Oral health care interventions for persons receiving community health- and care services and other prioritized groups. Overview of systematic reviews
Systematic review
|Published
The aim of this project was to summarize research on effects of oral health care interventions for persons receiving community health and care services and other prioritized groups. The Ministry of Health and Care Services commissioned the project as a follow-up of a request decision from the Parliament about dental hygienist competency in the municipalities.
Key message
The aim of this project was to summarize research on effects of oral health care interventions for persons receiving community health and care services and other prioritized groups. The Ministry of Health and Care Services commissioned the project as a follow-up of a request decision from the Parliament about dental hygienist competency in the municipalities.
We summarized results from six systematic reviews about effects of oral health care interventions for older persons in nursing homes, persons with serious mental illness, and persons with developmental disabilities. The evidence is mainly characterized by few and small studies.
The results show that
- Regularly scheduled dental visits and daily supervised tooth brushing for people with intellectual disabilities may decrease plaque in the long term, compared to usual care.
- It is uncertain whether information and supervision, and practice with instruction have an effect on plaque and gingival inflammation in older persons in nursing homes, persons with serious mental illness, or persons with developmental disabilities because we have low or very low confidence in the effect estimates.
- There is limited evidence on the interventions plaque registration, simple treatment, and interaction and organization of care.
- We lack summarized research on effect of interventions on the outcomes oral function, psychosocial function, and use of health care services.
We lack summarized research on oral health interventions for prisoners, persons with drug addiction, and persons in palliative care.
Summary
Background
The dental health service in Norway consists of a public sector that provides dental health services to parts of the population in accordance with the Dental Health Services Act, and a private sector that offers dental health services to the rest of the population. The county municipality shall promote oral health, organize preventive measures for the entire population, and provide a regular and outreach offer of dental health services to given groups in section 1-3 of the Act.
Objective
The aim of the current project was to summarize research about effects of oral health care interventions for persons receiving community health and care services and other prioritized groups. This commission is a follow-up of a request decision from the Parliament about dental hygienist competency in the municipalities.
Method
We searched for summarized research (systematic reviews, health technology assessments [HTA], published from 2015 onwards. We searched systematically in the following databases: CINAHL, Cochrane Database of Systematic Reviews, Embase, Epistemonikos, MEDLINE, Scopus, and websites of HTA organizations. We carried out the searches in May 2020.
Two authors independently screened titles and abstracts selected systematic reviews from full text publications and assessed the risk of bias in the included systematic reviews. One author extracted data form the reviews and another author verified the data extraction. We summarized relevant results in each review in text and tables and used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to assess our confidence in the effect estimates.
Results
We included six systematic reviews that we judged to have a low risk of bias. The reviews included 62 primary studies, of which most were randomized controlled trials. The reviews targeted older persons in nursing homes, persons with severe mental illness, and persons with developmental disabilities. The reviews covered the following outcomes relevant for our report: plaque, gingival inflammation, caries, and quality of life.
Older persons in nursing homes
Three systematic reviews included interventions for older persons in nursing homes. One review investigated the effect of education (information and practice) for residents and personnel to maintain or improve oral health. The review included nine randomized controlled trials with 3253 participants. Another review investigated effects of strategies to motivate residents for oral health care efforts. The review included four studies without control groups, in sum 122 residents in six nursing homes. The strategies could target the physical environment (e.g. mirrors, reminders, ergonomic toothbrushes), instruction to personnel and communication. The third review investigated oral hygiene interventions to prevent pneumonia in older persons in nursing homes. The review included four randomized controlled trials with 3095 participants. The interventions were oral care measures by instruction from professionals such as dentists, dental hygienists, or nurses specialized in oral care.
Summary of results for older persons in nursing homes: Information and practice may have little or no effect on plaque, gingival inflammation or caries in older persons in nursing homes, compared to usual care. We do not know if strategies to motivate residents for oral health care efforts and interventions to reduce pneumonia have an effect on plaque or quality of life because we have very low confidence in the estimates.
Persons with severe mental illness
One systematic review investigated effects of education about oral health (advice and instruction) with or without monitoring for persons with severe mental illness. The review included three randomized controlled trials with 1358 participants diagnosed with schizophrenia. It is uncertain whether advice and instruction have an effect on plaque in persons with severe mental illness because we have very low confidence in the estimates.
Persons with developmental disabilities
Two systematic reviews investigated effects of oral health care interventions for persons with developmental disabilities. One of the reviews included interventions such as use of different types of toothbrush and toothpaste, planning and training of caregivers or persons with developmental disabilities. The review included 19 randomized controlled trials and 15 non-randomized controlled trials with 1795 children and adults with developmental disabilities and 354 caregivers. The participants had varying degrees of developmental disabilities, and most of them lived in a home of their own. The other review included nine studies, four with a control group and five without, with 279 participants with Down syndrome. The participants lived in an institution or at home. The studies investigated effects of various oral health care interventions such as surgical treatment of gingival inflammation, instructions about brushing teeth, and use of mouthwash.
Summary of results for persons with developmental disabilities
Instruction and supervision for care persons may have little or no effect on plaque or gingival inflammation. It is uncertain whether use of a special toothbrush or electrical toothbrush have an effect on plaque or gingival inflammation, compared to a usual toothbrush. Regularly scheduled dental visits and daily supervised tooth brushing for people with intellectual disabilities may decrease plaque in the long term, compared to usual care. The intervention may have little or no effect on gingival inflammation. We do not know if daily tooth brushing carried out by professionals is more effective than once or twice a week, if toothpaste made to reveal plaque is more effective than usual toothpaste, or if individual oral care plans are better than usual care.
Discussion
We included six systematic reviews about oral health care interventions for older persons in nursing homes, persons with severe mental illness, and persons with developmental disabilities. The reviews included 62 primary studies of which 35 were randomized controlled trials.
The systematic reviews lacked information about the outcomes oral function, psychosocial function, and use of health care services. We found limited information about the interventions plaque registration, simple treatment and interaction and organization of care. We did not identify systematic reviews about oral health care for prisoners, persons with drug addiction, and persons in palliative care. The documentation is most comprehensive for the outcomes plaque and gingival inflammation.
The authors of the reviews used the GRADE approach to assess confidence in the effect estimates based on the domains study limitations, directness, consistency, precision, and publication bias. Study limitations and imprecision because of few and small studies led to downgrading for all outcomes. This means that we cannot be certain about the effects of the interventions, and that new studies may change our conclusions.
This report is an overview of systematic reviews. Such an umbrella review can be a good way of getting a broad summary of a research area, but it is important to point out that the method does not give exhaustive knowledge. New studies of oral care interventions may have been published after the search dates in the reviews.
The reviews often had limited information about the interventions and the professions who gave them. Thus, the conclusions may be too general to be useful in practice. The control conditions were often poorly described, and standard care could vary.
Conclusion
We systematically summarized results in systematic reviews about effects of oral health care interventions for older persons and other prioritized groups. The documentation we found is mainly characterized by few and small studies.
It is uncertain whether information, supervision, and practice with instruction have an effect on plaque and gingival inflammation in older persons in nursing homes, persons with serious mental illness, or persons with developmental disabilities. There is limited information about the interventions plaque registration, simple treatment, and interaction and organization of care. We lack information about the outcomes oral function, psychosocial function, and use of health care services. We lack summarized research on oral health interventions for prisoners, persons with drug addiction, and persons in palliative care.
