The international literature shows that the proportion of elderly people has increased considerably during the last decades and is expected to further increase during the next decades. This demographic shift will have important implications for health care services. More (frail) elderly people will present more morbidity and care dependency and, consequently, will need an increasing proportion of health care services [1
]. Those elderly people, who are not able to function independently, are often supported by domiciliary care service or admitted to (residential) care homes [2
Advances in oral health care and treatment during the last decades have resulted in a reduced number of edentulous individuals. A still increasing number of dentate elderly people have tooth wear, periodontal disease, oral implants, and sophisticated tooth- and implant-supported restorations and prostheses. Hence, they are in need of both preventive and curative oral health care continuously. Complexity of the oral conditions, oral mucosal lesions, systemic diseases, and medication use make (frail) elderly people more vulnerable to oral problems than younger age groups, especially when they are cognitively impaired [4
]. Weakened oral health due to neglect of self care and professional care and due to reduced oral health care utilization is already present when (cognitively impaired) elderly people are still community-dwelling [5
]. At the moment of (residential) care home admittance, many elderly people in countries all over the world are in need of oral health care urgently. If their needs are not met, their oral health will be persistently poor and will utmost probably further deteriorate during their residency because of increasing care dependency and subsequent lack of adequate oral health care [9
Systemic diseases affect oral health and vice versa [15
]. Several medications have also a negative effect on oral health by inducing xerostomia, hyposalivation, mucosal lesions, and abnormal bleeding [17
]. Hyposalivation is a specific problem because saliva plays a major role in protecting both hard and soft oral tissues [18
]. Furthermore, several aspects of oral health are affecting quality of life and well-being [19
]. Oral health influences mastication, food selection, weight, speech, taste, hydration, appearance, and psycho-social behaviour and is thereby a concern not only for the elderly individuals themselves, but also for their relatives and care providers [22
The key factor in realizing and maintaining good oral health is daily oral hygiene care by removing the oral bacterial plaque, mainly composed of pathogenic gram-negative germs [26
]. However, many residents of residential care homes and long-term care facilities are not able to clean their mouths and eventually removable dentures themselves. For proper daily oral hygiene care, they are dependent on nurses and nurse aides [28
]. However, the importance of oral health of residents is often misunderstood and neglected by nurses and nurse aides [30
]. A lack of oral health knowledge and oral health care skills of even qualified nurses is an important inhibiting factor in achieving an acceptable level of residents' oral hygiene [31
]. No prioritisation to oral health care of the residents themselves and their family is another barrier of proper oral health and daily oral hygiene care [32
]. Furthermore, in many cases a resident's repeated resistiveness is disincentive for nurses and nurse aides, leading to inadequate daily oral hygiene care [34
]. Teaching and qualifying nurses and nurse aides in providing individual oral health care for residents had until recently a low priority in managers and physicians of residential care homes and long-term care facilities [35
]. Convincing the managers and physicians of the benefits of oral health and adequate oral health care as well as improving the oral health knowledge and oral health care attitude and skills of nurses and nurse aides may contribute to an improvement of oral health and quality of life of residents. Although during the last several years increasing attention has been paid to improving oral health care, there is still a need for guidelines and effective protocols, for oral health and oral hygiene assessment tools for nurses and nurse aides, and for teaching nurses and nurse aides practical skills of daily oral hygiene care [37
]. In 2007, the Dutch guideline "Oral health care in (residential) care homes for elderly people"
was developed and presented to all (residential) care homes for elderly people in The Netherlands and a part of Flanders, Belgium. The Dutch guideline is satisfying the Appraisal of Guidelines Research & Evaluation Instrument (AGREE) [40
]. It describes all aspects of good oral health and oral health care, presents the methods and skills needed for providing oral health care to residents, and presents effective oral health and oral hygiene assessment tools. The ultimate objective of the guideline is to improve the oral health of the residents.
Any care guideline needs careful implementation as well as research for assessing its residents' and care providers' compliance. Guideline implementation involves the concrete activities and interventions undertaken to turn policies into desired results. Previous implementation research studies have revealed that implementation of a guideline is very complicated. Although numerous attempts have been made, an effective implementation method has not yet been discovered. Key factors are 'buying in' the care providers, determining during the implementation project which factors are stimulating or inhibiting the project, and determining the care providers' perceived barriers and compliance [41
The scientific hypothesis of the present study is that supervised implementation of the guideline "Oral health care in (residential) care homes for elderly people" is more effective in improving oral health and oral health care of the residents when compared to non-supervised implementation.
Aim and objectives
The overall aim of the study is to compare a supervised versus a non-supervised implementation of the guideline "Oral health care in (residential) care homes for elderly people". The aim can be rendered into 5 research questions:
1. Is there any statistically significant difference between oral hygiene levels of elderly residents in (residential) care homes with supervised implementation of the guideline when compared to those in (residential) care homes without supervised implementation of the guideline?
2. Is there at care home level any statistically significant difference between attitude and knowledge level of nurses and nurse aides of (residential) care homes with supervised implementation of the guideline when compared to those in (residential) care homes without supervised implementation of the guideline?
3. Is there any statistically significant difference in impact on the outcome variables of research questions 1 and 2 between the (residential) care homes in The Netherlands when compared to Flanders (Belgium) and which factors are causing the country differences?
4. Which factors are stimulating or inhibiting the implementation of the guideline in the (residential) care homes in The Netherlands and Flanders (Belgium)?
5. What is the compliance of and which barriers are perceived by the nurses and nurse aides in (residential) care homes in The Netherlands and Flanders (Belgium) while implementing the guideline?