pISSN, eISSN 0125-5614

Original Article M Dent J 2018; 38 (1) : 23-38

Knowledge, attitudes, and behavior towards oral health

among a group of staff caring for elderly people in
long-term care facilities in Bangkok, Thailand
Potchaman Sinavarat1, Smon Manosoontorn1, Chuchai Anunmana1
1
Department of Prosthodontics, Faculty of Dentistry, Mahidol University
Objective: To assess oral health knowledge, attitudes and behavior of personal oral health care among staff
caring for the elders.
Background: Frail and elderly people with chronic illness depend on caregivers’ help for their oral health care.
Materials and Methods: A questionnaire was used to collect data from staffs of long-term care (LTC) facilities in
large hospitals in Bangkok. The collected data included demographic characteristics, knowledge and attitudes
towards oral health care, behaviors of participants towards their personal oral care and daily oral care provided
for residents. The association between genders, educational levels, past training in elderly care and oral care,
and job positions were also assessed.
Results: 135 caring staff of 6 hospitals participated in this study. The results indicated that the nurses had higher
scores of knowledge than the other job positions, and educational level and job position showed significant
difference of knowledge (P<0.05). Half of the participants were unaware of dental plaque and did not recognize
that some medications affect salivation. The participants generally had positive attitudes towards oral health
care; however, nearly 20% thought teeth could not be saved through life. Most participants had fair personal
oral care. 90% reported that they performed oral care for residents and the difficulty in performing oral care was
residents’ in-cooperation.
Conclusion: As nurses are the key persons to set guidelines of oral care and provide training for caring staff,
this study suggested that nursing curricula should include oral health care teaching by dental personnel.
Oral health education programme should be arranged periodically for both caring staff and elder persons.
Therefore, the perception of oral care of residents may be changed. LTC facilities should develop policy related
to daily oral care for residents and dental professions collaborate with LTC facilities to provide support to caring
staff when indicated.
Keywords: Caring staff, Elderly person, Long-term care, Oral health care, Oral health education
How to cite: Sinavarat P, Manosoontorn S, Anunmana C. Knowledge, attitudes, and behavior towards oral
health among a group of staff caring for elderly people in long-term care facilities in Bangkok, Thailand.
M Dent J 2018; 38: 23-38

Introduction disability are more prevalent in older people, these

problems may prevent them from carrying out their
daily activities and make them more dependent.
Oral health, as emphasized in the World Therefore, some of them must rely on a caregiver’s
Oral Health Report 2003,1 is related to general help for their oral health care. Although most of
health, and it is an important part of quality of life. the elders remain in their homes, some of them
This is because oral diseases may be an important require care in long-term care (LTC) facilities
factor in the pathogenesis of cardiovascular where medical services, personal care, social
diseases, aspiration pneumonia and and supportive services are provided to serve
cerebrovascular diseases.2 The relationship of people with physical and/or mental limitation
oral health and general health is strongly evident over a sustained period. Long–term care services
among the elders. The reason is that many oral can be set in a rest home care (nursing home),
diseases have the same risk factors as chronic continuing care (in a hospital), dementia and
diseases.3 As chronic diseases and physical specialized hospital care.4
Correspondence author: Chuchai Anunmana
Department of Prosthodontics, Faculty of Dentistry, Mahidol University 6 Yothi st., Rajthewi, Bangkok, Thailand 10500
Email address: [email protected]
Received : 11 August 2017 Accepted : 28 March 2018
Potchaman Sinavarat, et al

Currently in the early of 21st century, the oral and reduced manual dexterity. As a result, poor
health status of the elders is changing towards oral health is the greatest dental problem of the
maintaining of natural teeth into old age.5 This elders.2, 14, 15 Poor oral health may be related to
means that the dependent elders with more poor nutrition, pain, weight loss, reduced quality of
natural teeth generally have more needs for oral life, and serious illness in old age.16, 17
health care. Unfortunately, oral hygiene care There is no doubt that dental personnel
of these natural teeth become much more should pay more attention to older people and try
difficult due to gingival recession, open gingival to raise the awareness of oral health practice of
embrasures, exposed root surface, malposed staff caring for elderly people in LTC facilities. As
teeth, reduced saliva flow, and use of poor knowledge and attitude are prerequisites to
fitting prosthetic devices, which can impair practice or behavior (KAP),18, 19 up-to-date there is
well-being. 6 As a result, it was reported that no published report on oral health knowledge and
older people living in LTC facilities had poorer attitude of caring staff working in LTC facilities in
oral health than those living in the community.7 Thailand. Furthermore, the perception and
Some researchers also stated that carers attitudes of nursing staff regarding their own oral
considered it was more difficult to help residents health care could reflect oral hygiene activities
with remained natural teeth than those with that were provided for the elders.20 Therefore, it
partial or complete dentures.8, 9 Therefore, oral was essential that the caring staff’s existing
health of these LTC residents was poor, with heavy knowledge, attitudes and behavior towards self
plaque accumulation and gingival inflammation, oral health care were assessed.
and the prevalence of coronal and root caries was A person’s attitudes are subjective and
high. While oral diseases may represent an affected by three components, including cognitive,
infection risk, a lack of knowledge to perform emotional, and behavioral components. The
proper oral health care among nursing personnel cognitive component represents the person’s
is reported.9-11 Moreover, qualified nurses only beliefs and thoughts that a person would relate
take responsibility in planning and evaluation of with a particular object. The emotional component
oral care and leave the practical handling of oral means feelings or emotions linked to an object or
care to other persons, for example, nursing a situation. The behavioral component refers to
assistances and caregivers with varying degrees past behaviors or experiences regarding an
of knowledge. Another factor attributed to object, therefore, some people might interpret
residents’ poor oral health is time constraints their attitudes from their experiences. Attitudes
associated with workload. The caring staff is often can be changed through persuasion, e.g. emotion
overloaded with various tasks. Thus they give a and new knowledge. Moreover, attitudes are a
low priority to oral hygiene compared with other hypothetical construction that cannot be observed
tasks, and some of them lack of oral health care directly and can be ranging from extremely
training or are uninformed of proper techniques of negative to extremely positive.21 Attitudes towards
oral hygiene.12 Some caring staff with residents’ dental care can be defined by self-assessment of
privacy and dignity in mind are reluctant to perform one’s dental health and recognition of the
oral care for these elderly persons.13, 14 However, importance of oral health, concerns about one’s
poor oral health of the elders does not only result dental health and the inclination to attend for
from the improper care of the staff, but also from regular dental examination.22
older persons themselves. Some residents do not The objectives of this study were:
wish oral care assistance and try to perform it 1. To assess oral health knowledge,
themselves. Generally, good oral care practiced attitudes and behavior of personal oral health care
by the elders may be impacted by poor eyesight among a group of staff caring for the elders in LTC
24 M Dent J 2018 April; 38 (1): 23-38
 Knowledge, attitudes, and behavior towards oral health among a group of staff caring for elderly people in long-term care facilities in Bangkok, Thailand

facilities in hospitals age, gender, level of education and the duration of

2. To describe the caring staff’s self- working on caring of older people. In the second
reported oral hygiene assistance they gave to the part, there were 12 items of questions related to
LTC residents. staff’s knowledge towards oral health, such as the
meaning and importance of dental plaque and
Materials and methods gingival bleeding; the consequence of gum
disease; the causes of tooth decay; and the
adverse effect of smoking. Sixteen items in part
Study design and study population three collected the data concerning staff’s attitudes
This cross-sectional study was carried out in towards oral health. The questions included the
LTC facilities in hospitals with bed size more than participant’s beliefs in oral health, participants’
91 (large hospital) in Bangkok, Thailand. Regarding satisfaction of oral function, feeling fear of dental
this criterion, there were thirteen large hospitals treatment and the past dental experience. Part
offering LTC services in the year of 2015. The four consisted of 6 questions related to staff’s
study population was nursing staff members, personal oral health care including methods of
including nurse and nursing assistant, and oral cleaning, frequency of tooth brushing and
caregiver. According to the purpose of this study, other oral hygiene aids and products used, such
the term “caregiver” means LTC facility staff as mouth rinse, dental floss, proxabrush, and
without nursing or nursing assistant qualification. toothpick. The last part contained 9 questions
They were employed to attend to the daily personal asking about experience of performing oral
care of residents. The staff that was included in hygiene care for the LTC residents, including care
this study had a minimum experience of 3 months. of natural teeth and dentures. The questionnaire
The exclusion criteria were that nursing staff and was subjected to repeat reviewing by three faculty
caregivers who had less than 3 months of colleagues who did not involve in the study to
experience in caring for residents, or those who minimize error. Subsequently, the questionnaire
were unwilling to participate. was pretested by another group of the study
population to ensure that all questions were clear
Methods and understandable.
Ethical approval for the study was obtained To collect the information, all nursing staff
from the Faculty of Dentistry, Mahidol University, and caregivers were informed about the study.
Institutional Review Board (COA.No.MU-DT/PY- When they agreed to participate, the informed
IRB 2015/037.2608). A letter was sent to the consents were signed and the questionnaires
directors of the selected hospitals informing the were distributed. Then the participants were
purpose and the procedure of the study. When explained how to mark their responses and were
they agreed to participate in the study, the ward made aware that there was more than one
director of LTC facility of each hospital was response for some questions. One of the
contacted, and permission was obtained to the investigators was always available during the
participants. completion of the questionnaire to clarify any
A standardized questionnaire for data unclear item.
collection was modified from Petersen et al.23 and
the survey form used in the 7th national oral health Data preparation and statistical analysis
survey, Thailand.5 The questionnaire, including 51 The questionnaires were checked for the
items, was divided into five parts. The first part completeness, scored for the correct answers,
contained general information regarding the staff’s summarized the score for each part of the

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Potchaman Sinavarat, et al

individual. The complete data of the participant Results

were managed into prepared database for
analysis. A descriptive analysis (percentages, One hundred and thirty-five staff members
means, and standard deviations) was applied to from long-term care facilities of six hospitals were
inform characteristics of the studied population, willing to participate in this study. All of the LTC
oral health knowledge, attitudes, behavior of self facilities provided both rest-home care and
oral health care and behavior of oral health care hospital care. The participants comprised 30
provided for the elderly residents. Test of (22.2%) nurses, 89 (65.9%) nursing assistants,
differences of interested variables were explored and 16 (11.8%) caregivers. Gender, age,
by t-test, and ANOVA. The data was processed educational level, job position, and past training
and analyzed using the Statistical Package for the and experience of the participants are presented
Social Sciences 18.0 (SPSS 18.0, SPSS Inc. in Table 1.
Chicago, IL, USA).24
Table 1 Distribution of socio-demographic characteristics among the caring staff (N = 135)
n (%)
Gender
Male 16 (11.85)
Female 119 (88.15)
Age (Years): Mean ± SD 35.21 ± 10.96
Education
Junior high school/lower 6 (4.51)
Senior high school/Vocational certificate 66 (49.62)
High vocational certificate/Associate degree 10 (7.52)
Bachelor degree/higher 51 (38.35)
Job position
Nursing assistant 89 (65.93)
Caregivers 16 (11.85)
Nurse 30 (22.22)
Previously trained in elderly care within 2 years
Yes 76 (57.14)
No 57 (42.86)
Previously trained in oral health care
Yes 38 (29.01)
No 93 (70.99)
Experience of elderly care
3 months – 1 year 19 (14.18)
1 - 3 years 26 (19.40)
> 3 – 5 years 13 (9.70)
> 5 years 76 (56.72)

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 Knowledge, attitudes, and behavior towards oral health among a group of staff caring for elderly people in long-term care facilities in Bangkok, Thailand

Oral health knowledge prescribed by the physician could reduce the

Table 2 illustrates the knowledge test with amount of saliva. Furthermore, 35.5% did not
12 multiple choice questions (correct=1; total agree or did not know that dry mouth can cause
score=12). Only 50.4% of the study population fungal infection in the mouth. Table 3 presents the
was aware that dental plaque is soft deposits comparison of knowledge scores by population
including bacteria on the teeth, which can cause characteristics. Nurses had higher mean scores
gum disease while the rest thought that dental than nursing assistants, and caregivers. The
plaque was either the hard deposits or substance results also revealed that educational level and job
that caused tooth discoloration. Generally, mouth position showed a significant difference of oral
dryness is one of the most common oral discomforts health knowledge (P<0.05). In addition, past
in the elders. However, 47.4% of the participants training and experience of the participants had no
did not recognize that some medications effect on the mean knowledge scores.

Table 2 Response distribution of caring staff to questions regarding oral health knowledge
Correct answer Wrong answer
n (%) n (%)
Do you agree that oral diseases can be prevented through proper oral
health care? 133 (98.51) 2 (1.48)
(Answer: agree)
Oral disease can induce infection in other organ, especially in the
elderly. 122 (90.37) 13 (9.62)
(Answer: agree)
What is “dental plaque"?
68 (50.37) 67 (49.62)
(Answer: soft deposits including bacteria on teeth)
Gingival bleeding is a sign of gingivitis. 121 (89.62) 11 (8.14)
The cause of gum disease is bacteria in dental plaque. 98 (77.77) 28 (22.22)
The consequence of gum disease is teeth become loose and fall out. 36 (26.66) 94 (69.62)
How can you prevent gum disease?
116 (85.92) 19 (14.07)
(Answer: brush and floss the teeth properly)
Some medications can reduce the amount of saliva.
71 (52.59) 64 (47.40)
(Answer: agree)
Mouth dryness can cause fungal proliferation and infection in the mouth.
87 (64.44) 48 (35.55)
(Answer: agree)
What is the cause of tooth decay?
(Answer: sugary and starch food combined with bacteria in 121 (89.62) 14 (10.37)
dental plaque)
How can you recognize tooth decay?
130 (96.29) 5 (3.70)
(Answer: black tooth and cavity)
What is the adverse effect of smoking to oral health?
113 (83.70) 22 (16.29)
(Answer: increase risk of gum disease and oral cancer)

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Potchaman Sinavarat, et al

Table 3 Comparison of knowledge scores by population characteristics (Total score = 12)

n Mean score SD p-value
Knowledge towards oral health care 135 9.01 1.72
Gender
Male 16 9.25 1.39
Female 119 8.97 1.76
Education* 0.028*
Junior high school/lower 6 9.17 2.31
Senior high school/Vocational certificate 66 8.55 1.60 0.021*
High vocational certificate/Associate degree 10 9.10 1.19
Bachelor degree/higher (Ref) 51 9.51 1.72
Job *** <0.001***
Nursing assistant 89 8.71 1.70 <0.001***
Caregiver 16 8.62 1.82 0.011*
Nurse (Ref) 30 10.10 1.26
Previously trained in elderly care within 2 years
Yes 76 9.08 1.70
No 57 8.93 1.78
Previously trained in oral health care
Yes 38 9.42 1.57
No 93 8.87 1.77
Experience of elderly care
3 months - 1 year 19 9.63 1.46
1-3 years 26 8.38 1.57
> 3 - 5 years 13 9.46 1.66
> 5 years (Ref) 76 9.01 1.78
* p-value < 0.05, ***p-value<0.001, Ref = Reference group

Attitudes towards oral health care component and the maximum positive attitude
This part contained 16 attitude statements, score was 42. The result revealed that the
including the participant’s beliefs in oral health participants generally held positive attitudes
care, satisfaction with their own oral function, and (Table 4). Most of them (80%) considered oral
their past dental experience. The attitudes in this health care as an activity that could prevent oral
study were classified into three levels: positive, diseases and 86.6% agreed that poor oral health
neutral, and negative attitudes, which were scored could affect quality of life. However, half of the
as 3, 2, and 1, respectively. Two attitude statements participants (51.1%) believed that loss of teeth
regarding the participant’s dentition status, and was a natural part of aging and one could do
the reason not to have dental visit were not marked. nothing to prevent tooth loss. Moreover, nearly
Therefore, only 14 items represented the attitude 20% thought that “brushing well is hard to achieve”

28 M Dent J 2018 April; 38 (1): 23-38

 Knowledge, attitudes, and behavior towards oral health among a group of staff caring for elderly people in long-term care facilities in Bangkok, Thailand

and “though you take good care of your teeth by result showed that nurse had higher attitude score
brushing well, you cannot save your teeth for life”. than other job positions (p<0.05). Considering the
The majority of participants (97.8%) were satisfied past training in elderly care and oral health care
with the function of their teeth and concerned factors, there was no significant difference of the
about their dental health. attitude score between the participants who had
Table 5 demonstrates the comparison of those trainings and the group that did not receive
attitude score by population characteristics. The such training.

Table 4 Percent of attitude towards oral health care

Positive Neutral Negative
Total
n (%) n (%) n (%)
What is your opinion about "oral health care"? 134 110 (81.48) 20 (14.81) 4 (2.96)
Do you agree that loss of teeth is a natural part of 134 50 (37.03) 15 (11.11) 69 (51.11)
aging and one can do nothing?
Do you agree that poor oral health can affect 134 117 (86.66) 4 (2.96) 13 (9.62)
people's quality of life with respect to impaired
eating, social appearance and communication?
Do you agree that dental caries are genetic problem 135 119 (88.14) 11 (8.14) 5 (3.70)
and therefore beyond control?
Do you agree that if you take good care of your teeth 135 108 (80.00) 12 (8.88) 15 (11.11)
by brushing well, you can save your teeth for life?
Do you agree that “brushing teeth well is hard to 135 103 (76.29) 5 (3.70) 27 (20.00)
achieve”?
Are you satisfied with the function of your teeth? 135 132 (97.77) 3 (2.22) 0 (0.00)
Do you fear of dental appointment or dental 135 53 (39.25) 48 (35.55) 34 (25.18)
treatment?
How are you concerned about your dental health? 135 131 (97.03) 4 (2.96) 0 (0.00)
How do you feel, if your dentist tell you that you are 134 126 (94.02) 0 (0.00) 8 (5.97)
not brushing well?
How often do you consider you ought to see a dentist? 135 117 (86.66) 0 (0.00) 18 (13.33)
When was your last visit to a dentist? 135 85 (62.96) 25 (18.51) 25 (18.51)
What was the reason for the last dental visit? 130 50 (38.46) 75 (57.69) 5 (3.84)
During your last dental visit, was the dentist willing 127 43 (33.85) 75 (59.05) 9 (7.08)
to spend time with you to discuss your problem and/
or treatment?

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Potchaman Sinavarat, et al

Table 5 Comparison of attitude score by population characteristics (Maximum attitude score = 42)
n Mean score SD p-value
Attitude towards oral health care 135 35.99 3.33
Gender
Male 16 36.31 4.15
Female 119 35.94 3.22
Education
Junior high school/lower 6 35.67 3.72
Senior high school/Vocational certificate 66 35.35 3.80
High vocational certificate/Associate degree 10 36.40 1.57
Bachelor degree/higher (Ref) 51 36.73 2.80
Job** 0.006**
Nursing assistant 89 35.45 3.50 0.004**
Caregiver 16 35.81 3.16
Nurse (Ref) 30 37.67 2.26
Previously trained in elderly care within 2 years
Yes 76 35.49 3.46
No 57 36.61 3.10
Previously trained in oral health care
Yes 38 35.79 3.90
No 93 36.16 3.11
Experience of elderly care
3 months - 1 year 19 35.89 2.82
1-3 years 26 35.81 2.65
> 3 - 5 years 13 35.54 3.23
> 5 years (Ref) 76 36.29 3.49
**p-value<0.01, Ref = Reference group

According to the participants’ reports, most check-up. The reasons not to see the dentist
of them (81.5%) had only natural teeth, 18.5% regularly were time constraints (35.4%), high cost
wore removable partial denture and there was no (24.4%), no oral health problem / no treatment
complete denture wearer. In assessing the past need (23.2%) and fear (15.8%). During the latest
dental experience, several participants (86.7%) visit to the dentist, more than half of the participants
thought that they should see a dentist at least once experienced the dentist did not spend enough
a year, but only 63% visited the dentist in the time to discuss their problems and treatment.
previous year because of having oral or dental When they were asked how they would respond if
symptoms. Preventive dental visits were infrequent, the dentist told them that they were not brushing
only 38.5% attended the dentist regularly for well, the majority (94%) were willing to improve.

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 Knowledge, attitudes, and behavior towards oral health among a group of staff caring for elderly people in long-term care facilities in Bangkok, Thailand

Behavior of participants towards their personal fluoridated toothpaste (Table 6). To clean the
oral health care interdental areas, 39.2% used dental floss, 21.5%
Questions related to participants’ personal used toothpick and only 11% used proxabrush.
oral health care comprised of 6 items. Three items However, there were 4 participants (1 nurse, 2
included the routine oral care that involved all nursing assistants, and 1 caregiver) who did not
participants such as techniques of teeth cleaning, brush their teeth, of these, three gargled and one
using of extra brushing aids (more than one rubbed her teeth with fingers. Among those
alternative was allowed), and type of toothpaste wearing removable partial denture, 90.5% routinely
used. The appropriate technique of each item was took dentures off when they went to bed but the
scored one point. The remaining three items, rest occasionally or never did. Table 7 shows most
including some specific oral care such as using of participants had fair personal oral health care, with
an electric toothbrush or questions related to the mean score about 2.94±0.80. The results
persons wearing removable dentures, which demonstrated that the mean behavior score
involved only 18.5% of the participants, had no among genders, educational levels, past training
point. Therefore, the maximum score of this part in elderly care and past training in oral care and
was 5 points. job positions were not statistically significant
Almost all participants (97%) reported that (P>0.05).
they cleaned their teeth using toothbrushes and
Table 6 Percent of behavior towards personal oral health care
n (%)
How do you clean your teeth and mouth routinely? (n = 134)
Do not use tooth brush 4 (2.97)
Use tooth brush 130 (97.01)
In case that you have natural teeth and choose "use toothbrush in 1", do you use any
brushing aids? (More than 1 item is possible) (n = 135)
No 18 (13.33)
Dental floss 53 (39.25)
Proxabrush 15 (11.11)
Toothpick 29 (21.48)
Mouthwash / salt water 75 (55.55)
In case that you have natural teeth and choose "use toothbrush in 1", which toothpaste do
you use? (n = 131)
Without Fluoride 4 (2.96)
With Fluoride 127 (94.07)
In case that you wear a removable denture, how do you routinely clean your "denture"? (n = 21)
Clean with tap water only 1 (4.76)
Toothbrush and toothpaste 17 (80.95)
Toothbrush and liquid soap 2 (9.52)
Use denture cleanser 1 (4.76)
In case that you wear a removable denture, do you take your denture off at night? (n = 21)
Routinely 19 (90.47)
Occasionally 1 (4.76)
Never 1 (4.76)
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Potchaman Sinavarat, et al

Table 7 Comparison of behavior score by population characteristics (Maximum score = 5)

n Mean score SD p-value
Behavior of dental health care 135 2.94 0.79
Gender
Male 16 2.94 0.77
Female 119 2.94 0.79
Education
Junior high school/lower 6 2.67 1.03
Senior high school/Vocational certificate 66 2.92 0.70
High vocational certificate/Associate degree 10 2.90 0.87
Bachelor degree/higher (Ref) 51 2.96 0.84
Job
Nursing assistant 89 2.96 0.73
Caregiver 16 2.69 0.70
Nurse (Ref) 30 3.03 0.96
Previously trained in elderly care within 2 years
Yes 76 2.95 0.86
No 57 2.93 0.70
Previously trained in oral health care
Yes 38 3.03 0.78
No 93 2.91 0.80
Experience of elderly care
3 months - 1 year 19 2.89 0.87
1-3 years 26 2.85 0.78
> 3 - 5 years 13 2.92 0.49
> 5 years (Ref) 76 2.99 0.82
Ref = Reference group

Daily oral care for residents problems that the staff confronted while
This part consisted of 9 statements. Six of performing tooth brushing, how the staff
them related to the oral and denture care, which recognized residents’ oral problems, and how
the LTC residents were receiving from the caring they solved the problem, had no score.
staff. Each correct answer of these 6 items was Table 8 summarizes the behavior of daily
scored 1-3 points, judged from the level of oral care for residents. The majority of the
correctness, and the incorrect answer had no participants (91%) reported that they performed
score. The other three questions related to the oral care for residents. Within this group, 18.8%

32 M Dent J 2018 April; 38 (1): 23-38

 Knowledge, attitudes, and behavior towards oral health among a group of staff caring for elderly people in long-term care facilities in Bangkok, Thailand

(25 participants) were nurses. Nine percent did shut, or moved their tongues from side to side, or
not carry out oral care for residents. The most bit on caring staff’s fingers. In addition, it was a
common reasons for not giving oral care were that very awkward thing to do because it was actually
the residents could perform it themselves and did hard to see inside the mouth and the procedure of
not wish oral care assistance. Some nurses cleaning might injure their teeth or gums. To
reported that it was not their responsibility. Other perform denture care, 58.5% helped residents
reasons were that they felt unpleasant with others’ clean their dentures using toothbrush and
mouth odor while some participants were afraid of toothpaste (78.3%) while 2.6% used toothbrush
catching diseases. When asked if they had any and liquid soap. It was noticed that denture
difficulty in performing oral care for residents with cleanser was rarely used (10%) among these
natural teeth, they reported that they really had participants.
trouble because some residents kept their mouths

Table 8 Percent of behavior of daily oral care for residents

n (%)
Have you ever cleaned residents' teeth?
Routinely 77 (57.89)
Occasionally 44 (33.08)
Never 12 (9.02)
How often do you perform oral health care for residents?
Twice a day 78 (63.93)
Once a day 37 (30.32)
Less than once a day 7 (5.73)
Did you ask residents to take their denture off at night?
Routinely 101 (78.29)
Occasionally 18 (13.95)
Never 10 (7.75)
Do you clean dentures for residents?
Routinely 79 (58.51)
Occasionally 36 (26.66)
Never 20 (14.81)
How often do you clean their dentures?
More than once a day 62 (55.35)
Once a day 46 (41.07)
Less than once a day 4 (3.57)
How did you clean their dentures?
Soak with water 10 (8.69)
Toothbrushes with toothpaste 90 (78.26)
Toothbrushes with liquid soap 3 (2.60)
Denture cleanser 12 (10.43)

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Potchaman Sinavarat, et al

In Table 9, the mean score of oral health working on elderly care for 3 months to 1 year had
care practice for the elders was 8.96±3.49. Female lower score than the other groups (P<.05).
showed higher average score than male (9.0 and To recognize residents’ oral problems, the
7.8, respectively), however, no significant participants reported that the general indications
difference (P=0.2) was found between male and of oral problems were gingival bleeding, gingival
female staff. Furthermore, the results showed no swelling, oral ulcer, black spots or tooth cavities,
significant differences (P>0.05) of the scores tooth mobility, cracked tooth, and when a resident
among the education levels, job positions, past did not want to eat. When asked how they managed
training of elderly care, and past training of oral to help those with oral problems, they reported
health care (except for the duration of working on that they would inform the head nurse (60%); refer
elderly care). Participants who had experience of to a dentist (25%); or inform a physician (13%).
Table 9 Comparison of oral health care score for residents by population characteristics
n Mean score SD p-value
Daily oral health care for residents 135 8.96 3.491
Gender
Male 16 7.75 4.00
Female 119 9.13 3.40
Education
Junior high school/lower 6 9.83 2.22
Senior high school/Vocational certificate 66 8.83 3.61
High vocational certificate/Associate degree 10 8.30 3.86
Bachelor degree/higher (Ref) 51 9.16 3.48
Job
Nursing assistant 89 9.28 3.51
Caregiver 16 8.69 2.82
Nurse (Ref) 30 8.17 3.73
Previously trained in elderly care within 2 years
Yes 76 8.91 3.48
No 57 9.02 3.60
Previously trained in oral health care
Yes 38 8.89 3.43
No 93 9.04 3.60
Experience of elderly care*** <0.001***
3 months - 1 year 19 5.42 3.58 <0.001***
1 - 3 years 26 8.77 2.99
> 3 - 5 years 13 9.85 2.60
> 5 years (Ref) 76 9.83 3.20
***p-value<0.001, Ref = Reference group
34 M Dent J 2018 April; 38 (1): 23-38
 Knowledge, attitudes, and behavior towards oral health among a group of staff caring for elderly people in long-term care facilities in Bangkok, Thailand

Discussion plaque was either hard deposits or substances

that caused tooth discoloration. This means that if
dental plaque was not removed effectively from
This study was conducted in LTC facilities in the teeth by appropriate brushing, the two main
six large hospitals that were willing to participate, dental diseases (e.g. dental caries and periodontal
thus, generalizability may be limited. Although it diseases) could not be avoided and subsequently
was possible that the participants may not be results in pain from these diseases and finally
representative of all caring staffs for older people, tooth loss. Effective plaque control is of fundamental
the results of this study may help indicate the importance in controlling of these oral diseases.25
knowledge, beliefs, and experience in oral health Although plaque removal is not very complicated,
care of a group of caring staff, which might reflect some areas may be difficult to assess, such as
their daily oral care for residents. This can provide interproximal areas, and those areas need some
some important data for further development of oral hygiene aids, such as dental floss and
protocols of oral care for functionally dependent proxabrush, for cleaning. The results of this study
older people. In addition, this project was carried revealed that few participants did not brush their
out using data from questionnaire derived from own teeth and only 11% used proxabrush. This
caring staff with various levels of education, which might reflect an inadequate oral health care for the
might affect the selection of responses. To residents. Moreover, brushing somebody else’s
minimize the participants’ misunderstanding of teeth needs skill and training. Caring staff needs to
questionnaire items, the questionnaire was know how to provide adequate oral health care for
pretested before starting the project by another the residents. Thus, dental personnel should
group of the study population. Subsequently, the routinely organize training in oral health care for
unclear statements were corrected to obtain caring staff. In addition, the knowledge of dental
simple items. Furthermore, one of the investigators plaque and its effects should be emphasized to
was always available during the completion of the them. Frenkel et al18 suggested that an annual
questionnaire. reinforcement should be provided in order to
Most of the caring staffs participated in this maintain the benefit of both oral health care
study were nursing assistants (65,9%), followed education and practical training. This time interval
by nurses (22%), and caregivers (11.8%). Half of might counteract the effect of knowledge fading
the participants (56.7%) were working on elderly over a period and the period of staff turnover in
care for more than 5 years, suggesting that they LTC.
had experience in caring of older people. As Many participants did not realize that older
various skills and duration of experience in people, especially frail and dependent, are at
providing care for older people may have additional risk of oral problems because salivary
influenced the selection of responses in the flow is often reduced substantially by using some
questionnaire, therefore, staff who had experience medications or other systemic factors which can
less than 3 months was excluded. increase risks of root caries and fungal infection. It
The participants in this study acknowledged is beneficial to ask LTC residents periodically
oral health care as an essential task to prevent oral about feeling of mouth dryness. If residents have
diseases, and oral diseases can be a risk factor of dry mouth, caring staff should perform appropriate
systemic infection in the elders. However, half of mouth care and provide proper dietary advice to
them were unaware of dental plaque as soft ensure good nutrition in these groups.25
deposits on the teeth. They thought that dental

http://www.dt.mahidol.ac.th/division/th_Academic_Journal_Unit 35
Potchaman Sinavarat, et al

In general, attitudes are difficult to measure assistance and were afraid of catching diseases.
because measurement is arbitrary, and perhaps Time constraint was not the reported barrier. Since
they cannot be observed directly. Therefore, in the manual dexterity to perform oral health care of
this study attitudes were put into a wide range of LTC residents tends to change as time passing,
positive, neutral and negative attitudes. Generally, caring staff should assess residents’ ability to
attitudes are based on knowledge of each brush their teeth or clean their dentures periodically,
individual. Attitudes may guide attention and for example every a few months, and assist them
affect people’s behavior in different ways.21, 26 It as soon as the problem of dexterity is observed.
seemed likely that the participants in this study In addition, further study should evaluate the
held positive attitudes towards oral health care. degree of dependency of residents before
Around 80% of the participants believed that collecting data of caring staff in performing oral
natural teeth could last for life. This is in agreement health care for residents. Generally, policy is very
with the study of Frenkel et al18 However, 51% of important to guide nursing staff to perform oral
the participants thought that tooth loss was a health care as well as oral care education and
natural part of aging and 20% thought “brushing training which can help them improve their
well cannot save teeth for life”. This might affect knowledge and skill.19 Therefore, LTC facilities
their attempt to perform oral health care for should develop policy of daily oral care for
residents. To change these negative attitudes residents including residents with semiconscious,
and to achieve behavioral change, many unconscious and with intubation, which need
studies have recommended oral health care different knowledge and skills. In the meantime,
education and practical training for nursing the content of oral health educational program
staff and caregivers.8, 18, 27, 28 should include the topic of personal protective
Most of the participants (86.7%) considered equipment and standard precautions so that the
they ought to see a dentist at least once a year. caring staff would gain confidence and feel safe
However, only 63% went to a dentist during the during assisting residents with oral health care.
previous year. Time constraints were the most Moreover, to get better cooperation from the
common reason (35%) and fear of dental visit was residents, the oral health education program
only 15.8%. This is in agreement with the study of should include not only the nursing staff but also
Wardh et al,8 which revealed that only 18% of the older persons as well.
participants were fear of dental visit. In contrast, One of the objectives for long-term care
the most common barrier of dental visit in school stresses that adequate oral health care is one of
children was fear.29 It is possible that education the most basic nursing care and must be
and better understanding of the importance of oral maintained in long-term care to enhance good oral
health may enhance overcoming fear in adults. health and general health.32, 33 Generally, nursing
According to the previous studies,14, 18, 30, 31 assistants take responsibility for oral health care in
caring staff may hold positive attitudes towards LTC facilities. Surprisingly, this current study
oral health care, yet fail to overcome barriers to found that 25 of 30 nurses participated in this
perform adequate oral care to the residents. Such research routinely or occasionally performed oral
barriers included low prioritization, revulsion, care for the residents. Perhaps this might be
resistance from residents, and lack of time or beneficial that the limitations and problems related
materials. In this current study, the reported to providing oral care to the residents could be
barriers were that the residents could perform oral recognized and the appropriate regulations and
care by themselves and did not wish oral care guidelines of oral care might be set in these LTC

36 M Dent J 2018 April; 38 (1): 23-38

 Knowledge, attitudes, and behavior towards oral health among a group of staff caring for elderly people in long-term care facilities in Bangkok, Thailand

facilities to ensure adequate oral health of the 2. Kandelman D, Petersen PE, Ueda H. Oral health,
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