Scenario of Oral Hygiene Care among Institutionalized Elderly in Kedah and

Kelantan, Malaysia

Ruhaya Hasan 1, Wan Muhamad Amir W Ahmad 2, Enny Esdayantey Abd Manab3
Nor Azlida Aleng4, Wan Muhammad Luqman Wan Rosdi5
1,2,3,5
School of Dental Sciences, Health Campus, Universiti Sains Malaysia (USM),
4,
School of Informatics and Applied Mathematics, Universiti Malaysia Terengganu (UMT),
21030 Kuala Terengganu, Terengganu

ABSTRACT

Introduction: Poor oral hygiene is an important matter to be considered,

because it is an initial factor contributing to general oral disease. Many
studies have been done to elderly toward poor oral health status. According
to previous research, there are very limited evidence based studies towards
oral hygiene among institutionalized elderly. The importance of oral
hygiene among elderly has been frequently described especially in relation
to medical illness. Based on this information, this study is intended to
implement oral hygiene intervention among the institutionalized elderly in
order to rectify oral health problems among the elderly living in institution
homes in Malaysia. The aimed of the study is to perceive an oral hygiene
status among elderly living in the public institution homes (Rumah Seri
Kenangan, RSK) in Kelantan and Kedah. Methods: A community trial
study was conducted in two RSKs which randomly allocated to
intervention and control group. Elderly residents were enrolled and
underwent oral hygiene assessment at baseline, and follow up visits after 3
and 6 months. Results: The results indicated that there was significant
difference in denture and dental plaque scores (p <0.001) between
intervention and control group. The mean denture plaque score in
intervention group (RSK Pengkalan Chepa) was lower compared to those
in control group (RSK Bedong). Similarly, the total mean in dental plaque
scores among institutionalized elderly residing in intervention group was
lower than in control group, following six months period of study.
Conclusion: This study clearly shows that at a modest cost, ONE package
(Oral Health Nutritional Education for Elderly) able to exert positive
influence in oral hygiene in elderly residents. This indicated that oral health
intervention is deemed important to maintain healthy status especially
among institutionalized elderly.

Key words: Oral hygiene, health intervention, control group, elderly

residents, plaque score, denture plaque, ONE package.

1. INTRODUCTION

Oral hygiene routine for the elderly in institution setting has a unique and different challenge,
since residents usually depend on assistance by others, who are mostly caregivers. Thus it is
essential to monitor oral hygiene of the institutionalized residents, in order to ensure a high
standard of care coordinated by the responsible workers. Nicol et al.1 reported that an oral
health programme which included theoretical knowledge and practical sessions offered to the
respective care staffs in an institutional home was proven to be able to exert positive effect
towards personal ability to perform oral hygiene procedures among elderly respondents .
Besides practicing proper oral hygiene, older people also need extra help in terms of general
needs including eating2. In most of the institution homes, meals are concentrated to a few
hours in a day, thus elderly usually facing difficulties to complete their meal in full portion.
This may lead to eating incompetence which later resulted in lack of dietary intake and poor
nutritional status3. Mathey et al.4 stated that environmental factors, including quality of food
prepared by staff, is equally important for nutritional health in nursing home resident
population. It was further suggested by Loreflt et al.5 that increasing staff knowledge with
proper guidance in handling the meal preparation may improve nutritional status among this
group of population.

As these matters intervenes each other for the benefit of elderly well being, there is a growing
awareness among the dental professionals regarding the link between nutrition and oral health
status among the elderly6. As highlighted before, there are limited studies to link between oral
hygiene with nutritional status on this type of population. However, earlier suggestions have
been made on the importance of nutrition education programme to be supplemented with oral
hygiene programme among elderly residents 7,8. This evidence fits with our current suggestion
to foresee the effectiveness of health education programme, primarily focusing on oral
hygiene and nutrition education in the elderly care institution. The continuity of advance
research should be aimed on the role of oral care providers in terms of proper advice of oral
hygiene care, especially on how it relates to the nutrition to be applied for this group of
population. This data will be vital in order to enhance oral health and nutritional status for
long term health benefits among the elderly. Numerous international studies have shown poor
oral hygiene among institutionalized elderly, which presented with plaque levels and oral
mucosal lesions. It was reported that mean plaque and gingival indices were relatively high,
suggesting that plaque retention a common problem in elderly people 9,10. It was further
postulated that poor oral hygiene among this group of population caused by inadequate
hygiene practice due to difficulty in mechanically removing plaque due to their diminished
manual dexterity, impaired vision, and chronic illness. In further study done by Arpin et al.11
poor oral health was highly reported among the older people living in the institution
compared to other categories of elderly, which mainly resulted from inadequate oral hygiene
practice.

There were several related studies on oral health status of institutionalized elderly which
specifically confined in Asian population. An oral health survey conducted at elderly
institution Kitakyushu, Japan by Miyazaki et al.12 suggested that plaque indices for both teeth
and dentures of the elderly residents was significantly low, with 68% of total residents
showing visible dental plaque. Meanwhile Gervasio et al.13 noted that poor oral health status
was noted among elderly who live in three institution home in Manila, Philippines and
required special attention.

Another study by Lo et al.14 in Hong Kong also described similar findings, reported that high
mean DMFT scores (23.0) of dentate elderly living in care institution, with almost 41% of
them had calculus over their teeth. These particular results indicated poor oral hygiene was
generally reported in this group of elderly people.

This study discover the implement oral hygiene intervention among the institutionalized
elderly in order to rectify oral health problems among the elderly living in institution homes
in Malaysia. The aimed of the study is to perceive an oral hygiene status among elderly living
in the public institution homes (Rumah Seri Kenangan, RSK) in Kelantan and Kedah that can
be beneficial for all elderly in Malaysia.

2. OBJECTIVE AND SAMPLE SIZE DETERMINATION

The main objective of the study is to compare mean of dental plaque and denture plaque
within intervention group (continuous oral health education) and control group (existing oral
health programme) over a period of 6 months. Using Power and Sample Size Calculations
software by Dupont and Plummer (1990), we calculate the sample size based on the
information, alpha, level = 0.05 , power of study = 0.8, standard deviation = 0.49 and
detect the difference =0.28. The require sample size is 49 per group. After considering
20% dropout, 49 49 0.20 59 is needed for each group. So, the total sample size is
118 patients.

3. MATERIAL AND METHODS

This was a community trial study conducted between 21 th April 2014 and 15th November
2014. It consisted of three phases within a total of six months period of study. Phase One
involved measurement data (oral examination, anthropometry and questionnaires) and a first-
hand health education programme known as the Oral Health Nutrition Education (ONE)
package. After three months, Phase Two (post intervention) consisting of follow up
measurement (oral examination, anthropometry and questionnaire) and a second session of
ONE commenced. Finally, following another three months (total period of study 6 months),
follow-up data measurement was performed in Phase Three (post intervention).

In the intervention group, baseline measurement was conducted among elderly respondents to
obtain basic data prior to the intervention programme during Phase One. Baseline
measurement was of great importance since it was able to recognize the extent of oral hygiene
and nutritional status, as well as allow for further data comparison. Within the same phase,
oral health and nutrition education programme was arranged specifically to the caregivers and
kitchens cooks whom became main targeted group. Meanwhile, caregivers/cooks as well as
elderly in the control group continued with the existing standard of oral health and nutrition
given by Ministry of Health throughout the period of study. Subsequently, Phase Two was
accomplished three months after completion of Phase One. Similarly with the previous phase,
elderly respondents were measured for the specific parameters. The caregivers and cooks
underwent interventional programmes consisting of oral health and nutrition education. The
final phase (Phase Three) was conducted to obtain post-intervention data from the elderly
respondents, three months after the second phase. In the meantime, elderly in the control
group were measured in each Phase Two and Phase Three for data comparison. Rumah Seri
Kenangan (RSK) Pengkalan Chepa, Kelantan was selected as the intervention group, whereas
RSK Bedong was selected as the control group. The intervention group (RSK Pengkalan
Chepa) received a special package of health education known as Oral Health Nutrition
Education, known as the ONE package. Meanwhile, RSK Bedong, which acted as the
control group, received existing health programme by Ministry of Health

4. RESULTS AND DISCUSSION

4.1 Changes in Dental and Denture Plaque Scores in Intervention and Control Group

The mean scores of denture plaque and dental plaque were measured repeatedly among
elderly respondents in intervention and control group (baseline, post 3 months, and post 6
months). These particular changes were compared between respondents in the intervention
group (RSK Pengkalan Chepa) where the caregivers exposed to ONE package whereas
respondents in control group (RSK Bedong) followed the existing programme conducted by
Ministry of Health. The significance level was set at p < 0.05.

4.2 Mean Differences of Plaque Scores Between Baseline, Post 3 Months and Post 6
Months In Intervention and Control Group
In the intervention group, pairwise comparison of mean denture plaque score was statistically
significant (baseline to 6 months), whilst other pairs were found to be non-significant. There
were significant differences in all pairs comparison of mean dental plaque scores following
Bonferroni correction (baseline to 3 months, 3 months to 6 months, baseline to 6 months). It
was apparent in the control group that significant differences were noted in several pairs in
relation to mean denture plaque scores (3 months to 6 months and baseline to 6 months). In
the meantime, significant comparison in mean dental plaque scores within control group was
only reported between baseline to 6 months (Table 4.1(a) and Table 4.1(b) )

Table 4.1(a)The Mean Difference of Plaque Scores in Intervention and Control Group
Intervention (n=87)
Mean score difference t statistics p value
Variables (95% CI) (df)
Denture plaque
Baseline to 3 month -0.06 (-0.15, 0.04) -1.22 (46) 0.69
3 month to 6 month -0.10 (-0.19, -0.14) -2.34 (45) 0.06
Baseline to 6 month -0.16 (-0.26, -0.05) -3.04 (45) 0.01

Dental plaque
Baseline to 3 month -0.09 (-0.15, -0.02) -2.64 (36) 0.03
3 month to 6 month -0.21 (-0.30, -0.11) -4.39 (32) <0.001
Baseline to 6 month -0.31 (-0.21,-0.40) -6.46 (32) <0.001
Multiple paired t test.
Significant difference after Bonferroni correction

Table 4.1(b)The Mean Difference of Plaque Scores in Intervention and Control Group
Control (n=87)
Mean score differences t statistics (df) p value
Variables (95% CI)
Denture plaque
Baseline to 3 month 0.11 (-0.01, 0.23) 1.93 (32) 0.18
3 month to 6 month 0.17 (0.09, 0.26) 4.11 (31) <0.001
Baseline to 6 month 0.28 (0.13,0.42) 3.82 (31) 0.003
Dental plaque
Baseline to 3 month 0.10 (0.01, 0.20) 2.12 (52) 0.12
3 month to 6 month 0.03 (-0.02, 0.07) 1.08 (50) 0.9
Baseline to 6 month 0.13 (0.05, 0.22) 3.22 (50) 0.006
Multiple paired t test.
Significant difference after Bonferroni correction

4.3 Changes In Plaque Scores Within Intervention and Control Group (Time Effect)

The mean plaque scores of respondents in intervention group (received ONE package)
and control group (continued with existing standard by Ministry of Health), were
compared based on different time intervals (baseline to 3 months, 3 months to 6
months, baseline to 6 months). There was a clear tendency towards significance of
denture plaque score in the intervention group (p= 0.05). Meanwhile, mean dental
plaque score within intervention group significantly decreased with time (after 6
months period of study) F (1.66, 64) = 26.86, p < 0.001 ( Table 4.2(a) and Table 4.2(b) ) .
Contrary to the control group, there was a significant increment in mean denture
plaque score from baseline to the end period of study, F (1.51, 62) = 11.11, p value
<0.001. Within the same group, the trend of mean dental plaque score significantly
increased, from baseline to the end 6 month period of study F (1.34, 100) p = 0.009
(Table 4.2(a) and Table 4.2(b)).

Table 4.2(a) The Effect of Time on Plaque Scores Within Intervention and Control Group
Intervention (n=87)
Mean (95% CI) F statistics p value
Variables (df)
Denture plaque score
Baseline to 3 month 2.79 (2.62, 2.97)
3 months to 6 months 5.60 (2,90)a 0.05
Baseline to 6 months 2.74 (2.59, 2.90)
2.63 (2.49, 2.77)
Dental plaque score
Baseline to 3 months 2.76 (2.68, 2.84) 26.86 <0.001
3 months to 6 months 2.66 (2.57, 2.75) (1.66,64)b
Baseline to 6 months 2.46 (2.37, 2.54)
Repeated measure ANOVA.
a
Mauchlys test not significant (p>0.05), assumption of sphericity was assumed.
b
Mauchlys test significant (p<0.05), assumption of sphericity violated. Greenhouse-
geisser correction was used

Table 4.2(b) The Effect of Time on Plaque Scores Within Intervention and Control
Control (n=87)
Mean (95% CI) F statistics p value
Variables (df)
Denture plaque score
Baseline to 3 month 2.90 (2.75, 3.05) 11.11 <0.001
3 months to 6 months 3.00 (2.90, 3.11) (1.51, 62)b
Baseline to 6 months 3.18 (3.08, 3.27)
Dental plaque score
Baseline to 3 months 2.68 (2.57, 2.79) 6.24 0.009
3 months to 6 months 2.79 (2.70, 2.90) (1.34, 100)b
Baseline to 6 months 2.81 (2.75, 2.87)
Repeated measure ANOVA.
a
Mauchlys test not significant (p>0.05), assumption of sphericity was assumed.
b
Mauchlys test significant (p<0.05), assumption of sphericity violated. Greenhouse-
geisser correction was used
 (a) (b)

Figure 4.2(a) and (b) Dental plaque score changes within the intervention group

(a) (b)

Figure 4.3(a) and (b) Dental plaque score changes within the control group

4.4 EFFECTIVENESS OF ONE PACKAGE

4.4.1 Effectiveness of ONE package between intervention and control group

The effectiveness of this programme on intervention group (RSK Pengkalan Chepa) was
evaluated after 6 months period of study. Post 6 months assessment was considered suitable
since it had more stable effect compared to 3 months period of study.

Oral hygiene plaque scores

The results indicated that there was significant difference in denture and dental plaque scores
(p <0.001) between intervention and control group. The mean denture plaque score in
intervention group (RSK Pengkalan Chepa) was lower compared to those in control group
(RSK Bedong). Similarly, the total mean in dental plaque scores among institutionalized
elderly residing in intervention group was lower than in control group, following six months
period of study (Table 4.3).
 Table 4.3. Comparison of Effectiveness of Programme between Intervention and Control Group
Variables Group of study Mean difference t p value
Intervention Control (n=87) (95% CI) statistics(df)
(n=87)
Mean (SD) Mean (SD)
Oral hygiene score
Denture plaque 2.63 (0.47) 3.18 (0.26) -0.54 -5.92 (76) <0.001
score (-0.72, -0.36)
Dental plaque 2.45 (0.23) 2.81 (0.21) -0.36 -7.21 (82) <0.001
score (-0.45, -0.26)

Figure 4.4: Plaque Scores Changes Between Intervention and Control Group

5. CONCLUSION

The results indicated that there was significant difference in denture and dental plaque scores (p
<0.001) between intervention and control group. The mean denture plaque score in intervention
group (RSK Pengkalan Chepa) was lower compared to those in control group (RSK Bedong).
Similarly, the total mean in dental plaque scores among institutionalized elderly residing in
intervention group was lower than in control group, following six months period of study (Table
4.3). It may be concluded that following the implementation of ONE package, the mean denture
plaque and dental plaque within the intervention group statistically decreased with time. Analysis
on group comparison indicated significant improvement in mean denture and dental plaque scores
in the intervention group as compared to the control group. Finally, based on the analysis of
effectiveness of ONE package, better performance in plaque scores and dietary intakes was noted
in intervention group,
6. REFERENCES

[1] Nicol, R., Petrina Sweeney, M., McHugh, S., & Bagg, J. (2005). Effectiveness of health
care worker training on the oral health of elderly residents of nursing
homes. Community Dentistry and Oral Epidemiology, 33(2), 115-124.

[2] Weening-Verbree, L., Huisman-de Waal, G., van Dusseldorp, L., van Achterberg, T. &
Schoonhoven, L. (2012). Oral health care in older people in long term care facilities: A
systematic review of implementation strategies. International Journal of Nursing
Studies, 50(4), 569-582.

[3] Beck, A. & Ovesen, L. (2004). The effect of diet modification on dietary intake, and body
weight of elderly nursing home residents formerly receiving chopped or blended diets. A
pilot trial. Foodservice Research International, 14(4), 211-219.

[4] Mathey, M.-F. o. A., Siebelink, E., de Graaf, C. & Van Staveren, W. A. (2001). Flavor
enhancement of food improves dietary intake and nutritional status of elderly nursing
home residents. The Journals of Gerontology Series A: Biological Sciences and Medical
Sciences, 56(4), M200-M205.

[5] Loreflt, B., Andersson, A., Wirhn, A.-B. & Wilhelmsson, S. (2011). Nutritional status
and health care costs for the elderly living in municipal residential homesan
intervention study. The Journal of Nutrition, Health & Aging, 15(2), 92-97.

[6] Peterson, P. E. & Yamamoto, T. (2005). Improving the oral health of older people: the
approach of the WHO Global Oral Health Programme. Community Dentistry and Oral
Epidemiology, 33(2), 81-92.

[7] Langan, M. J., & Yearick, E. S. (1976). The effects of improved oral hygiene on taste
perception and nutrition of the elderly. Journal of gerontology, 31(4), 413-418.

[8] Loreflt, B., & Wilhelmsson, S. (2012). A multifaceted intervention model can give a
lasting improvement of older peoples nutritional status. The journal of nutrition, health
& aging, 16(4), 378-382.

[9] Steele, J., Sheiham, A., Marcenes, W. & Walls, A. (1998). National diet and nutrition
survey: people aged 65 years and over. Volume 2: Report of the oral health survey,
Department of Health London, United Kingdom.

[10] Simons, D., Kidd, E. & Beighton, D. (1999). Oral health of elderly occupants in
residential homes. The Lancet, 353(9166), 1761.

[11] Arpin, S., Brodeur, J. M. & Corbeil, P. (2008). Dental caries, problems perceived and use
of services among institutionalized elderly in 3 regions of Quebec, Canada. Journal of
the Canadian Dental Association, 74(9), 807-807d.
[12] Miyazaki, H., Shirahama, R., Ohtani, I., Shimada, N. & Takehara, T. (1992). Oral health
conditions and denture treatment needs in institutionalized elderly people in Japan.
Community Dentistry and Oral Epidemiology, 20(5), 297-301.

[13] Gervasio, N., Escoto, E. & Chan, W. (1997). Oral health status of institutionalized
geriatric residents in Metro Manila. The Journal of the Philippine Dental Association,
50(1), 4-23.

[14] Lo, E., Luo, Y. & Dyson, J. E. (2004). Oral health status of institutionalised elderly in
Hong. Community Dental Health, 21(3), 224-226.