Using role-substitution to improve oral health of dependent older people residing in care homes and assisted living settings in the United Kingdom

Abstract
Objectives
To determine whether Dental Therapists and Dental Nurses could reduce plaque levels of dependent older adults residing in care homes and assisted living settings, when compared to ‘treatment as usual’.

Methods
A two-arm pragmatic cluster randomised controlled trial over a six-month period was undertaken based on an a priori assumption of superiority. Forty-eight dependent setting across Wales, North-West England, London and Northern Ireland were recruited. Dependent settings were excluded if they solely focused on end-of-life or palliative care or were already participating in an oral health prevention programme. Residents were excluded if they were below sixty-five years of age or if they were receiving end-of-life or palliative care. Dependent settings were randomised using an adaptive algorithm, which generated the randomisation sequence. After allocation, the Chief Investigator, Principal Investigators and the trial statistician were blinded until the trial was completed and the analysis complete. Due to the nature of the intervention, outcome assessors, those delivering the intervention and the residents were not blinded.

Dental Therapists provided routine dental care according to their Scope of Practice. Dental Nurses administered fluoride varnish, oversaw the use of high-strength fluoride toothpaste and sought to improve the level of day-to-day prevention offered by the formal carers. Current practice formed the control arm. In the United Kingdom this is often ad hoc and relies on dentists, if available, visiting residents presenting with clinical symptoms. The intervention period lasted for six months.

The primary outcome measure was the proportion of residents that demonstrated a 50% reduction in the Silness and Löe plaque index. Secondary outcome measures were the number of new carious lesions (coronal and root caries), bleeding on probing, Oral Impacts on Daily Performances, EuroQol five dimensions questionnaire (quality of life measure), oral symptoms, episodes of pain and episodes of unscheduled care, number of onward referrals to dentists.


Results
Twenty-four dependent settings were allocated to receive the intervention and 24 continued with 'treatment as usual'. 41.7% of the settings were in London, 33.3% were in Wales or the Northwest of England and 25.0% of the settings were in Northern Ireland. One hundred and twenty-two residents were allocated to the control arm and 142 residents in the intervention arm. The mean age was 85 years and 67.2% were female. Levels of cognitive impairment were high in both arms (mean score 13.7 on the Six Item Cognitive Impairment Test). No statistically significant differences were found in the primary or secondary outcome measures at six-months. No differences were apparent in the number of adverse events related to the trial by group.

Conclusions
A six-month intervention using Dental Therapists and Dental Nurses did not produce any measurable improvements in oral health within dependent settings when compared to treatment as usual. High levels of cognitive impairment may have contributed to the lack of any effect seen.