Table 2 Scoping review of oral health education interventions in community nursing settings

Brickhouse, T.H.,Haldiman, R.R., Evani, B. (2013) [36] – USA

Propensity score matched (PSM) control

Health visiting for at-risk children and families

N = 216 children. Participated in CHIP Begin with a Grin. 6-36 months.

CHIP Begin with a Grin – Community health nurses and paediatric nurse practitioners applied fluoride dental varnish to the teeth of children aged 6-36 months not currently seeing a dentist. Educated primary caregiver on oral hygiene, nutrition and oral health literacy. Aimed to reduce childhood caries. Practiced these oral health techniques with nurse.

Created control group using PSM. 216 intervention, 216 control. Used Medicaid database to gather data and conduct a quasi-experimental study.

Dental utilization (number of claims for dental care)

Logistic regression

Significantly higher instances of making > 1 dental claim for intervention group. 3 times more likely to have at least one dental claim. Odds ratio: 3.0, confidence interval: CI: 1.9–4.7)

None reported.

Whittle, J.G., Whitehead, H.F., Bishop, C.M. (2008) [37]– England

Randomised control trial

Health visiting for children at home

251 control, 250 intervention, aged 3 years

No name stated - Dental health advice given to parents by health visitor. Leaflet “giving teeth a good start”, 440 pm fluoride toothpaste and child toothbrush also provided. Main messages were around how to avoid sugar, increase health eating, tooth brushing, educating children from infancy about oral health and selecting an appropriate toothbrush and toothpaste. Diet record sheets and advice given at 20 months, and more toothpaste and toothbrush.

Control and intervention samples were recruited at 8 months old, randomised using balanced blocks, stratified by ethnicity and location. First visit for intervention group was soon after recruitment, then again at 20 months. Sample tested at 3 years for decayed, missing and filled surfaces (DMFS), then again at 5 years. Also compared with large census data (n = 2253) at 5 years.

Teeth were examined using British Association for the Study of Community Dentistry survey items for decayed, missing and filled surfaces of teeth. Recorded number in these three categories.

Calculated 95% Cis for DMFS data and compared for significant differences.

No statistically significant differences were found between control and intervention groups, although the gap widened as the children grew older. A significant difference was found between the intervention group and the data for all 5-year-olds in the area, with intervention group having significantly less incidences of damaged, missing or filled surfaces in their teeth.

None reported.

Haber, J., Hartnett, E., Hille, A., Jessamin, C. (2020) [38] – USA

Quasi-experimental.

Nurse home visiting for first-time mothers

4 nurses in intervention plus support group, 10 nurses in a comparison group of intervention only with no support. 27 clients of intervention nurses (first time mothers).

Cavity Free Kids – Evidence based curriculum, Cavity Free Kids, was given to Nurse Family Partnership nurses (a not-for-profit program for nurse home visiting to low-income first-time mothers by a registered nurse). Cavity Free Kids is a 2-hour program to increase knowledge and practice behaviours of oral health. Aimed to increase integration of oral health into home visiting (from pregnancy to age 2).

N = 32 nurses received the oral health intervention, but only Miami based nurses were given instruction and support to integrate into practice. Non-Miami nurses formed a comparison group (but had received the original intervention). 4 Miami nurses completed survey data collection at baseline, 30 days and 90 days. 10 non-Miami nurses also completed data collection. 27 clients of Miami nurses were given a 10-item telephone questionnaire at baseline, 30 and 90 days.

Oral health knowledge and practice behaviours (nurses, self-report). Oral health child care behaviours, oral health behaviours, information received about oral health (clients).

Descriptive statistics to compare nurse groups, paired sample t-tests to measure change in client outcomes from baseline to later data collection points.

At 90-day follow-up, non-Miami nurses (no support) reported lower levels oral health practice behaviours than Miami nurses who received support, including: reporting of explanation to clients about how to brush children’s teeth and lower levels of referring 0–2-year-olds to a dentist, and discussion of how to prevent cavities in 0–2-year-olds. Miami clients reported increased levels of information received from nurses about oral health and increased cleaning of their child’s mouth. Clients who ‘graduated’ the full 2-year NFP program completed an additional survey – none reported any visible plaque, staining or decay on their child’s teeth (signs of ECCs).

100% of Miami nurses who received support were using the intervention in practice at 90 days. Only 30% of non-Miami nurses (no support) were using the intervention

Lewis, A., Kitson, A., Harvey, G. (2016) [39] – Australia

Pre-post implementation study

Home care

319 home care clients (aged 61-82)

Better Oral Health in Home Care (BOHHC) – multidisciplinary model incorporating oral health assessment, oral healthcare planning, actioning daily oral care, and referral for dental treatment. Training and skill development for home care workers.

Mixed methods. Analysed oral-health assessments of home care clients, self reported OH outcome data from pre and post BOHHC implementation. Pre and post training questionnaires. Dental referral statistics analysed for changes pre-post. Qualitative data from steering committee meetings, and project meetings.

Analysed oral-health assessments of home care clients, OHIP-14 – self reported OH outcome data from pre and post BOHHC implementation. Pre and post training questionnaires. Dental referral statistics also analysed. Qualitative data from steering committee meetings, and project meetings.

Comparison of pre and post means (McNemar tests). Thematic analysis for qual.

Oral Health assessment increased – no uptake at pre-test, four home care providers had uptake at post-test. Oral Healthcare planning also increased from zero home care providers to four. Increased staff confidence at delivering oral care. Increased self-reported oral health, but too much missing data to allow conclusion around reduction in oral disease.

Home care workers data revealed a ‘lone worker’ theme with considerable time pressure. Promoting a “stop, check and act” strategy was developed to help in this context. Implementation and process analysis – building relationships was a key to facilitating delivery. Cultural respect for Aboriginal community clients. Mentoring from project director. Universal integration of BOHHC model was a facilitator, alongside knowledge transfer (KT) with an assigned KT expert.

Lewis, A., Harvey, G., Hogan, M., Kitson, A. (2019) [40] – Australia

Realist evaluation

Home care

Twelve home care staff, two patients

Better Oral Health in Home Care (BOHHC) – A multidisciplinary model incorporating oral health assessment, oral healthcare planning, actioning daily oral care, and referral for dental treatment. Training and skill development for home care workers.

14 semi-structured interviews, face to face or phone. Two time points. One at point of implementation, a second five years’ post-implementation

Facilitators and barriers to intervention delivery, contextual characteristics which supported or undermined the embedding of the intervention.

Thematic analysis

Home care workers reported significantly improved OH knowledge and skills and this increased staff ability to recognise patients in need of OH support and dental referrals.

High level corporation engagement was achieved. Development of capacity building networks (internal and external) was seen as a facilitator. OH assessment tool was introduced. High staff turnover was a barrier.

A. Nihtilä, K. Komulainen, E. Tuuliainen, I. Nykänen, S. Hartikainen, A.L. Suominen. (2017) [41]– Finland

Non randomised population study with control and intervention

Home care

Patients receiving home care (n = 141 intervention, n = 108 control, aged 84.3, 84.6 years respectively)

Nutrition, Oral Health and Medication – NutOrMed – Tailored dietary and oral health intervention for home care clients 75 years or over. Individual counselling on dry mouth care. Advice on topical therapies. Nutrition intervention for patients at risk of malnutrition.

Interviews before and after a tailored intervention. In-home.

Xerostomia, liquid intake, dietary changes

Descriptive

Xerostomia decreased by 7.1%, liquid intake increased 21.6%, eating fruits and vegetables increased 10% in intervention group. Control group - 2.8% Increase in xerostomia, liquid intake decreased 5.4 and 2.1% increase in eating fruits and vegetables. Topical therapies alone not enough, interventions for nutrition stated to be particularly effective for xerostomia. Dietary changes noted to be effective for xerostomia (but no evidence stated for the breakdown of these conclusions).

None reported.

Nihtilä A, Tuuliainen E, Komulainen K, Nykänen I, Hartikainen S, Tiihonen M, Suominen AL. (2019) [42] - Finland

Non randomised population study with control and intervention

Home care

intervention group, n = 119, Mini-nutritional assessment (MNA) of < 24. Control group, n = 97, MNA < 24.

Nutrition, Oral Health and Medication – NutOrMed – Xerostomia intervention – targeted intervention for patients reporting occasional or continuous dry mouth. Written information about importance of saliva and symptoms and causes of dry mouth. Individual instructions on moistening their mouth, to use xylitol tablets or chewing gum, or dry mouth products. Advice to spread cooking oil on mucosal surfaces. Tailored nutrition intervention based on MNA score and information on plasma albumin level and 24-hour dietary recalls. Nutritionist developed a care plan to increase number of meals, energy and protein intake. Also aimed to increase liquid intake when necessary. Main goal is to correct dietary insufficiencies and make food substitutions. Patients also received written information on increasing energy and protein, good sources of protein and calcium, and good nutrition for older adults. Instructions given to participants and / or caregiver or home care nurse.

Participants given baseline examination and interview. Then six months later, data collection was repeated. Caregiver or nurse was interviewed if client was not able to reply to the interview questions to cognitive impairment.

Xerostomia (single item question – does your mouth feel dry – ‘no’, ‘occasionally’, continuously’), problems biting, problems swallowing, malnutrition or risk of malnutrition (measured using MNA < 24). Daily eating and drinking, measured as < 3 warm meals, < 2 portions of fruits or vegetables, <=5 glasses of liquids.

Restructured control and intervention groups to combine control with nutrition only intervention group – comparing xerostomia and nutrition intervention group (n = 66) with intervention (n = 138).

Feeling of dry mouth decreased by 30.3% in xerostomia intervention group vs increase of 8.7% in no xerostomia intervention group. Also reported larger decrease in malnutrition or risk of malnutrition for this group. Comparisons. Decrease in xerostomia in those suffering from occasional xerostomia was 27.3%. Drinking more than 5 glasses per day increased by 19.1% and eating three or more warm meals increased by 8.1%..

None reported.

Tuulainen, E., Nihtila, A., Komulainen, K., Nyaken, I., Hartikainen, S., Tiihonen, M., Suominen, A.L. (2020) [43] – Finland

Non randomised population study with control and intervention

Home care

231 home care clients. 75% female. 89% classified as “frail”.

Nutrition, Oral Health and Medication – NutOrMed – A nutrition intervention and an individually targeted oral health-related preventive intervention was carried out according to individual needs of the participants in the intervention group. This intervention was composed of written and oral instructions about denture hygiene, dental hygiene and cleaning of the oral mucosa, which were given to the participant or to the caregiver or nurse.

Compared control vs intervention, and “frail” vs “non frail” within these two groups. Baseline and six-month follow-up.

Oral cleaning (toothbrushing and denture cleaning frequency) and clinically determined oral hygiene (occurrence of plaque) and health (number of teeth, presence of dentures, decayed teeth and bleeding on probing)

Compared intervention outcomes for frail and non-frail participants using chi square and Mann Whitney U analyses. Multivariate logistic regression analyses to examine association between being frail score in oral health measures

A modest positive change (5.6%) in toothbrushing frequency was observed in frail intervention patients, with an 11.1% decrease in control group. Larger benefits for good denture hygiene (16.5% increase) in frail intervention group than in control group (2.3%). Larger increase in denture cleaning for control group (9.3%) than for intervention group (3.1%). Logistic regression: Frail clients had lower odds of toothbrushing and denture cleaning at baseline, higher odds for females and those using large numbers of drugs. At follow-up, frail clients still had lower odds of toothbrushing and denture cleaning, but this was no longer significant. Intervention group had higher odds to brush teeth or clean dentures. For toothbrushing those using higher numbers of drugs and for cleaning dentures those having a higher number of teeth were more likely to clean their teeth or dentures at least twice per day. No significant associations between clients classified as frail at baseline and having plaque in  ≥ 20% of teeth or being edentulous, either at baseline or at follow-up.

None reported.

Wu, S.J., Wang, C.C., Kuo, S.C., Shieh, S.H. and Hwu, Y.J [44]. (2020, Taiwan)

Concurrent triangulation mixed-methods

Home care

25 nurses, 27 nursing assistants, 28 administrators and social workers, working in home & community (80%) or care institutions services (20%)

Oral hygiene education program. One day (8 hour) oral healthcare teaching established by Taiwanese Ministry of health and welfare. Four hours of presentations on relationship between oral health and general health in older adults and preventing oral diseases. One hour presentation on oral care using dental models. One hour of demonstrations of oral hygiene skills. Two hours of ‘teach-back’ technique of oral hygiene skills and a skills test of brushing and flossing.

Pre & post assessment to assess oral hygiene knowledge, attitudes and skills. Three month follow-up survey of practical application. N = 6 participants took part in 8-10 minute phone interview about changes to daily practice since the education.

Oral hygiene knowledge, attitude and skills, changes to practice since receiving the program (quantitative). Practicability of the program to improve long term care services (qualitative)

Pre-post quantitative results analysed using paired t-tests and Cohen’s d effect sizes.

Qualitative data reported as summaries under thematic headings. No detail given on how themes were determined.

Less than one fifth of participants had previously received oral hygiene training. Significant improvements in pre-program and post-program oral health knowledge and attitude (measured on day of education program). Significant increase in use of oral hygiene skills (based on the oral cleaning products used; the sites receiving oral cleaning; and the frequency of performing daily oral cleaning for clients) from pre-program to three months post-program. Qualitative data suggests improvements in: clarifying misconceptions of oral health, improved staff experience (i.e. a positive experience at delivering oral health care) and identifying the importance of oral health care, especially in clients with dysphagia. Revealed a lack of oral health care training prior to the intervention and implications of oral health for other conditions such as aspiration pneumonia.

None reported.