Improving Uptake of Evidence-Based Oral Care in Long-Term Care

Oral care (OC) received by older adults in long-term care (LTC) has been deemed “deplorable.”¹ Functional and cognitive impairments experienced by older adults in LTC result in reliance on staff to provide or facilitate OC. Even with staff assistance, the quality of OC provided may be affected by older adults who are resistant to care assistance. Poor OC can negatively impact an older adult’s quality of life, health status, and medical costs. 

In LTC, a common misconception among staff is that tooth loss is a natural part of aging.^2,3 Today, most adults are expected to maintain their teeth over their lifetime,⁴ though with complex prostheses and bridges requiring meticulous OC.⁵ Uncontrolled diabetes, pneumonia, malnutrition, and weight loss have been linked to poor oral health.⁶ Poor OC leads to chronic oral infections associated with heart and lung disease, as well as stroke¹ and pneumonia, which is the second most common infection in LTC.⁷ There are approximately 2 million cases of LTC-acquired pneumonia per year, which result in death more than any other infection.⁸ Pneumonia correlates with the highest rates of morbidity and mortality in LTC; mortality may reach as high as 55%.^7,9 Pneumonia increases health care costs from $5800 to $20,000 per episode.¹⁰ Of the more than 7 billion Medicare dollars spent on pneumonia annually, 28% was allocated for nursing home residents.⁸ It has been estimated that 21% of documented pneumonia cases in a 2-year span could have been prevented with adequate OC and without resident swallowing difficulties.⁹

A reciprocal link between poor oral health and poorly controlled diabetes exists.^11-13 Additionally, there is a link between frequency of tooth brushing and endothelial dysfunction, which is the first step in atherosclerosis.¹⁴ Loss of 10 or more teeth has been correlated with presence of carotid artery disease.¹⁵ Men with 24 or less teeth and severe periodontitis are at increased risk of cerebral ischemia.^16,17 While these findings are not specific to LTC residents, many such residents have diabetes and comorbid cardiovascular conditions, which may be heightened by poor OC.⁶

Poor OC is associated with oral pain and social isolation. A qualitative study of older adult participants revealed that poor dentition limits food choices and causes minor-to-severe pain.¹⁸ Participants ranked oral health as a core personal and social feature. If the mouth was viewed as “unclean” in the study, this equated to negative self-worth and subsequent social withdrawal.¹⁸

The American Dental Association¹⁹ recommends adults brush their teeth twice a day for 2 minutes. Unfortunately, these recommendations “have largely been ignored” in LTC.⁹ Residents often rely on staff to assist or perform OC due to physical and/or cognitive limitations. Previous research has demonstrated that staff do not comply with OC recommendations or protocols.¹⁹ Reasons for staff noncompliance include high volume resident assignments,²⁰ lack of adequate OC supplies,^21,22 and lack of education or skills to provide optimal OC to residents, especially for those with dementia who express care-resistant behaviors during OC.^2,20

Despite challenges of adhering to OC recommendations, there are known facilitators. Adherence to OC guidelines has improved when (1) support is provided from an OC champion^6,23-25; (2) a focus is provided on enhancing staff awareness of the importance of OC via the use of OC tool kits and OC posters; and (3) staff are provided online access to the protocol.⁶

When evidence-based OC interventions were enacted in previous studies, the demonstrated result was positive resident outcomes, including decreased pneumonia,²⁶ febrile days,²⁶ oral bacterial counts,^27,28 improved protective cough reflexes,²⁹ and cognitive function.^26,30 Currently, there are no studies that evaluate outcomes of an evidence-based OC protocol that includes care-resistant behavior strategies utilizing existing LTC staff.

Known barriers to uptake of evidence-based OC approaches include negative attitudes of staff toward oral health of older adults and OC delivery, fears of harming residents during OC, and lack of knowledge about person-centered approaches to care-resistant behaviors that occur during OC.^2,31,32 

The purpose of this quality improvement project was to implement an evidence-based OC protocol designed to enhance the delivery of routine OC to older adults residing in an LTC facility. This protocol sought to mitigate known barriers to optimal OC through: (1) development and delivery of a 90-minute education session with staff; and (2) designation of an OC champion to promote the protocol. Objectives developed for the project were: (1) assess the impact of staff knowledge, current practices, beliefs, and attitude regarding OC pre- and post-implementation; (2) implement the protocol; (3) evaluate protocol adherence; and (4) solicit staff perceptions of barriers and facilitators to implementation.

Methods

Setting and Participants

A 134-bed, not-for-profit, corporate owned LTC facility in rural, central Pennsylvania was the site for this project. OC provided to residents was deemed inadequate prior to project initiation. Inadequate OC products, (eg, toothettes or swabs, proven as ineffective OC^14,15), were used to provide OC to resistive residents or those prescribed no oral food or fluids. Staff had not received education related to optimal OC delivery or training related to person-centered care approaches to care-resistant behaviors. No champion had been designated to focus on enhancing OC. 

All direct care staff currently employed by the LTC facility were included in the project, including registered nurses, licensed practical nurses, and certified nursing assistants (CNA). The facility employed 150 direct care staff.

Procedures

A total of ten 90-minute education sessions were provided during a mandatory staff in-service in August 2017. During each session, participants received a paper packet that included a numbered OC pre-test. Unique numerical participant identification was documented by the project leader for completion of matched pre- and post-tests.  

Delivery of educational content related to the protocol began after pre-tests were collected. Hard copies of the protocol were provided to each participant. A PowerPoint presentation reviewed the following contents: (1) definition of OC/oral health; (2) complications of poor OC; (3) elements of the protocol; (4) facilitators to OC; (5) barriers to OC; and (6) person-centered approaches to care-resistant behaviors encountered during OC. During the didactic presentation, care-resistant behaviors were defined. Staff were instructed to obtain OC preferences from the resident and/or family. Establishing rapport with approach was encouraged, and approaching at eye level or below in an unhurried manner with a smile to elicit resident cooperation, was presented.

The intervention was led by a nurse practitioner who engaged the LTC facility in partnership around this improvement effort. The facility agreed to designate the assistant director of nursing as OC champion. In her role as OC champion, she served as a resource to staff for questions, clarifications, or assistance with the protocol. She was trained in huddles, which allowed staff to present challenging cases of care-resistant behavior strategies that were implemented and remained ineffective.  

Threat reduction strategies were explained and encouraged to potentially enhance OC completion in residents with care-resistant behaviors. Threat reduction strategies reviewed included judicious touch, priming, gestures/pantomime, cueing, avoiding elderspeak, encouraging self-care, chaining, bridging, distraction, hand-over-hand technique, mirror-mirror technique, and rescuing. Video clips on these strategies created by Dr Rita Jablonski-Jaudon were played for demonstration. Permission to incorporate this video was provided by Dr Jablonski-Jaudon and may be viewed at https://youtu.be/UlDL3YQPDNY. 

Of the 150 direct care staff, 64% (n = 96) participated in the OC pre-test and education. Following 8-weeks of implementation of the protocol, staff were recruited to complete a matched OC post-test prior to a regularly scheduled staff meeting. Participants who did not complete a pre-test were not eligible to complete the post-test. Seventy-three percent (n = 70) of the staff completed the matched post-test after protocol implementation.

Measures

Descriptive and open-ended question methodologies were utilized to measure outcomes in this project. The pre-test measured staff OC knowledge, beliefs, attitude, and self-reported practices (Supplementary Box 1, found at the bottom or in attached PDF).  A matched post-test re-measured staff OC knowledge, beliefs, attitude, and self-reported practices (Supplementary Box 2). OC audits by the project leader at 2, 4, and 6 weeks after implementation measured staff adherence to the protocol. A standardized, structured, observational audit tool was utilized to ensure fidelity. Audits were completed on various days of the week with morning and bedtime care through simple random sampling. 

Data Analysis

Matched t tests were calculated for all OC products by dentition (Table 1). Statistically significant increased use of OC products, pre-determined as P < .05, resulted from each category of resident dentition.

Simple descriptive statistics and content analysis of open-ended questions were utilized to obtain outcomes data and evaluated the effectiveness of the project. Descriptive statistics were computed for basic demographics of participants, OC knowledge, attitude, beliefs, self-care practices, and care audits. Statistical analysis for descriptive statistics were conducted using Microsoft Excel. Open-ended responses regarding OC knowledge along with barriers and facilitators to protocol implementation were analyzed using qualitative methods.

Results

Participants

The majority of the participants (N=70) were CNAs (62.9%), younger than 25 years, and had a high school education (51.4%). More than half of the participants had worked in the facility 5 years or less, and most worked on the day shift. Demographic data on the pre- and post-tests described the participants (Table 2).

Article continues after table.

OC Knowledge

Two pre-test questions measured staff OC knowledge. The first question was structured as an open-ended inquiry of, “At this nursing home, what is the routine for OC?” The second question was a yes/no question that asked if he/she knew of a written OC policy.

At baseline, staff responses to the first question were stratified into one of two categories related to time of OC (n = 46) or type of OC delivered (n = 15). Two of the most frequent responses were related to time of OC: providing morning and evening care (n = 37), followed by twice a day without mention of a specific time (n = 9). 

In post-test comparisons, participants’ answers were stratified into one of three categories: time of OC, type of OC delivered, or combined time and type of care responses. Sixty-four percent (n  = 45) answered with time of OC-related responses. The two most frequent time of OC-related responses were providing morning and evening care (n = 18) followed by twice-a-day care (n = 13). Thirteen percent (n = 9) answered with a type of OC-related response. A new response that incorporated best practice into staff-reported daily OC practices was reported by 14% (n = 10) of participants: twice a day for 2 minutes.  

Quantitative responses for a policy on OC included 76% (n = 53) yes, 10% (n = 7) no, and 14% (n = 10) did not respond. On the post-test, 86% (n = 60) reported that there was a policy while 13% (n = 9) reported there was no policy. Only 1% (n = 1) did not respond on the post-test.  

OC Practices

Self-reported practices were measured by five questions. The first question required participants to indicate how many times per day—ranging from one to five—that they provided OC to residents. The additional four questions required participants to rate—on a visual analog scale (VAS) from 0 to 100—the frequency they utilized specific OC products for residents with varied dentition. Forty-three percent (n = 30) of staff reported that OC should be provided twice a day on the pre-test compared to 75% (n = 51) of staff on the post-test. “Once a day” was the second most frequent response (32.9% on the pre-test vs 18.6% on the post-test).  

Decreased use of toothpaste was reported in residents with dentures on the pre-test (mean = 69, standard deviation [SD] = 43.05, n = 70) as compared to post-test (mean = 52.88, SD = 44.72, n = 70), t(56) = 1.94, P < .03, two-tailed.

OC Beliefs

OC beliefs were measured by four questions (Table 3). VAS from agree to disagree (0 to 100%) was utilized for responses. Participants marked their level of agreement on the scale for each question. Three of the four beliefs had statistically significant improvement from pre- to post-test in matched t tests. 

OC Attitude

OC attitude was measured with one VAS question (Table 3). Responses ranged from dislike/repulsive (0%) to satisfaction (100%), with participants marking their level of agreement on the scale. There was no statistically significant change in staff attitude regarding OC in matched
t test comparisons.

OC Audits

The OC Audit Checklist was utilized during audits at weeks 2, 4, and 6 after protocol implementation. CNAs provided all OC or set-up for residents to provide oral self-care. Twenty-one audits were completed on varied days of the week, including weekend days. No staff were observed utilizing interdentate brushes or lip moisturizer in any audit. Time of care decreased in subsequent audits, ranging from 13.17 minutes to 2.5 minutes, with an average care time of 6.5 minutes. Residents brushed their own teeth an average of 36.5 seconds, while staff brushed the residents’ teeth an average of 40.6 seconds. Eleven residents (52%) did not have brushing by either themselves or staff.

Threat reduction strategies utilized during audits included low voice (n = 9), gesturing (n = 5), pantomiming (n = 1), and chaining (n = 1). Pantomiming with gesture assists with communicating and cueing residents to perform or start OC in a nonthreatening manner. Chaining is a variation of priming in which the OC is initiated by the caregiver and then allows the resident to take over the activity. Threat reduction strategies were successful 33.3% of cases in reducing care-resistant behaviors at the 2-week audit and 54.5% of the time at the 4-week audit. Threat reduction strategies were not observed during the 6-week audits. On two occasions (18.2%), threat reduction strategies were not effective with residents during OC.

Additional audit results are presented in Table 4. Interrater reliability of the audit was performed with the OC champion. All responses were reviewed with no discrepancies noted, with the exception of time of care. This was resolved noting a 2-minute difference in watch settings. Once adjusted and time synchronized, audits were equivalent.

Barriers and Facilitators

The OC post-test measured barriers to implementation through use of a checklist of common barriers. Quantitative response choices included fear of harm, lack of OC supplies, care-resistant behaviors, and lack of support.
Facilitators to implementation were also measured using a post-test checklist. Quantitative response choices included OC champion and huddling. OC champion was the most reported facilitator (70%; n = 49). Huddling was identified as a facilitator by 47% (n = 33) of participants.

Huddling

Frequency and duration of huddling sessions were measured. A log of each huddling session was to be kept by the OC champion, though no huddling sessions were reported completed.  

Discussion 

This project sought to examine the uptake of evidence-based approaches utilized by existing LTC staff when providing OC to LTC residents at a rural facility. There was a 10% increase in staff agreement that an OC policy existed after the intervention. Pre-test responses for OC routine were related to time of OC or type of OC. Post-test responses included time of OC, type of OC, or combined time and type responses. Combined responses aligned with the intent of the protocol to provide OC twice a day with teeth brushing for 2 minutes. In pre-test responses, 43% (n = 30) of staff reported providing OC twice a day, compared with 75% (n = 51) of staff on the post-test. A 32% increase in knowledge of the importance of providing OC twice a day, as evidenced by the introduction of the protocol, was noted.  

Toothpaste and mouthwash were the most utilized supplies. Statistically significant increases in their use for edentulous residents corresponded with the protocol. In residents with dentures, toothpaste was reported to be used for OC, despite education that toothpaste can abrade and damage dentures. This practice continued throughout the study at a consistent rate, but a statistically significant reduction in toothpaste use was reported. A notable detail uncovered during educational sessions was that the facility did not supply denture paste. This was resolved by the OC champion prior to protocol implementation. After resolution, there was a statistically significant decrease in toothpaste with a statistically significant increase in denture paste. There was no statistically significant difference with denture or toothpaste in residents having natural teeth and dentures. This was unexpected and requires additional exploration to determine causation. Statistically significant increases were reported with peroxide mixture and prescription mouthwash not recommended in the protocol. LTC administration reported increased dental referrals unrelated to this intervention that resulted in orders for these products.    

Interdentate brushes were a self-reported practice for all resident dentition types in the pre-test. A statistically significant increase in brush use was reported in residents with natural teeth, despite brushes not being available prior to project implementation. This finding may be the result of a lack in clarity on the survey. No interdentate brushing was observed in audits.  

Pre-test findings (Table 3) revealed over 90% of staff agreed with three of four beliefs. Rates of post-test agreement with three beliefs increased (Table 3). Pre-test findings revealed that 56.58% (SD = 31.20) of staff believed the misconception that “tooth loss is a natural part of aging.” This rate correlated with findings in a previous study reporting mean endorsement of 60.6% (SD = 38.1).² In this project, there was a statistically significant decrease (t(67) = -2.03, P = .02) in belief of this misconception after education.

Staff attitude had no statistically significant difference (t(65) = .46, P = .32) over the course of the intervention. More than 80% of staff reported satisfaction with providing OC. This may be due to social desirability response bias. Previous studies reported that staff view OC as “unpleasant”³² and “repulsive.”³ 

The mean time for OC was 6.5 minutes (SD = 2.12). Average resident teeth brushing was 36.5 seconds compared with 40.6 seconds when staff observed brushing. This was lower than the 2-minute brushing time detailed in the protocol but longer than times reported in the available literature.¹⁹ However, 52% of residents had no teeth brushing, which was lower than previous observations of 84% of residents with no brushing.¹⁹ Only 42.9% of residents had their tongue brushed or examined and mouth rinsed after brushing, which were components of the protocol (Table 4).  There were no observations of interdentate brushes or lip moisturizer used as a result of the intervention. OC self-reported practices are a sharp contrast to actual care provided.¹⁹ Care-resistant behavior strategies were effective 47.1% of the time per OC episode when used during OC and ineffective 11.8% of the time per OC episode. No previous studies were identified that utilized existing staff to compare this type of outcome, so findings were informative.

Solicitation of perceptions of barriers and facilitators to implementation were compiled. Pre-test responses to barriers were consistent with the literature, citing uncertainty in dealing with care-resistant behavior as the primary reason OC is not completed.^2,3,33,34 Post-test responses were also consistent with the literature, citing fears of harm,^2,32 lack of supplies,^2,33 care-resistant behavior, and lack of support as barriers to care.²⁰ Facilitators included the OC protocol, OC champion, and huddling. An OC protocol was a facilitator in previous studies.⁶ OC champions emerged from OC projects in the literature.^6,23-25 Huddling was reported as a facilitator, but no huddling sessions were completed or recorded, per the OC champion. 

Recommendations for implementing this protocol in other LTC facilities are outlined in Table 5. These recommendations may assist with improved uptake of the protocol. They would also address sustainability. If a facility is not familiar with huddling, implementation of this technique for quality improvement prior to OC protocol implementation may enhance success of the implementation. Developing an OC inventory and reviewing the current OC supplies prior to project implementation is also suggested. This would assure that all protocol supplies are readily available for staff and resident use. Breaking down the education to initially focus on threat reduction strategies then later adding the OC protocol may enhance OC success. This would decrease the content introduced to staff in one sitting and may further increase retention. Establishing the OC champion(s) prior to project implementation is essential and should include a staff member with an interest in improving care rather than a member of the administrative team in the facility. CNAs with an interest in OC and work different shifts may be more appropriate champions. This would afford other CNAs ongoing support at all times, shifts, and days. Resident outcomes should also be tracked. This was completed outside of the project by the facility. Sustainability should be the long-term goal of this project. Introducing an OC protocol should result in adoption of the protocol into facility and/or corporate policy for best practice. This should be reviewed annually for evidence-based guideline changes with re-education to staff on the protocol.

Immediate implications of this study include increased staff OC knowledge, a practical and reproducible protocol for improving OC in LTC facilities, and enhancement of infection control not measured in this project. With 1.4 million Americans residing in LTC³⁵ and the incidence of nursing home-acquired pneumonia estimated to be 1 to 3.2 per 1000 patient days with 600,000 emergency department visits,³⁶ the financial impact of improved OC on the health care system is immense.

There were several limitations with this study. The OC champion changed roles during the project and was less available than originally anticipated. Huddling sessions were a new concept for the staff at the onset of the intervention, which may have limited their use. Another limitation was self-reported data. Coleman and Watson³³ noted a contrast with staff self-reported data and OC observations. Self-reported practices did not match with audits completed in this project. Also, the findings from this project are not generalizable, due to a small sample size and implementation in only one facility. A delay in administering matched OC post-tests may have been a final limitation. 

Conclusion

Providing OC education and implementing an evidence-based OC protocol at an LTC facility can increase staff OC knowledge and beliefs. Implementation of the outlined protocol provide a reference of care for all LTC residents, regardless of dentition or dysphagia. Long-term implications may include better resident health and increased quality of life through the use of person-centered techniques. Implementing an evidence-based OC protocol with existing staff after education, along with audits, has the potential to change OC practices in LTC and may result in improved resident quality of life, decreased morbidity and mortality from pneumonia, and significant health care savings. 

References

1. Cohen-Mansfield J, Lipson S. The underdetection of pain of dental etiology in persons with dementia. Am J Alzheimers Dis Other Demen. 2002;17(4):249-253.

2. Jablonski RA, Munro CL, Grap MJ, Schubert CM, Ligon M, Spigelmyer P. Mouth care in nursing homes: knowledge, beliefs, and practices of nursing assistants. Geriatr Nurs. 2009;30(2):99-107.

3. Dharamsi S, Jivani K, Dean C, Wyatt C. Oral care for frail elders: knowledge, attitudes, and practices of long-term care staff. J Dent Educ. 2009;73(5):581-588.

4. US Department of Health and Human Services. Oral health in America: A report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. https://babel.hathitrust.org/cgi/pt?id=mdp.39015050784522;view=1up;seq=5. Accessed August 12, 2019.

5. McNally ME, Matthews DC, Clovis JB, Brillant M, Filiaggi MJ. The oral health of ageing baby boomers: a comparison of adults aged 45-64 and those 65 years and older. Gerodontology. 2014;31(2):123-135.

6. McNally M, Martin-Misener R, McNeil K, et al. Implementing oral care practices and policy into long-term care: the Brushing up on Mouth Care project. J Am Med Dir Assoc. 2015;16(3):200-207.

7. Dhawan N, Pandya N, Khalili M, et al. Predictors of mortality for nursing home-acquired pneumonia: a systematic review. Biomed Res Int. 2015;2015:285983.

8. Zimmerman S, Cohen LW, Scales K, et al. Pneumonia identification using nursing home records. Res in Gerontol Nurs. 2016;9(3):109-114. 

9. Quagliarello V, Ginter S, Han L, Ness PV, Allore H, Tinetti M. Modifiable risk factors for nursing home-acquired pneumonia. Clin Infect Dis. 2005;40(1):1-6.

10. Sjögren P, Wårdh I, Zimmerman M, Almståhl A, Wikström M. Oral care and mortality in older adults with pneumonia in hospitals or nursing homes: systematic review and meta-analysis.
J Am Geriatr Soc. 2016;64(10):2109-2115.

11. Camen GC, Caraivan O, Olteanu M, et al. Inflammatory reaction in chronic periodontopathies in patients with diabetes mellitus. Histological and immunohistochemical study. Rom J Morphol Embryol. 2012;53(1):55-60.

12. Casanova L, Hughes FJ, Preshaw PM. Diabetes and periodontal disease: a two-way relationship.
Br Dent J. 2014;217(8):433-437.

13. Furukawa T, Wakai K, Yamanouchi K, et al. Associations of periodontal damage and tooth loss with atherogenic factors among patients with type 2 diabetes mellitus. Intern Med. 2007;46(17):1359-1364.

14. Kajikawa M, Nakashima A, Maruhashi T, et al. Poor oral health, that is, decreased frequency of tooth brushing, is associated with endothelial dysfunction. Circ J. 2014;78(4):950-954.

15. Desvarieux M, Demmer RT, Rundek T, et al. Relationship between periodontal disease, tooth loss, and carotid artery plaque. Stroke. 2003;34(9):2120-2125.

16. Grau AJ, Becher H, Ziegler CM, et al. Periodontal disease as a risk factor for ischemic stroke. Stroke. 2004;35(2):496-501. 

17. Joshipura KJ, Hung H, Rimm EB, Willett WC, Ascherio A. Periodontal disease, tooth loss, and incidence of ischemic stroke. Stroke. 2003;34(1):47-52.

18. Macentee M, Hole R, Stolar E. The significance of the mouth in old age. Soc Sci Med. 1997;45(9):1449-1458.  

19. Jones AL, Dwyer LL, Bercovitz AR, Strahan GW. The National Nursing Home Survey: 2004 overview. Vital Health Stat 13. 2009;(167):1-155.

20. Hoben M, Hu H, Xiong T, Kent A, Kobagi N, Yoon MN. Barriers and facilitators in providing oral health care to nursing home residents, from the perspective of care aides-a systematic review protocol. Syst Rev. 2016;(5):53.

21. Lev A, Aied AS, Arshed S. The effect of different oral hygiene treatments on the occurrence of ventilator associated pneumonia (VAP) in ventilated patients. J Infect Prev. 2015;16(2):76-81.

22. Boltz M, Capezuti L, Fulmer TT, Zwicker D, Teton Data Systems (Firm), STAT!Ref (Online service). Evidence-Based Geriatric Nursing Protocols for Best Practice. 5th ed. New York, NY: Springer Publishing Company, LLC; 2016. https://ebookcentral.proquest.com/lib/pensu/detail.action?docID=4454388.

23. Bassim CW, Gibson G, Ward T, Paphides BM, DeNucci DJ. Modification of the risk of mortality from pneumonia with oral hygiene care. J Am Geriatr Soc. 2008;56(9):1601-1607.

24. De Visschere L, Schols J, van der Putten GJ, de Baat C, Vanobbergen J. Effect evaluation of a supervised versus non-supervised implementation of an oral health care guideline in nursing homes: a cluster randomised controlled clinical trial. Gerodontology. 2012;29(2):e96-106.

25. Sloane PD, Zimmerman S, Chen X, et al. Effect of a person-centered mouth care intervention on care processes and outcomes in three nursing homes. J Am Geriatr Soc. 2013;61(7):1158-1163.

26. Yoneyama T, Yoshida M, Ohrui T, et al. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc. 2002;50(3):430-433.

27. Adachi M, Ishihara K, Abe S, Okuda K, Ishikawa T. Effect of professional oral health care on the elderly living in nursing homes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002;94(2):191-195.

28. Ishikawa A, Yoneyama T, Hirota K, Miyake Y, Miyatake K. Professional oral health care reduces the number of oropharyngeal bacteria. J Dent Res. 2008;87(6):594-598.

29. Watando A, Ebihara S, Ebihara T, et al. Daily oral care and cough reflex sensitivity in elderly nursing home patients. Chest. 2004;126(4):1066-1070.

30. Ueda K, Toyosato A, Nomura S. A study on the effects of short-, medium- and long-term professional oral care in elderly persons requiring long-term nursing care at a chronic or maintenance stage of illness. Gerodontology. 2003;20(1):50-56. 

31. Jablonski RA, Munro CL, Grap MJ, Elswick RK. The role of biobehavioral, environmental, and social forces on oral health disparities in frail and functionally dependent nursing home elders. Biol Res Nurs. 2005;7(1):75-82.

32. Kullberg E, Forsell M, Wedel P, et al. Dental hygiene education for nursing staff. Geriatr Nurs. 2009;30(5):329-333.

33. Coleman P, Watson NM. Oral care provided by certified nursing assistants in nursing homes. J Am Geriatr Soc. 2006;54(1):138-143.

34. Jablonski RA, Munro CL, Grap MJ, Elswick RK. The role of biobehavioral, environmental, and social forces on oral health disparities in frail and functionally dependent nursing home elders. Biol Res Nurs. 2005;7(1):75-82.

35. Centers for Disease Control & Prevention. National center for health statistics: Nursing home care. www.cdc.gov/nchs/fastats/nursing-home-care.htm. Updated May 3, 2017. Accessed August 12, 2019.

36. Liapikou A, Polverino E, Cilloniz C, et al; Community-Acquired Pneumonia Organization (CAPO) Investigators. A worldwide perspective of nursing home acquired-pneumonia compared to community-acquired pneumonia. Respir Care. 2014;59(7):1078-1085.