure 1).

Indexes
MPS is a combined mucosal score and plaque score index
used both for edentulous and dentate individuals. Before
oral measurements, dental prostheses were removed if
present. Mucosal score (MS) rates changes in the oral

Figure 1 Flow chart over clinical registrations according to the study protocol, the total number of residents and also for the intervention group (I) and the control group
(C) throughout the study. From baseline to the end of the study at six-month follow-up. Instruments: Mucosal and plaque score index (MPS), modified sulcus bleeding index
(MSB) and root caries.

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mucosa, and plaque score (PS) rates the amount of plaque
both on natural teeth and on removable dentures and fixed
prosthodontics. MS and PS are rated from 1 to 4 (4 is the
most severe). By interpretation of the index, MS and PS
are combined. The purpose of the index is to validate oral
hygiene and not to serve as a diagnosis.30

MSB was used to measure bleeding from the gingival
margin on the buccal surface of the Silness-Loe index
teeth12,16,24,32,36,44 or, when missing, the closest tooth32

was assessed according to MSB, which has four levels
(0–3) where 3 is the most severe.31

Root caries33 was assessed according to five levels on
the buccal surface on Silness-Loe index teeth.

Nursing Staff
Nursing staff from four nursing homes participated in this
part of the study, with a total of 50 participants included.
The intervention group contained 35 participants at base-
line and 20 participants at six-month follow-up. The con-
trol group contained 15 participants at baseline and 15
participants at follow-up. Twelve participants from the
intervention group and 2 participants from the control
group could be followed using a four-digit code number
from baseline to six-month follow-up and were therefore
designated as the identified group.

Study Process
All nursing staff (nursing aides, assistant nurses, registered
nurses and other staff such as administrators and man-
agers) participated in an oral health education programme
at study start, given by one RDH who was not otherwise
involved in the study.

Intervention
The nursing staff’s knowledge and attitude towards oral
health were registered prior to participating in the educa-
tional programme at baseline using two questionnaires. The
questionnaires were repeated at the six-month follow-up.

Questionnaires
The questionnaires used were the Nursing Dental Coping
Belief Scale (Nursing DCBS)34 questionnaire and
a knowledge-based questionnaire regarding oral health.35

Both questionnaires were distributed to the current nursing
staff working at the nursing homes that day, at baseline
and at six-month follow-up. The questionnaires were pseu-
donymised with a four-digit code number.

The nursing DCBS index is a tool used to measure how
groups of nursing staff differ in their priorities and how they

meet their responsibilities for oral health care.34 The DCBS
was developed by Jacobs & Stewart and is based on three
major models of cognitive behavioural psychology consisting
of Julian Rotter’s locus of control (divided into IL and EL),
Albert Bandura’s self-efficacy and Donald Meichenbaum’s
self-instructional technique.36 The DCBS consists of four
dimensions: “internal locus of control (IL)”, “external locus
of control (EL)”, “self-efficiency (SE)” and “oral health-care
beliefs (OHCB)” and has been used in various types of care-
related research.37 The IL dimension evaluates people’s self-
control and self-experienced beliefs concerning events in life,
for example, “I believe brushing can help prevent cavities”,
and people with high degrees of IL expect themselves to have
great control and responsibility over events in life. In contrast,
people with high degrees of EL expect and believe that their
lives are influenced by environmental factors outside their own
control, for example, “No matter how hard I work on taking
care of my teeth, I still get tooth decay”.36 The SE dimension
evaluates people’s beliefs concerning their own capability to
affect a specific situation,38 for example, “I believe I know
how to brush my teeth correctly”.36 The OHBC dimension
evaluates faulty and irrational beliefs about dental disease,38

for example, “Once gum disease has started it is almost
impossible to stop”.36 The responses in DCBS are listed on
a scale, with five options ranging from “strongly agree” to
“strongly disagree”, including a “do not know” option.34

The Handbook of Healthcare was the second question-
naire used in the study and is based on questions regarding
knowledge about oral health needs in care-dependent
elderly. It was retrieved from www.vardhandboken.se,
which is a website that was initiated by the Swedish
Association of Local Authorities and Regions to provide
education and support to care providers. The questionnaire
consists of nine questions about the use of dental pros-
theses and how to clean them, oral dryness, oral hygiene
performance, Revised Oral Health Assessment Guide
(ROAG), etc. Each correct answer gives 1 point and zero
points are awarded for incorrect answers.35

Statistics
The data collected at baseline were presented with mean
values and standard deviations (SD) or as frequencies. The
results were presented with changes from baseline to the
three- and six-month follow-ups in frequency tables.
Comparisons between Group I and Group C were made
using Fisher’s exact test. P values <0.05 (95% CI) were
considered statistically significant.

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Statistical methods used for the knowledge and attitude
questionnaires were two-way variance analysis (ANOVA)
and Fisher’s exact test.

The participants (both the residents and the nursing
staff) were treated as independent groups during analysis.
The study was originally planned to last for one year but
was concluded at six months due to financial reasons.

Results
Residents
The mean number of natural teeth was 20.2 (SD 3.0) and 26%
of the study participants received assisted oral care. Ninety-six
percent had contact with dental care providers in the
previous year. The mean prescribed medication was 9.7 (SD
3.8) and 29% of the participants were registered with dry
mouth according to self-experienced reports and the mirror-
sliding friction test. A total of 14 participants used their electric
toothbrush daily and strained food was medically prescribed
for 3% of the participants. Additional baseline data are pre-
sented in Table 1. Of the 146 included residents, a total of 124
residents completed the entire study. Reasons for dropouts
were events of death or hospitalization. There were more
women than men in the total study material but no statistical
difference between Groups I and C existed at baseline.

Oral Hygiene and Root Caries
MPS
For MPS, improvements from baseline to six-month fol-
low-up were seen in both Group I and Group C. Both

groups showed improved PS, but without significance.
For MS, a significant difference between Group I and
Group C (p=0.04) was seen within the period between
the three- and six-month follow-ups. In Group I, 20% of
the participants showed improved MS, in comparison with
13% in Group C (Tables 2–4).

MSB
The MSB index was combined and is presented as MSB 0
+1 and MSB 2+3. For Group I and Group C, an improve-
ment throughout the study could be seen within the groups
(Table 5).

Root Caries
The root caries index was reduced from five levels to three
and is presented as healthy (caries score of 1), initial caries
lesion (caries score of 2 and 4) and active caries lesion
(caries score of 3 and 5). Improvements were seen in both
Group I and Group C for healthy and initial caries lesions
throughout the study period, without significant difference
between the groups. The last follow-up period between three
to six months showed improvement for Group I regarding
active caries lesions, with an improvement of 17% in com-
parison with 4% in Group C (p=0.05) (Table 6–8).

Nursing Staff
The Nursing Staff’s Knowledge and Attitudes
The intervention group showed a statistically significant
improvement in comparison with the control group in the

Table 1 Baseline Data For Residents

Group I (n=72) Group C (n=74) Total (n=146)

Age, mean value (SD) 89 (4.0) 88.7 (4.2) 88.9 (4.1)

Men, n (%) 16 (22) 22 (29.7) 38 (26.0)

Natural teeth, mean value (SD) 20.5 (2.9) 19.9 (3.1) 20.2 (3.0)
Implants, n (%) 5 (6.7) 7 (9.5) 12 (8.2)

Removable partial denture, n (%) 9 (12.5) 10 (13.5) 19 (13)

Removable full denture, n (%) 1 (1.14) 0 (0) 1 (0.7)
Got help with daily oral hygiene, n (%) 16 (22.2) 22 (29.7) 38 (26.0)

Used fluoride toothpaste, n (%) 70 (97.2) 65 (87.8) 135 (92.5)

Tooth brushing/day, mean value (SD) 1.7 (0.5) 1.8 (0.6) 1.8 (0.6)
Interproximal cleaning/week, n (%) 30 (44.4) 30 (40.5) 60 (42.5)

Used electric toothbrush, n (%) 9 (12.5) 5 (6.8) 14 (9.6)

No dental exam/dental check-up > 12 months, n (%) 5 (6.9) 1 (1.4) 6 (4.1)
Number of prescribed medications, mean value (SD) 9.8 (3.8) 9.5 (3.8) 9.7 (3.8)

Dry mouth, n (%) 26 (36.1) 16 (21.6) 42 (28.8)

Strained food, n (%) 2 (2.8) 3 (4.1) 5 (3.4)
Nutritional drinks, n (%) 12 (16.7) 5 (6.8) 17 (11.6)

Abbreviations: n, number; SD, standard deviation.

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OHCB dimension (p=0.03) and EL dimension (p=0.0017).
In the identified group, there was a statistically significant
difference in the IL dimension group (p=0.03).

For the knowledge-based questionnaire, an improve-
ment (p=0.05) was found between the intervention and
the control group from baseline to six-month follow-up.

Table 2 Plaque Score (PS) from Baseline (B) Among The Intervention (I) and Control (C) Group to Three- and Six-Month Follow-Ups

PS B–3 Months B–6 Months 3–6 Months

p-value 0.24 0.34 0.80

I (n=70) C (n=61) I (n=69) C (n=55) I (n=69) C (n=55)

Deteriorated n (%) 4 (5.71) 7 (11.48) 3 (4.35) 3 (5.45) 16 (23.19) 11 (20.00)

Unchanged n (%) 33 (47.14) 21 (34.42) 40 (57.97) 25 (45.45) 44 (63.77) 35 (63.64)

Improved n (%) 33 (47.14) 33 (54.10) 26 (37.68) 27 (49.09) 9 (13.04) 9 (16.36)

Abbreviations: n, number of participants.

Table 3 Mucosal Score (MS) from Baseline (B) Among the Intervention (I) and Control (C) Group to Three- and Six-Month Follow-
Ups

MS B–3 Months B–6 Months 3–6 Months

p-value 0.10 0.12 0.04*

I (n=70) C (n=61) I (n=69) C (n=55) I (n=69) C (n=55)

Deteriorated n (%) 11 (15.71) 4 (6.56) 8 (11.59) 1 (1.82) 17 (24.64) 6 (10.91)

Unchanged n (%) 22 (31.43) 29 (47.54) 31 (44.93) 28 (50.91) 38 (55.07) 42 (76.36)
Improved n (%) 37 (52.86) 28 (45.90) 30 (43.48) 26 (47.27) 14 (20.29) 7 (12.73)

Notes: *p <0.05. All other comparisons, not significant.
Abbreviations: n, number of participants.

Table 4 Mucosal And Plaque Score (MPS) from Baseline (B) Among the Intervention (I) and Control (C) Group to Three- And Six-
Month Follow-Ups

MPS B–3 Months B–6 Months 3–6 Months

p-value 0.77 0.42 0.51

I (n=70) C (n=61) I (n=69) C (n=55) I (n=69) C (n=55)

Deteriorated n (%) 10 (14.29) 6 (9.84) 7 (10.14) 3 (5.45) 24 (34.78) 14 (25.45)

Unchanged n (%) 13 (18.57) 13 (21.31) 24 (34.78) 16 (29.09) 30 (43.48) 29 (52.73)

Improved n (%) 47 (67.14) 42 (68.85) 38 (55.07) 36 (65.45) 15 (21.74) 12 (21.82)

Abbreviations: n, number of participants.

Table 5 Modified Sulcus Bleeding Index (MSB) at Baseline (B), and After Three- And Six-Month (M) Follow-Ups and Difference (Diff)
Between Time, Intervention (I) and Control (C) Group

Baseline 3 Months Diff B–3M 6 Months Diff B–6M

I n=72 C n=74 I n=70 C n=61 I n=70 C n=61 I n=69 C n=55 I n=69 C n=55

MSB level 0–1

mean (SD)

2.07

(1.70)

1.66

(1.12)

2.15

(1.70)

1.79

(0.94)

0.08 0.13 2.41

(1.76)

2.30

(1.14)

0.34 0.64

MSB level 2–3
mean (SD)

0.98
(1.54)

1.35
(1.04)

0.84
(0.26)

1.28
(0.63)

– 0.14 – 0.07 0.59
(0.13)

0.70
(1.47)

– 0.39 – 0.65

Notes: MSB 0–1 positive values show improvement, MSB 2–3 negative values show improvement.

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Discussion
The present study was a part of a project with the aim to
evaluate regular professional cleaning and information/
instructions regarding oral health care performed in nur-
sing homes.2 It concluded that professional cleaning has
a favourable effect on gingival bleeding, and verbally
given individual oral hygiene instruction resulted in
greater reduction of dental plaque, which indicates that
both education and individual oral hygiene instruction
with “hands-on” training ought to be included in domicili-
ary oral health care programmes.2 In the present study, the
intervention has therefore been a combination of these two
parts. Furthermore, a root caries index and the knowledge
and attitudes of nursing staff towards oral health care were
added to the study design.

The indexes used in the study are somewhat subjective
since they are performed to estimate the amount of plaque,

gingivitis, root caries and mucosal status by visual assess-
ment. For this reason, calibration was performed in this
study between the three RDHs collecting data to minimize
differences in the assessment tasks. The present study
chose the instrument and index for their simple equipment
and ease of use and because they are preferable when
performing a study in a home environment. According to
the World Health Organization (WHO), “The examination
for dental caries should be conducted with a plane mouth
mirror. The use of radiography for detection of approximal
caries is not recommended because the equipment is
impractical to utilize in most field situations”.39

Statistical adjustment for background variables was not
performed, as they showed no skewness, neither for age nor
gender. In the present study, twenty study participants
dropped out due to death or hospitalization during the study
period, one in Group I and nineteen in Group C (Figure 1).

Table 6 Root Caries Score of 1 Among The Participants (n) At Baseline (B) And Three- And Six-Month Follow-Ups

Root Caries Score of 1 B–3 Months B–6 Months 3–6 Months

p-value 0.41 0.84 0.76

I (n