A registry study of oral health problems and preventive interventions among older persons receiving municipal healthcare – PROSENIOR

Abstract Aim The aim was to identify planned and completed preventive interventions among older persons with oral health problems receiving municipal health care. A further aim was to determine the correspondence between oral health problems and planned preventive interventions among older persons with oral health problems receiving municipal health care. Design Cross‐sectional register study. Methods Oral health data from the Swedish national quality registry, Senior Alert, were extracted for 4,024 older persons (≥65 years) receiving municipal health care in a county in Southern Sweden. Data were statistically analysed. Results A large majority of older persons (97.4%) with assessed oral health problems had at least one planned preventive intervention, and approximately three quarters of the planned interventions were completed. There seemed to be a mismatch between type of oral health problems and preventive interventions as not all older persons had a planned preventive intervention related to their specific oral health problem.


| BACKG ROU N D
It is to be noted that poor oral health among older persons is common both internationally and nationally, and a systematic review (Wong et al., 2019) reported that a majority of older persons had problems with oral cleanliness and health. Moreover, the prevalence of poor oral health in Italian nursing homes has been estimated to be approximately 44% and even higher among those with cognitive impairment (54%) and those with higher dependency on assistance (56%) (Chiesi et al., 2019).
In Norwegian nursing homes, 40% had poor oral health (Willumsen et al., 2012), and in Swedish nursing homes, 42% had oral health problems and men had more oral health problems than women (Bellander, Andersson, Nordvall, et al., 2021). Importantly, the prevalence of oral health problems differs between types of housing, where oral health problems are more common in home health care than in nursing homes (Czwikla et al., 2021). A recent study , conducted in southern Sweden, shows that the prevalence of the risk for poor oral health was approximately 34% among older persons receiving municipal health care, that is community care service of older persons. The care of older people is in Sweden primarily a municipal responsibility and mainly financed by taxes (Swedish Institute, 2021).
Although the prevalence of the risk for poor oral health varied in different types of housing -31% among older persons in short-term nursing care, 28% among older persons living in their own homes and receiving municipal health care, and 34% in nursing homes -the prevalence of the risk for poor oral health was greatest among older persons in dementia care units (42%) .
Essentially, increasing dependence on others in everyday life and decreasing cognitive ability among older persons leads to poorer oral health status and increased need for assistance with oral care (Zenthöfer et al., 2014). Although promoting oral health is a responsibility for nurses as being one of the fundamentals of nursing care (Kitson et al., 2010), assisting older persons with their oral health is often overlooked by nurses (Costello & Coyne, 2008;Ek et al., 2018). Reasons for this oversight have been related to lack of knowledge, education and training in providing oral care, time constraints, general dislike of oral care among the nursing staff (Wårdh et al., 2012). Other reasons have been related to working experience, that is nurses with shorter experience seem less likely to provide oral care (Edman & Wårdh, 2022). A recent review (Oda et al., 2022) found that barriers for nurses to provide oral care were lack of clear guidelines and protocol for the provision of oral care. Another reason is older persons' resistance to receiving help with oral care (Hoben et al., 2017;Oda et al., 2022). Altogether, this can be reflected in a large unmet need for oral care among older persons, which has been shown in a Swedish study by Forsell et al. (2009) reporting that only 6.9% of those in need of assistance with oral care actually received it. There is, as far as we know, nothing to suggest that this problem has changed for the better over time.
Despite the fact that oral health problems are common among older persons worldwide and constitute a risk for morbidity and mortality, oral health care seems to be a nursing element with room for improvement, and there is a need for increased knowledge about preventive interventions especially in elderly care in Sweden.
Consequently, the aim of the current study was to identify planned and completed preventive interventions among older persons with oral health problems receiving municipal health care. A further aim was to determine the correspondence between oral health problems and planned preventive interventions among older persons with oral health problems receiving municipal health care.

| Design
The current study is part of the research project PROSENIOR, which focuses on the prevention of common risk factors such as poor oral health among older persons receiving municipal care (https:// mau.se/en/resea rch/proje cts/prose nior/). The design was a crosssectional register study based on oral health data extracted from the Swedish national quality registry called Senior Alert, which is one of the largest and most frequently used quality registries in Sweden.
Senior Alert is a well-integrated tool for the prevention of pressure ulcers, falls, malnutrition, and poor oral health among older persons (≥65 years). Prior to registration, older persons are informed about the registry by their healthcare providers, and they give their oral consent for registration. Thereafter, healthcare providers register data from the conducted risk assessments and planned and completed preventive interventions. The intention of the registry is to systemize the preventive care work, reduce risks and improve patient safety (Edvinsson et al., 2015;Senior Alert, 2021). The current study followed the STROBE guidelines (von Elm et al., 2008).

| Study population
The current study was based on 4,024 older persons (≥65 years) receiving municipal health care in a county in Southern Sweden and whose oral health problems and associated preventive interventions were registered in Senior Alert.

| Data extraction
Oral health data from Senior Alert were extracted for the period

| Instrument
The Revised Oral Assessment Guide (ROAG), which is used for oral assessments in older persons, has shown both good inter-rater reliability (Andersson et al., 2002) and reproducibility (Ribeiro et al., 2014). In Senior Alert, a somewhat modified version, the ROAG-J, is used to assess risks for poor oral health. ROAG-J also in-

| Definitions
The type of housing was defined according to : Short-term nursing care: a shorter stay facility for older persons at special municipal residential care homes that offer rehabilitation, aftercare, diagnosis and assessment of needs.
Home health care: receiving health care in one's own home.
Nursing home care: receiving municipal health care in residential care homes.
Dementia home care: receiving municipal health care in residential care homes for older persons with dementia diagnosis.

| Analysis
SPSS version 26 (IBM Corp) was used for statistical analyses.
Descriptive statistics (frequencies, percentages, means and standard deviation [SD]) were used to describe the study population.
Chi-square tests were used to test differences in proportions between men and women. p-values < .05 were considered statistically significant. Missing data were handled according to the listwise deletion, that is in analyses including planned interventions the complete cases were used (Kang, 2013).

| Ethics
Data in the current study were used after approval from Senior Alert and the Regional Ethical Review Board at Lund University

| RE SULTS
The total sample consisted of 4,024 older persons at risk for oral health problems (64.1% women) with a mean age of 85.4 (SD 8.0) years and a majority (67.5%) living in nursing homes (Table 1).
The proportion of any planned intervention for oral health problems was 97.4% in the total sample and was similar in both women and men. Approximately 98% of the older persons in short-term nursing care had a planned intervention and 94.6% in home health care. Regarding planned interventions that were registered as completed for oral health problems, the highest proportion was found in dementia care units (80.3%) and the lowest in home health care (63.5%) ( Table 2).

| Oral health problems
Oral health problems related to the Teeth in terms of Coating or food debris locally were reported among 43.4% of the older

| Causes for oral health problems
Of the investigated causes, Impaired ability to understand information and instructions was reported among 39.4%. Sore mouth at or between meals was significantly more common among women than men at 4.7% versus 3.2%. (Table 4).

| Planned preventive interventions
The most frequent planned preventive interventions were Tooth brushing (planned for 56.2%) and Moisturizing the mouth (planned for 22.2%), while Local pain relief of the lips, mucous membranes and tongue were rarely planned. Consultation with a dentist when scoring 3 on any of the oral health assessments was planned for 9.7%, while 7.5% Resisted all preventive measures (Table 5).

| DISCUSS ION
The current study shows that among older persons with assessed oral health problems, a large majority had planned preventive interventions, and approximately three quarters of these interventions were completed. However, there was a mismatch between type of oral health problem and preventive interventions.
Common oral health problems were related to the Teeth. Impaired ability to understand information and instructions was the most TA B L E 2 Distribution of any planned and completed interventions for oral health problems among older people presented for the total sample and by sex and type of housing   (Lindmark et al., 2020;McGrath & Bedi, 1991;van de Rijt et al., 2021) and has shown that the promotion of oral hygiene is an essential basic part in nursing (Pipe et al., 2012).  In contrast to our results, which showed that Tooth brushing was the most common planned intervention (56.2%), this was planned only among 13.5% of the older persons in the study by Rantzow et al. (2017) in which Moistening of the mouth was the most common planned intervention. In our study, the proportion of both any and completed preventive interventions was smaller in home health care than in the other types of housing. This may indicate that preventive work is more challenging and requires other routines than in nursing homes where nursing staff are present more constantly.
Older persons' resistance has been raised as an important barrier to performing oral care (Hoben et al., 2017: Willumsen et al., 2012. In our study, resistance to preventive interventions was only reported among 7.5%, which is in line with Rantzow et al. who reported resistance among 4.8%, but contradicting Willumsen et al. (2012) who reported that almost half of the nurses encountered patients resisting help every day. A recent interview study (Koistinen et al., 2021) with older persons in short-term care showed that they wanted to maintain control over their tooth brushing and that assistance was unthinkable at present but could be considered when not being able to do so themselves. It was also emphasized that many of the older persons had not visited dental care for many years due, for instance, to hospitalizations, declining health, and because the teeth were no longer a priority. Considering that poor oral health is associated with malnutrition (Lindroos et al., 2019;van Lancker et al., 2012) and aspiration pneumonia (van der Maarel-Wierink et al., 2011) and has an impact on quality of life in older persons (Lindmark et al., 2020;McGrath & Bedi, 1991;van de Rijt et al., 2021), it seems important to offer regular dental care in municipal care. According to the ROAG-J, a dentist should be consulted and offered when the older persons score a 3 on any assessment, but it is of course important to take the older person's autonomy into consideration because it may be that a dentist appointment is not desired. However, in our study, Consultation with dentist when scoring a 3 on any assessment was planned for 9.7% of the older persons, which is somewhat higher than in Rantzow et al. (2017) who reported 5.7%. This could be viewed as alarming and suggesting room for improvement, but another explanation could be that the older persons have simply declined the offered dentist appointment.

| Limitations
A limitation is the lack of available medical data and scant background data in Senior Alert, which most likely would have added value to the interpretation of the results. Another weakness is the missing data for the different performed interventions. However, the missing data were handled according to the listwise deletion, that is, in analyses including intervention the complete cases were used (Kang, 2013). Another limitation may be that the included instructions were not fully adhered to by the registration professionals, which may be an explanation for the missing data. Although

| CON CLUS ION
A large majority of older persons with assessed oral health problems had at least one planned preventive intervention, and approximately three quarters of these interventions were completed. Importantly, there seemed to be a mismatch between type of oral health problems and preventive interventions as not all older persons had a planned preventive intervention related to their specific oral health problem. Because oral health is an important element in nursing care, the current findings argue that there is room for improvement and suggest the need for educational interventions for nursing staff about the promotion of oral health.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the national quality registry Senior Alert. The data are not publicly available due to privacy or ethical restrictions.

E TH I C A L A PPROVA L
The study was ethically approved by the Regional Ethical Review Board, Lund, Sweden (2015-484).