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New study aims to improve mouth care, reduce disease in older adults

In recent years, research has suggested that pneumonia, the leading cause of infectious death in nursing homes, could be prevented if residents received better daily mouth care. Now, a new UNC study could pinpoint just how significant an effect improved brushing and flossing could have on infection prevention in older adults.
Researchers at the School of Social Work, Department of Family Medicine, Schools of Public Health and Dentistry and the UNC Center for Infectious Diseases are collaborating on the five-year, $2.5 million study, which is being funded by the federal Agency for Healthcare Research and Quality. Fourteen nursing homes in North Carolina are expected to participate in a randomized trial, said School of Social Work Professor Sheryl Zimmerman, who is leading the research study.
The centerpiece of the project is a person-centered training program known as “Mouth Care Without a Battle,” which teaches nurses, direct care workers, and family caregivers how to effectively provide quality mouth care to people who are unable to provide their own care, especially those with physical or cognitive impairments. Zimmerman and her UNC colleagues developed the program and launched it earlier this year.

Sheryl Zimmerman, Ph.D.

The mouth care training program is based on a successful program that UNC researchers developed years ago to address bathing challenges for individuals caring for people with Alzheimer’s disease and related dementias. Today, “Bathing Without a Battle,” is used in nursing homes nationwide.
Mouth care, which has always been a problem, deserves equal attention, said Zimmerman, the School’s Kenan Flagler Bingham Distinguished Professor.
“In some cases, we have found nursing home residents who haven’t had their teeth brushed for years,” she said. “The bottom line is that the majority of people in nursing homes need help with mouth care, but the minority get help. People in assisted living and those living at home need help, too.”
There is evidence that up to 84 percent of residents in nursing homes need assistance with tooth brushing, including denture wearers. Although nursing home staff assist residents with many other needs, such as bathing and feeding, they generally do not offer consistent oral care. One reason for poor care is that some older adults with disabilities or dementia are sometimes resistant to mouth care, and staff are challenged with how to approach residents in a more acceptable way, Zimmerman said.
Without proper and regular tooth brushing and flossing, residents may suffer from painful cavities, gum disease, or worse. “What people need to understand is that mouth care is not grooming,” she explained. “It’s health care. It’s infection control.”
People, especially older adults, can be at risk for pneumonia when bacteria that accumulates on teeth is inhaled. Nationally, there are two million cases of pneumonia in nursing home residents annually—half of which researchers say might be avoided with better mouth care.
UNC researchers think their person-centered approach could be central in reducing pneumonia. Mouth Care Without a Battle, which is available through a series of DVDs, teaches basic mouth care techniques and strategies, including how to brush with a non-foaming cleaning paste or rinse, use an interdental brush and apply fluoride paste. The program also provides techniques to address behavioral challenges.
Last year, a pilot-test of the mouth care program was conducted with three nursing homes and produced promising results. Among other findings, researchers discovered that “as little as eight weeks of mouth care could significantly improve oral hygiene outcomes.” In addition, findings showed that “all measures of gingival and tooth health were also significantly improved overall.” Moreover, researchers noted an improvement in nursing home staff attitudes about mouth care.
Zimmerman said she and her colleagues hope to learn even more with the current project, which is expected to enroll nearly 1,500 nursing home residents. Such a broader sample could help researchers more definitively evaluate the relationship between enhanced mouth care and pneumonia incidence, she said. The study will also examine the program’s potential as a cost-saving intervention. If nursing home staff can provide better mouth care, then perhaps fewer residents will get sick and be hospitalized, Zimmerman explained.
Long-term, researchers hope the mouth care program will prove to be a sustainable approach that can be replicated across the country.
“It takes a long time for change, but we have reasons to believe it’s going to work because we’ve developed this program based on our bathing program that has been widely adopted,” Zimmerman added. “Ultimately, the goal is that we will reduce pneumonia and that personalized mouth care practices will become a standard of care in all nursing homes.”
By Susan White