Nakamura et al.

Int Chin J Dent 2005; 5: 53-60.

Items used to assess oral health in care-dependent persons andchanges in oral condition after care intervention
Yasushi Nakamura, DDS,a Rika Kanaoka, DDS, PhD,b Yoshihisa Yamabe, DDS, PhD,band Hiroyuki Fujii, DDS, PhDbab

Graduate School of Biomedical Sciences, Nagasaki University, and Division of Removable
Prosthodontics and Management of Oral Function, Department of Development and Reconstructive
Medicine, Course of Medical and Dental Sciences, Graduate School of Biomedical Sciences, Nagasaki
University, Nagasaki, Japan

Purpose: The purpose of the present study was to provide a reference for the selection of assessment items
useful in examining changes in intra-oral condition and oral function before and after care intervention.
Materials and Methods: The subjects were 90 care-dependent individuals living in 17 facilities for the elderly.
Each individual was examined by a dentist and assessed on a total of 32 items, and a care plan was prepared on
the basis of this information. Professional care was provided twice a month for a continuous period of fourmonths. The findings after care intervention were categorized as improved, unchanged, worsened or obscure.
Results: A significant improvement was observed in 12 items related to intra-oral condition (nine items related
to oral hygiene status and three items related to denture handling and occlusion) and nine items related to oral
function (p<0.05 in all cases).
Conclusion: These results suggest that oral care intervention would exert an effect on intra-oral condition andoral function in care-dependent persons and underlines the appropriateness and usefulness of care in this subject
group. Results obtained in this study offer an incentive for care-dependent persons and caregivers and thus canserve as a useful index on the frontlines of care. (Int Chin J Dent 2005; 5: 53-60.)
Key Words: assessment item, care-dependent person, intra-oral condition, oral function, oral health care.

Introduction
Normalization1 and community-based rehabilitation2 are gaining wide acceptance as social measures forcare-dependent individuals living in facilities for the elderly and infirm, and oral cleaning, dysphagia
rehabilitation and other forms of oral health care are considered to contribute to the quality of life (QOL) of
care-dependent individuals.3,4
In view of these contemporary trends, efforts to maintain oral health and to ensure that individuals use theirmouths and teeth to ingest food right to the end of their lives are important, not only in terms of nutrition, butalso in terms of human dignity.5 These efforts therefore constitute an essential duty of the dentist.
The first author, through home-visit dental treatment and dental health care activities, experienced cases inwhich oral health care intervention produced obvious results and other cases in which it was difficult todetermine the actual effectiveness. A number of oral health assessment charts are available in Japan at present,6
but no assessment chart has been established to address the specific characteristics of care-dependent individuals
or to provide an appropriate care menu responding to these characteristics. This situation jeopardizes both theselection of assessment items on the front lines of health care and the objectivity of the care menu prepared on
the basis of the information thus obtained. It also obscures the evaluation of care results.
The purpose of the present study was to collect and analyze the practical data from oral health care conductedunder control,7 with the aim of providing a reference for the selection of assessment items useful in determining
intra-oral status, oral function and the effects of oral health care in care-dependent individuals.

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Int Chin J Dent 2005; 5: 53-60.

Materials and Methods
The subjects of the present study were 90 care-dependent individuals (34 males and 56 females ranging in age
from 43 to 95 years; mean=82 years) living in 17 facilities for the elderly participating in the Oral Health Care
Project for Institutionalized Elderly conducted by Nagasaki Prefecture, Japan, in 1999 and 2000 to promote thenormalization and community-based rehabilitation of care-dependent persons. They were suffered from dental
and feeding problems related to oral health care and thus selected as examinee by caregivers in his or her facility.
And these 17 facilities could accommodate 1,480 individuals. Prior to the start of research, informed consent
was obtained from each person or his/her next of kin. All of the individuals were in either the chronic ormaintenance stage of the impairments that impelled them to enter the facility (Fig. 1). The subjects did notinclude any patients in the acute stage of diseases such as cerebral apoplexy.

Dem

41

CVA

40

40

19

Hyp
Obs

17

HD

15

PD

35
29

6

DM

5

TKJD

4

RD

4

MT

3

CSH

3

Dep

No. of subjects

9

Fra

22

3

0

3
0

20

0~20
10

20

30

21~60

61~90

91~99

1
100

40

Barthel Index in score

No. of individuals

12
Fig. 1. Distribution of the cause of impairment in bedridden patients. Illnesses suffered by three ormore individuals were extracted. The number of individuals overlaps in some cases. The
abbreviations are: Dem, Dementia; CVA, Cerebro-vascular accident; Hyp, Hypertension; Obs,
Obscure; HD, Heart disease; PD, Parkinson’s disease; Fra, Fracture; DM, Diabetes mellitus; TKJD,
Transformed knee-joint disease; RD, Respiration disease; MT, Malignant tumor; CSH, Chronic
subdural hematoma; and Dep, Depression.
Fig. 2. Characteristics of subjects in Barthel Index: 0-20, total dependence; 21-60, severe
dependence; 61-90, moderate dependence; 91-99, slight dependence; and 100, independence.
Table 1. Road map of oral health care intervention.
1. Evaluation of intra-oral conditions (18 items) and oral functions (14 items)
2. Making a report on supportive items of oral health care
3. Making a plan for oral health care (primary plan)
4. Holding a care conference by care team for each case
Amendment and confirmation of the plan for oral health care (final plan)
5. Daily oral health care by caregivers
6. Confirmation and guidance on oral heath care methods once a monthProfessional oral health care by dental hygienist twice a month
7. Four-months-later, reevaluation of the intra-oral conditions and oral functions(on the same items at the first evaluation)
This road map was made with reference to literatures 9 and 10. Care team consisted of a dentist, oral hygienist and caregivers(nurse, physical therapist, occupational therapist, speech therapist, certified care worker, etc.). A doctor and a user's family also
participate if needed.

The characteristics of activity of daily living (ADL) assessed by the Barthel Index8 are presented in Fig. 2. The
oral health care intervention procedure adopted in the present study is summarized in Table 1. This procedure

54

Nakamura et al.

Int Chin J Dent 2005; 5: 53-60.

was similar in certain respects to the procedures described in the other papers.5,7,9 To begin, the dentist in charge
examined each individual and assessed 18 items related to intra-oral condition and 14 related to oral function(Table 2).
Table 2. Assessment items.
Intra-oral Conditions
Oral Cleaning Condition (OCC)
Gingival Swelling (GSw)
Gingival Bleeding (GBl)
Dental Calculus (DCa)
Tongue Plaque (TPl)Halitosis (Hal)Dry Mouth (DMo)Independence for Brushing (IBr)Independence for Mouth Rinsing (IMR)
Independence for Denture Cleaning (IDC)
Oral Mucousal Disease (OMD)
Existing Dentition (EDe)
Denture’s Concerns
With or Without Denture (WWD)
Frequency of Denture’s Usage (FDU)
Independence for Denture’s Insertion and Removal (IDIR)
Independence for Denture’s Management (IDM)
Denture’s Stability (DSt)
Occlusion (Occl)

Oral Functions
Mouth Opening (MOp)
Ptyalism (Pty)
Mouth Rinsing (MRi)
Mastication (Mas)
Oral Sign in dysphasia (OSi)Tongue Movement (TMo)Oral Regurgitation (ORe)Nasal Regurgitation (NRe)
Swallowing at pharyngeal stage (Swa)
Cough (Cou)
Hawking (Haw)
Articulation (Art)
Utterance (Utt)Hoarseness (Hoa)

Since a ranking scale was adopted for all items, the dentists in charge held prior consultations to determine
and unify the evaluative standards. On the basis of the data thus obtained, the dentists in charge selected theitems deemed necessary to support the oral health care in each individual from a list-table5 and then completed areport using these items (Fig. 3).
Next, while referring to the reports on care plan formulation,5,10 we selected the problems related to caremanagement noted at the time of initial evaluation and drew up a preliminary plan for oral health care including
a detailed list of goals and care items for each care-dependent individual (Fig. 4). Subsequently, the preliminaryplan was discussed in a care conference attended by dentists, dental nurses and caregivers in the respective
institutions and modified when necessary. Finally, the caregivers implemented oral health care every day
according to the final plan reached on the basis of these preparations. And professional oral health care (POHC)
by dental hygienist had given twice a month for four months. The findings recorded after care intervention werecategorized as improved, unchanged, worsened or obscure.
The changes in oral conditions before and after care intervention were analyzed by the sign test, using thetwo-tailed test with an alpha level of 0.05.

Results
The subjects of the present study were people who had been admitted to facilities with some illness that
impaired daily life functions. These underlying illnesses included dementia, cerebro-vascular accident (CVA),
hypertension, heart disease and Parkinson’s disease (Fig. 1).
The characteristics of their ADL (Barthel Index8) were summarized in Fig. 2 on a basis of classification
modified by Shar et al.11 The 64 subjects (71%) were total or severe dependent individuals, the median of the55Nakamura et al.

Int Chin J Dent 2005; 5: 53-60.

Barthel Index were 40 (mean=43.5).

And supportive items in present oral health care and number ofcare-dependent individuals by each item were summarized in Table 3.
A list on supportive items of oral health care
Medical examination;2000 year

2 month

6 day

User ’s name; S. H.
Sex;

male

femaleBirth date;

1923 year

Supportive items

1 month

25 day (age 77)

Necessity of intervention

Intra -oral Conditions
1. Halitosis
2. Dry mouth
3. Gingival bleeding
4. Tooth mobility
5. Dental caries

yes
yes
yes
yes
yes

no
no
no
no
no

Oral Functions
6. Utterance
7. Articulation
8. Ingestion
9. Mastication
10. Mouth Rinsing
11. Swallowing
12. Mouth opening
13. Tongue movement
14. Lip seal
15. Nasopharyngeal closure

yes
yes
yes
yes
yes
yes
yes
yes
yes
yes

no
no
no
no
no
no
no
no
no
no

Denture16. Insertion and Removal
17. Construction
18. Repair
19. Adjustment
20. Cleaning

yes
yes
yes
yes
yes

no
no
no
no
no

Fig. 3.
An example reporton supportive itemsof oral health care.
Dentist reports tousers or his/her
next of kin thatproblems wereconfirmed asindicated above
and thatappropriate support
for oral health care
will be provided.
name; S.H. age; 77goal of oral caredisease or impairment

1. improvement ofdysphagia
2. improvement oforal hygiene status(1) CVA(2) DM(3) dementia(4) ataxia in right handproblems

user’s goal

dysphagia
ptyalismcoughhoarsenesswants to be better

articulation disability Practices exercise

caregiverdental chart

primary; 2000y.2m.6d.
final; 2000y.2m.16d.

15nurse; Sakamoto, K
ST; Mizumoto, D

17~11,21~27
47~41,31~37
periodontitis

bydentist; Nakamura, Y.
hygienist; Jojima, H.

when

where

ADL
score

details of care

supportive item

every day living room exercise of swallowing
before eating
lip seal
every day living room lip seal exercise, lip icing
nasopharyngeal closure every day living room thermal stimulation

articulation training

2/weekconfirmation andguidance on care

1/monthevaluation

How (contents of intervention) who

training of swallowing

nurse or family

improved

nurse
nurse

improvedunchanged

speech therapist unchanged

treatment
room
Treatmentroomphonation of“pa”, “ta”, “ka”, “la”
tongue maneuver
conference by care teamTreatment
room

professional oral hygiene care dental hygienist improved
functional training of dysphagia

poor oral cleaning

accepts professional POHC
oral health care
(POHC)

2/monthgingival swelling

independence of
tooth brushing

every day lavatory

encourage
announce

sex; maleannounce and encourage
brushing by care giver

dentistnurse
familyimproved

Fig. 4. An example of plan for oral health care. Terms described in a format beforehand were printed
by bold type. Italic descriptions were written by the dentist and/or dental hygienist in charge.

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Nakamura et al.
Table 3.

Int Chin J Dent 2005; 5: 53-60.

Supportive items of oral health care, and number of care-dependent individuals taken
corresponding intervention.

Supportive items

Contents of intervention

Number of individuals

Intra-oral Conditions
1. Halitosis
2. Dry mouth
3. Gingival bleeding
4. Tooth mobility
5. Dental caries

Oral cleaning, Tongue cleaning, Periodontal treatment, etc.
Fluid intake, Artificial saliva, Oral moisture jell, Functional oral health care, etc.
Oral cleaning, Periodontal treatment, Scaling, etc.
Periodontal treatment, Teeth fixed, Occlusal adjustment, etc.
Dental caries treatment.

59
15
44
19
53

Oral Functions
6. Mouth opening
Mouth opening exercise, etc.
7. Lip sea1
Lip seal exercise, Lip icing, Lip massage, etc.
8. Ingestion
Lip seal exercise, Tongue maneuvers, etc.
9. Mouth rinsing
Lip seal exercise, Pushing exercise, Soft blowing exercise, etc.
10. Mastication
Mastication exercise, Denture's treatment, etc.
11. Tongue maneuvers
Tongue protrusion, Tongue ROM exercise, etc.
12. Nasopharyngeal closure Soft blowing exercise, Thermal stimulation, etc.
13. Swallowing
Thermal stimulation, Mendelsohn maneuver, Supraglottic swa11ow, etc.
14. Articulation
Lip seal exercise, Tongue maneuvers, Phonation of "pa" "ta" "ka" "la", etc.
15. Utterance
Pushing exercise, Respiration exercise, Soft blowing exercise, etc.

12
28
36
23
40
31
17
26
35
31

Denture16. Insertion and Removal
17. Construction
18. Repair
19. Adjustment
20. Cleaning

26
25
17
21
49

ROM, Range of motion.

Among the oral conditions, the results on oral hygiene status after care intervention are shown in Fig. 5. The
highest level of improvement was observed in oral cleaning condition (54%), followed by tongue plaque,halitosis, gingival swelling and gingival bleeding. A statistically significant improvement was observed in nineout of 11 assessment items in this category (p<0.05). When the number of examinees [n] (shown in the column
on the left side of Fig. 5), excluding the individuals found to have been in an optimal state at the first assessment,
is presented as a common denominator of the rate of improvement expected to rise, and it is possible that theindividuals found to be “unchanged” included those who maintained an optimal status as a result of careintervention.

Fig. 5.
Changes in oral hygiene status after
intervention. Horizontal axis,changes after intervention (%).
Figures on bar show the number of
examinees. [n], The number of
examinees in which positive effects
were expected. Abbreviations aredescribed in Table 2. *p<0.05. No
p-value was obtained in the case of
number of examinees was less than
six.

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Int Chin J Dent 2005; 5: 53-60.

Among the oral conditions, the results on denture handling and occlusion after care intervention are shown in
Fig. 6. A statistically significant improvement was observed in three items: denture’s stability, independence for
insertion and removal of denture, and occlusion (p<0.05).
The changes in oral functions after care intervention are shown in Fig. 7. Since few of the examinees were
expected to show positive effects of intervention, the rate of improvement was lower than that observed in oral
hygiene status (Fig. 5), but the number of cases of worsening was low and a significant improvement wasobserved in nine items including oral sign in dysphasia after care intervention (p<0.05).

Fig. 6.
Changes in denture wearing andocclusion after intervention.
Horizontal axis, changes after
intervention (%). Figures on bar
show the number of examinees. [n],The number of examinees in which
positive effects were expected.
Abbreviations are described in Table
2. *p<0.05.

Fig. 7.
Changes in oral functions after
intervention. Horizontal axis, changes
after intervention (%). Figures on bar
show the number of examinees. [n],The number of examinees in which
positive effects were expected.
Abbreviations are described in Table
2. *p<0.05.

Discussion
In studies on cerebral apoplexy patients, it was reported that very few subjects with a Barthel index of 40 or
lower showed independence in feeding, continence, grooming or other functions and that these subjects weretotally or partially dependent on care-givers for assistance in moving about.12
The characteristics of the subjects in the present study (Figs. 1 and 2) did not differ significantly from those in
the other reports suggesting that the characteristics of patients in facilities are more or less consistent throughout
Japan.12,13
With regard to oral conditions and general health, current studies suggest that changes in oral conditions could
exert an influence on food choice behavior,14 nutrition,15 physical and mental activity,16 and ADL and QOL.17 It

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Int Chin J Dent 2005; 5: 53-60.

has also been reported that oral cleaning contributes to the prevention of aspiration pneumonia.18 Furthermore, it
has been proposed that professional oral health care (POHC) combining dysphagia functional training conducted
once every one or two weeks for a period of about six months can be expected to bring about an improvement inoral hygiene status.3
The concepts and methods of the oral health care administered in the present study share many common
points with the above reports. These can be summarized as follows: 1) emphasis on oral health care andfunctional oral rehabilitation7 centering around oral cleaning and dysphagia rehabilitation, 2) implementation ofa controlled oral health care management system,5,7 3) POHC administered twice a month for a continuous
period of four months, 4) assessment of oral function as well as oral condition, 5) evaluation of results bycomparing conditions before and after the administration of care in a specific group of subjects.
In the present study, after the oral health care administered to individuals in the chronic and maintenance stage,
significant improvement recognized in nine items related to oral hygiene conditions (Fig. 5), three items related
to denture handling and occlusion (Fig. 6), and nine items related to oral functions (Fig. 7). These improvements
are consistent with those reported in other studies.3,19 Thus above results seems to support an appropriatenessand effectiveness of the care administered in our study, which included a combination of oral cleaning anddysphagia rehabilitation or professional oral health care intervention. Moreover, the items showing a significant
improvement are variables that respond rapidly to care intervention and thus provide an index that will be usefulon the front lines of oral health care and inspire both care-dependent individuals and their caregivers.
There were also some items in the present study that remained unchanged after care intervention. However,the 39 cases showing “unchanged” for oral cleaning condition (Fig. 5) are comprised of 16 individuals who
maintained an optimal condition from before to after care intervention and 23 who had a poor condition before
care intervention and showed no improvement thereafter. The same phenomenon occurred in the items related
to denture handling and occlusion (Fig. 6) and oral function (Fig. 7). In other words, there are many cases inwhich “no change” expresses the fact that an optimal condition was maintained (i.e. deterioration prevented)
throughout the period of the present study and thus underlines the effectiveness of the care intervention.
However, there were also items such as utterance and hoarseness in which improvement was lacking (Fig. 7),
pointing to issues that need to be addressed, such as the period and methods of care and the organization of thecare team. Future care intervention should allow for the selection of assessment items and care menus geared to
the needs of specific subject groups, such as the stroke model, dementia model20 and disusing syndrome model.21
The results of the present study reflect the characteristics of the care period, contents of care, and thecare-dependent group.

A long-term investigation is necessary to evaluate the effectiveness of occlusal

improvement and other results of prosthodontic treatment, and further consideration should be paid to theassessment of care-dependent persons in the acute stage and to evaluation of the data thus obtained.

Conclusion
The results of the present study suggest that oral care intervention would exert an effect on intra-oral conditionand oral function in care-dependent persons and underlines the appropriateness and usefulness of care in thissubject group. Moreover the items showing a significant improvement offer an incentive for care-dependent
persons and caregivers and thus can serve as a useful index on the frontlines of care.

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Int Chin J Dent 2005; 5: 53-60.

Acknowledgment
This study was accomplished in part through the Oral Health Care Project for Institutionalized Elderly conducted by
Nagasaki Prefecture, Japan, in 1999 and 2000. We would like to express gratitude to all the persons who provided assistancein this study.

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Reprint request to:
Dr. Rika Kanaoka
Division of Removable Prosthodontics and Management of Oral Function
Graduate School of Biomedical Sciences, Nagasaki University
1-7-1, Sakamoto, Nagasaki 852-8588, Japan
Fax: +81-95-849-7694 E-mail: kanaoka@net.nagasaki-u.ac.jp
Received June 15, 2005. Revised July 4, 2005. Accepted July 5, 2005.
Copyright ©2005 by the Editorial Council of the International Chinese Journal of Dentistry.

60