j.1741-2358.2011.00562.x

Or ig ina l a r t i c l e

Attitudes to and knowledge about oral health care amongnursing home personnel – an area in need of improvement

Inger Wardh1, Margareta Jonsson2 and Maude Wikstrom3

1Karolinska Institutet, Department of Dental Medicine, Huddinge, Sweden; 2Public Dental Health, Jonkoping County Council, Sweden;3Sahlgrenska Academy, Goteborg University, Sweden

doi: 10.1111/j.1741-2358.2011.00562.x

Attitudes to and knowledge about oral health care among nursing home personnel – an area in needof improvement

Background: In 1999, a dental reform became law in Sweden that regulated both dental care to

dependent individuals and training in oral health care for nursing home personnel. Substantial resources

have been channelled into these efforts, but the outcome of these efforts has not been evaluated. The aim

of this study was to explore attitudes to and knowledge about oral health care among nursing home

personnel more than 5 years after the law was adopted, that being 2005.

Methods: A total of 454 individuals employed at nursing homes answered a questionnaire of 16 multiple-

choice items concerning attitudes to and knowledge about oral health care.

Results: Eighty-nine per cent considered oral health care to be an important part of good nursing. The

answers indicated problems, however, when it came to its implementation and knowledge, and 35% stated

that they had had no formal education in oral health care.

Conclusions: Despite generally positive oral health care attitudes, it is important that oral health care

education is available to and made of interest for all nursing home personnel, especially in light of the

increase in number of natural teeth and frequency of crowns and bridges among dependent elderly.

Keywords: education, nursing homes, oral care.

Accepted 17 July 2011

Introduction

The proportion of elderly people in the popula-

tion is increasing rapidly. By 2000, there were 69

million people over the age of 80 in the world,

and there are estimated to be 377 million by

2050.1 The proportion still having their natural

teeth in their old age is also increasing. Hugoson

et al.2 showed that the proportion of edentulous

80-year-olds had decreased from 56% in 1983 to

3% in 2003 in the Swedish county of Jonkoping.

In a Norwegian study3 on oral health status of

elderly residents living in nursing homes, the

frequency of edentulous participants decreased

from 71% in 1988 to 43% in 2004. In the den-

tate residents, the number of natural teeth and

the frequency of crowns and bridges had

increased. A recent study in Sweden revealed that

the edentulous rate among dependent home-

dwelling elderly was 32%, about 8% of whom

had osseointegrated implant bridges.4 This

development is undoubtedly positive, but it also

constitutes a challenge to the nursing home per-

sonnel when the elderly residents are in need of

support with their daily oral health care.

Today, it is known that poor oral health condi-

tions have a negative impact on general health and

quality of life in older adults.5 One of the WHO

priority action areas is, therefore, oral health

improvement amongst the elderly.6

In 1999, dental remuneration was regulated by

law in Sweden, and the legislation also regulated

dental care for dependent elderly individuals. It

stated that these patient groups should have access

to:

• an oral health care assessment in their home/

residence, free of charge,

• basic dental care at subsidised rates and

• nursing home personnel who are trained in oral

health care.

� 2011 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: e787–e792 e787

Usually, a dental hygienist performs the oral

health care assessment. Basic dental care can in-

clude scaling, extractions, fillings and adjustment of

dentures,7,8 scaling and plaque removal. The

nursing home personnel should be offered training

in both theoretical and practical oral health care

once a year. This training is also usually given by a

dental hygienist.

Substantial financial resources have been chan-

nelled into these efforts since the law was imple-

mented, but the outcome of the efforts has not

been evaluated. The aim of this study was to

explore the attitudes to and knowledge about oral

health care among nursing home staff more than

5 years after the law was adopted – 2005. It was

part of a quality insurance project for nursing home

work.

Material and methods

The personnel at 12 nursing homes in the county of

Jonkoping and the city of Goteborg, who had had

access to the oral health training programme for

nursing home personnel included in the Swedish

dental reform, were invited to participate in the

study. A total of 630 nursing home employees,

working at the nursing homes on a daytime sche-

dule, were invited to participate. The nursing

homes were selected as representing different

geographical areas, community sizes and types of

facility. The number of beds at the nursing homes

varied between 25 and 90. In Sweden today, many

nursing home residents have dementia or another

serious illness, because the official policy is that

when elderly nursing home residents deteriorate,

they are not to be moved to other housing. Most

nursing homes have special units for residents with

dementia.

The questionnaire used in the study included

questions on gender, working experience, profes-

sion and earlier oral health care training, as well as

16 multiple-choice questions on attitudes to and

knowledge about oral health care. The question-

naire concluded with one open item for free com-

ments about oral health care work. The questions

were selected from two previously validated ques-

tionnaires.9,10 The selection process included a

discussion how to choose the most valuable ques-

tions concerning attitudes to and knowledge about

oral health care among nursing home staff. The

discussions were held with a reference group,

consisting of five nursing home employees who

were not participating in the main study, led by

author MJ. The nursing home personnel were

informed about the study, both verbally and in

writing, before inclusion. The local handling of the

questionnaires was left to the nursing home man-

agers.

Data analysis

The quantitative data were presented in total

numbers or frequencies. The qualitative data were

content analysed11 by reading the written com-

ments and seeking meaning units (a group of words

or statements that bear the same central meaning).

These meaning units were then sorted into catego-

ries, which represent a group of contents that

shared a common denominator. The categories

were founded in the data by a selection of

descriptive text quotations.

Results

A total of 454 nursing home personnel (72%)

agreed to participate in the study. Six were regis-

tered nurses. Thirty-two per cent had been working

for more than 20 years in nursing and 5% for

2 years or less. Sixty-five per cent of the nursing

home personnel answered that they had received

formal training in oral health care as part of their

basic education and/or during their employment.

Eighty-eight per cent had an appointment for a

check up at a dental clinic themselves once a year.

Almost all the respondents stated that they gave

oral health care to one or more of their residents

every day, and 89% considered oral health care as

an important part of good nursing. Seventy-seven

per cent of the respondents were of the opinion

that the residents would tell them when they were

in need of help with their oral health care man-

agement.

Tooth brushing was considered by 60% to be a

troublesome activity in nursing home care (Fig. 1),

and close to 80% answered that the greatest

obstacle to overseeing oral health care was that the

residents were not cooperative (Fig. 2). More than

half of the participants were of the opinion that a

person’s teeth will fall out in old age whether or

not they are well taken care of (Fig. 3).

With regard to questions related to oral health

care, the majority, 94% of the respondents, an-

swered that fluorides strengthen the teeth; 70%

were aware that dental plaque, in combination

with sugar consumption, was a reason for the

development of caries. The most common reason

for gingivitis seemed to be less well known. Forty-

seven per cent answered that they brushed more

cautiously when the residents’ gums were bleed-

ing. Thirty-six per cent were of the opinion that a

� 2011 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2012; 29: e787–e792

e788 I. Wardh et al.

dental prosthesis could be left in the oral cavity

during the night if the residents so wished.

The question about what type of education or

help from the dental team that would best con-

tribute to improving the residents’ oral health care

had an internal drop out of 16%. Of those who

answered the question, 40% thought that more

time would be the most important factor. Twenty-

five per cent considered help from the municipal

dental team preferable, 21% practical oral health

care training and 13% favoured theoretical train-

ing. Sixteen per cent of the participants, or 75

participants, gave free comments on oral health

care work. The qualitative content analysis showed

that the oral health care work included some

common dimensions, or categories, although we

did not rank them.

The first category was Uncooperative residents:

The most difficult are persons that refuse to open their

mouth for their carers, and do not want help or think

it is unnecessary.

The second category was Need of oral health care

education:

Even the nursing staff notices bad oral health care

work. I think it is good that they (the dental hygien-

ists) come and teach us how to do this because there

are those who do not know anything about what to

do.

The third category was A good reform:

The elderly have much better teeth due to the edu-

cation about how important it is to care for their teeth,

even if there are things to be improved. There is lack

of time but the reform is a fantastic advantage for the

elderly.

0

10

20

30

40

50

60

70

Hairwashing Feeding Changing diapers Toothbrushing

Figure 1 The participants were

asked which of the four alternatives:

hair washing, feeding, changing dia-

pers and tooth brushing was, in their

experience, the most troublesome to

help a patient/resident with. The

results are given in per cent of all

answers. N = 413.

0

10

20

30

40

50

60

70

80

Rather don´t wantto do it

Don´t have enoughwith time

The elderly manageby themselves

The residentsdon´t cooperate

Figure 2 The participants were

asked which of the four alternatives,

don’t want to do it, don’t have

enough time, the residents manage

by themselves, the residents don’t

cooperate, was the greatest obstacle

to giving help with oral health care.

The results are given in per cent of all

answers. N = 444.


Attitudes to and knowledge about oral health care e789

The fourth category was Need of improved nursing

home personnel cooperation:

The nursing staff ought to be present when the oral

health care assessments are performed on the elderly.

The fifth category was Lack of nursing home per-

sonnel empathy:

It’s pure laziness from the staff not to brush the teeth

of the elderly, and when there isn’t time. Imagine not

to have your teeth brushed! You will always start with

yourself.

Discussion

Many efforts have been made worldwide to

improve oral health care in nursing.12 The Swedish

dental remuneration reform is one such effort, but

its effects have not been evaluated. One of the aims

of the Swedish dental reform was to support the

nursing home personnel with knowledge and

motivation to perform oral health care to improve

the quality of life and nutrition of the elderly. This

is secured through both theoretical and practical

training. The training sessions are offered free of

charge to the nursing home personnel by a dental

team paid by the local government, but it is the

responsibility of the nursing home managers to

arrange for their staff to attend.

As regards the dropout rate, other studies in

similar contexts have shown a response rate

somewhere between 2513 and 75%14 of the sam-

ple. The dropout rate in the present study was

28%. It may be difficult to obtain a higher rate,

because of staff turnover, sick leave and working

schedules. There are probably also individuals who

decline to participate in ways that might skew the

result in a somewhat more positive direction. Free

comments, given by only 16% of the participants,

were probably also made by those with the greatest

interest in oral health care.

Although 95% of the respondents had worked at

nursing homes for more than 2 years, more than

one-third had not received any oral health care

training. Studies from other countries have shown

that between 39 and 45.3%15,16 of nursing home

personnel have been trained to perform oral health

care on their patients. Despite the system of offer-

ing oral health care training to all nursing home

personnel, the responsibility for ensuring that they

attend is still with the nursing home managers.

Often, temporary staff members are not allowed to

attend the training sessions, and disturbances in the

daily working plan is another reason for not

allowing participation. One explanation for this

could be high workloads.10

There were only a few registered nurses partici-

pating in the present study. Although there are not

many registered nurses in Swedish elderly care,

their participation is very important as they are

responsible for the nursing work, despite the fact

that they are seldom involved in the practical

handling of the tasks,10 and they serve as managers

for the other nursing home personnel. It has been

reported that the registered nurses sometimes

consider oral health care as the responsibility of the

dental profession,17 but the present study does not

support such findings. We were unable to draw

conclusions about this owing to the small number

of participating registered nurses.

Although nursing home personnel consider oral

health care to be a part of good nursing, as sup-

ported in other studies,16,18 it has low priority in

the daily work.10 The majority of the nursing

home personnel in this study regarded tooth

brushing as the most troublesome nursing activity

and stated that the greatest obstacle to not giving

oral health care was that the elderly residents

were not cooperative, which has been highlighted

many times before.9,18,19 Thus, although so many

of the staff members found tooth brushing diffi-

cult, only 25% thought that help from the dental

team would improve the oral health care. Perhaps,

the nursing home personnel did not have confi-

dence in the ability of the dental staff to handle

uncooperative residents or perhaps, they were

aware of their own professional nursing respon-

sibility for the daily care. Many were of the

opinion that the elderly themselves spoke up

when they needed help with their oral health

care. Could this be an excuse for not performing

0

10

20

30

40

50

60

Doubtful Don´t agree Agree

Figure 3 The participants were asked to give one of the

three alternative answers: doubtful, don’t agree and

agree, to the statement: ‘Even if you take good care of

your teeth, they will fall out when you get older.’ The

results are given in per cent of all answers. N = 454.



oral health care for uncooperative elderly resi-

dents? Dental fear among the nursing home per-

sonnel may be another reason.9

The nursing home personnel’s view of oral

health care has been described as influential both

in terms of the value set on oral health and the

performance of oral health care at a nursing

home.20 Oral health care education has been

shown to improve both the nursing home person-

nel’s attitudes towards and knowledge of oral

health care.21–23 Training may, thus, lead to

improved performance, but there is very little

research discussing the effects of such training.21

Paulsson et al.24 showed that 3 months after oral

health care training, the nursing home personnel’s

self-reported skills in performing oral health care

on their patients had improved, but studies have

failed to show any effect on the patients’ oral

health/oral hygiene.25

What kind of oral health training is of interest to

the nursing home personnel and will result in

better oral health care for dependent individuals?

Some authors have pointed out the value of con-

tinuous support and supervision in oral health care,

especially when dealing with elderly individuals

with dementia,26 but the present study did not give

much support to practical oral health care training

as the best way of improving oral health care.

Although many of the respondents in the present

study had regular dental care themselves, many

were also of the opinion that a person’s teeth will

fall out as they become older. It may be difficult for

people to push for oral health care, if they think it is

meaningless in the long run. Other studies also

show that about 50% of nursing home personnel

had the misconception that tooth loss is a natural

process.16,21 What effects does this opinion have on

oral health? Is there a need of supplementary

assistance, for instance from municipal dental

hygienists?

Conclusions

The results of the study indicate that the nursing

home personnel have a generally positive attitude

towards oral health care, but when it comes to

implementation and knowledge, there are needs

for improvements.

It is important that oral health care education is

available to and made of interest for all nursing

home staff. In addition, it is possible that in the

nursing home context for the elderly of today,

nursing home personnel cannot handle the daily

oral health care alone, but need assistance from, for

example, municipal dental hygienists.

Acknowledgements

We thank all the nursing home personnel who

enabled us to complete this project and dental

hygienists Fayezeh Shams Nejad and Linda Stens-

trom as well as language reviewer Linda Schenck.

The study was financially supported by the

Jonkoping County Council.

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Correspondence to:

Inger Wardh, Karolinska Institutet, Department of

Dental Medicine, PO Box 4064, SE-141 04 Hudd-

inge, Sweden.

Tel.: +46 8 524 882 26

E-mail: [email protected]



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j.1741-2358.2011.00562.x