Title: Improving the Oral Health of Older People in Care Homes: a Feasibility Study (TOPIC)
Funder: Department of Health and Social Care

Abstract: Poor oral health is an increasingly common problem for older adults (defined as those over 65 years of age). It impacts on their quality of life, their general health and diet. Access to domiciliary services is difficult and hospital admission for dental problems can be distressing and costly. Income-related inequality in oral health of older adults is a major issue. Therefore, effective prevention of oral diseases is paramount. Four per cent of people aged over 65 and one fifth of those aged over 85 live in care homes. Half of all care homes residents have their own natural teeth but their oral health is much worse than their community living peers (e.g. caries prevalence was 73% vs. 40%). With increasing age, the ability to care for their mouth deteriorates, poly-pharmacy leads to dry mouth, and diets can become rich in sugars. All these factors increase the risk of oral disease and directly impact on comorbidities. Strategies for this population are to prevent disease and reduce pain and co-morbidity. However, a Public Health England survey showed current provision and service to be poor. A Priority Setting Partnership led by a co-PI of this project found that maintaining function, dignity and the fear of losing the ability to look after your own teeth were key issues among older adults. The World Health Organisation has focused on healthy ageing and prioritised the designing of health and long-term care systems that are fit for ageing populations. However, the evidence for interventions on promoting oral health among care home residents is weak, with uncertainty about effect size estimates, recruitment, retention, fidelity and appropriate outcome measures. This makes the design of a full trial problematic at this stage. A recent NICE guideline (NG48) aims to maintain and improve the oral health of care home residents. The aim of this study is to assess the feasibility of promoting oral hygiene and preventing oral diseases in older people in care homes, following the NICE guideline recommendations related to prevention of oral diseases. Work-Stream (WS) 1 will determine whether a pragmatic cluster-randomised controlled trial is feasible. Preventive elements of the NICE guideline (oral health assessment of residents; daily assisted tooth-brushing with 1,500ppm fluoride toothpaste; and a staff training package) will be contrasted to routine practice in eligible dentate residents. WS2 will use semi-structured interviews and focus groups with residents, care home managers and staff to understand the context and explore the intervention’s acceptability and fidelity. WS3 will produce a cost-consequence model that identifies key outcomes relevant to different stakeholders and the potential to reduce these to a core set of indicators. It will also explore issues associated with the valid, reliable and efficient collection and reporting of core indicators. Feasibility study outcome measures will be recruitment, retention, acceptability to residents and treatment fidelity. Potential outcome measures for the definitive trial include: coronal and root caries lesions, dental plaque, quality of life, oral pain and treatment appointments. The research will determine whether the evaluation of the complex intervention (preventive aspects of the NICE guideline for oral health in care homes) is feasible and acceptable. It will also provide valuable information about how best to recruit residents and undertake research in care homes.

Lay abstract: The ageing population is increasing in number. Currently, half of all residents enter care homes with some of their own natural teeth and this proportion is likely to increase. Preventing dental disease for care homes residents is important for their function and quality of life. Good oral health affects the ability to eat and communicate, appearance and self-esteem through, for example, the willingness to smile. It also reduces the need to provide treatment in care homes, which is often difficult and costly. A study exploring the priorities for older people as their needs change and they move into supported accommodation, found that preventing oral disease was considered paramount. A national survey however, found that current prevention practices and services in care homes are poor. There are also large gaps in the scientific literature about how best to prevent oral disease among care home residents. NICE guidelines on the maintenance of oral health in care homes have been published, but we do not know how feasible and effective these recommendations are in practice. As a result, a feasibility study is necessary to inform the design of a larger definitive trial. This study aims to assess the feasibility of an intervention to improve the oral health of older people (defined as those who are sixty-five years or older) in care homes, based on the NICE guideline. Care homes will be randomly divided into two groups: intervention and control. The intervention consists of: • an oral health assessment of residents • daily “support worker assisted” tooth brushing with high concentration fluoride toothpaste • a staff training package on how to improve oral health Three work streams are proposed. The first work stream will assess the feasibility of undertaking the intervention. Eligible residents who have their own natural teeth will be recruited. Baseline assessments will be conducted, using trained dentists to collect clinical information. Other data (e.g. sociodemographic, quality of life) will be collected via questionnaires administered by researchers. Recruitment, retention and the acceptability of the interventions for residents, staff and managers will be determined. After twelve months, the health of the residents’ mouths will be assessed again and the questionnaires administered again and findings will be compared to those at baseline. The second work stream will interview residents, managers and staff to understand the acceptability of the proposed intervention. These interviews will help ensure residents and staff are involved throughout the study and that the impact of the intervention for residents is fully understood. A theoretical framework will be used to understand the factors that facilitate the uptake of the intervention and encourage it to become “normal practice”. The third work stream will explore issues relating to an economic evaluation that presents costs and different outcomes in order to help making decisions. It will identify the outcomes considered important to different stakeholders; determine the possibility of producing a core set of indicators that can support decision making and; explore the issues associated with the collection of data for the core indicator set. The research will determine whether an oral health intervention based on the NICE guideline can be implemented in care homes. It will also provide valuable information about how best to recruit residents and undertake research in care home settings.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: ORAL AND GASTROINTESTINAL