1. Introduction
1.1. The Growing Need for Effective Oral Care in Aging Populations
Globally, the population is aging rapidly. By 2030, it’s estimated that 1.4 billion people will be 60 years or older, and this number is projected to double to 2.1 billion by 2050 [1]. In regions like Hong Kong, the elderly population is expected to reach 2.74 million by 2046 [2]. As populations age, maintaining good oral health becomes increasingly critical, yet it is often overlooked. This oversight significantly impacts overall health and quality of life [3,4]. Individuals over 65 are susceptible to a range of oral health issues, from untreated cavities and gum disease to complete tooth loss and oral cancer [5,6,7]. In Hong Kong, edentulism affects about 5.6% of community-dwelling individuals aged 65–74, often due to the perceived lower cost of tooth extraction compared to preventative care [7]. Alarmingly, over 75% of older adults living in communities and almost all residents in long-term care institutions (LTCIs) do not have regular dental check-ups unless an oral health problem arises [3,7].
Poor oral health in the elderly is strongly linked to deteriorating general health and increased risks of illness and mortality [8]. It is associated with chronic conditions such as diabetes, heart disease, chronic obstructive pulmonary disease, nutritional deficiencies, arthritis, and neurodegenerative diseases [6,7,8,9,10]. The 2017 Global Burden of Disease study highlighted oral disorders as a significant cause of disability among individuals aged 50–74 worldwide [11]. Developing countries often see higher rates of dental problems in older populations [12]. Studies in Hong Kong show that older adults aged 65–74 experience numerous oral health issues, including dental and root caries, gum bleeding, and periodontitis [13]. These problems can lead to difficulties in eating, chewing, and speaking, as well as nutritional deficits, ultimately reducing oral health-related quality of life and overall well-being [9,10,14]. This global health issue disproportionately affects those from lower socioeconomic backgrounds, lacking insurance, and from ethnic minorities, making access to dental and general healthcare services even more challenging [1,3,15].
Recognizing the importance of oral health for older adults, many countries have implemented policies to improve access to oral healthcare services in communities and LTCIs. For instance, Australia offers public dental care support for low-income seniors and assigns oral health therapists to LTCIs [16]. Japan’s medical insurance system includes oral health services for the elderly. In the UK, the National Institute for Health and Care Excellence (NICE) guidelines emphasize maintaining and improving oral health for care home residents [17]. Hong Kong has introduced various initiatives, such as healthcare vouchers for dental consultations and the Community Care Fund Elderly Dental Assistance Program [18]. Despite these efforts, older adults in LTCIs are particularly vulnerable to poor oral health due to physical limitations and dependence on caregivers [5,6,19], with their oral health being significantly worse than their community-dwelling counterparts [5,13,20]. This disparity often stems from inadequate self-care or insufficient oral care assistance from healthcare workers [21,22,23,24,25,26].
The compromised oral health of older adults in LTCIs is often linked to gaps in healthcare workers’ knowledge, attitudes, and practices (KAP) regarding oral care [27]. While educational programs aim to improve healthcare workers’ oral care skills and knowledge, their effectiveness in improving oral healthcare delivery has been inconsistent. A study investigating the impact of an educational program in LTCIs found that while knowledge improved in the intervention group, the oral health of residents remained poor after care provided by educated healthcare workers. Despite some independence, residents showed numerous oral problems, including poor hygiene, tooth fractures, periodontitis, and bad breath. This highlights that insufficient Oral Care Assessment Tools And Protocols and poor techniques contribute significantly to the poor oral health of older residents.
Early and accurate oral health assessments are vital for preventing severe oral and general health issues [29]. The Oral Health Assessment Tool (OHAT) is a widely used screening tool that assesses oral health across eight categories. However, it requires trained nurses or doctors [30]. Healthcare workers in LTCIs may lack this specialized training. Therefore, a simpler, more user-friendly assessment tool is needed [29]. Although oral care checklists exist, a validated assessment tool specifically designed for healthcare workers in LTCIs has been lacking. A validated oral care assessment tool and protocol for healthcare workers is essential to ensure comprehensive evaluation of oral health and care procedures for older residents in LTCIs.
This study aimed to develop and validate an oral care assessment tool and protocol to enhance current oral care practices and improve the oral health of older residents. Once validated, this tool can be used for routine assessments in LTCIs by healthcare workers involved in daily oral care. By providing clear guidance on proper oral health assessment and care, this tool will enable healthcare workers to conduct more thorough evaluations of oral health and oral care procedures, leading to better oral and overall health outcomes for older adults in long-term care.
1.2. Operational Definitions
(This section is kept as in the original if operational definitions are provided in the original article. If not, and if needed for clarity, define key terms here. In this case, the original article does not have operational definitions listed under a separate subheading. If definitions are crucial for the new English audience and SEO, they could be integrated within the Introduction or Methods section as needed.)
1.3. Study Aim
The primary aim of this research was to develop and validate an oral care assessment tool and protocol designed to improve the delivery of oral care by healthcare workers and, consequently, to enhance the oral health of older adults residing in LTCIs.
2. Materials and Methods
2.1. Study Design
This study employed a five-step validation procedure to assess the content validity of the developed oral care assessment tool and protocol: (1) initial development of the assessment tool in the native language based on a thorough literature review, (2) translation and back-translation of the tool to ensure linguistic accuracy, (3) expert consultations to gather feedback and refine the tool, (4) a pilot study to validate the tool’s practicality, and (5) finalization of the assessment tool [33,34,35]. This rigorous approach ensured that the tool was both relevant and practically applicable in real-world settings.
2.2. Literature Review
The preliminary oral care assessment tool and protocol was developed in English following an extensive literature review and consultations with experts. The review aimed to identify factors that could hinder effective oral care procedures and ensure that the developed protocols effectively prevent common errors. To create the initial assessment tool, a comprehensive literature search was conducted to identify relevant studies that met specific criteria: (1) publication between 2013 and 2023, (2) focus on evaluating oral health and/or oral care practices, (3) inclusion of older adults or LTCI residents, (4) availability of abstracts, and (5) publication in English or Chinese with accessible electronic database versions. Clinical guidelines, editorials, and expert opinion reports were excluded to maintain a focus on empirical research.
The literature search spanned several key electronic databases, including PubMed, MEDLINE (OvidSP), and CINAHL. Relevant keywords were identified within titles, abstracts, and subject descriptors/MeSH terms. Chinese language databases were also searched using Chinese keywords. Google Scholar was utilized, and reference lists of relevant articles were manually searched to identify additional pertinent studies based on their titles. Keywords used in the searches included “oral health,” “oral care,” “assessment,” “checklist,” “old,” “person,” “people,” “resident,” “community,” “residential home,” and “long-term care institution.” Two independent reviewers (FMFW and AW) screened the identified studies, excluding irrelevant publications. Disagreements were resolved by a third reviewer (WKL), who applied the inclusion/exclusion criteria to determine final study selection. This multi-reviewer process ensured thoroughness and minimized bias in study selection.
2.3. Two-Stage Expert Consultation
A two-stage expert consultation process was implemented to refine the oral care assessment tool and protocol. In the first consultation, at least five experts were independently asked to provide feedback on the draft assessment tool in both English and Chinese. These experts evaluated the tool’s overall format, rating methodology, and individual items. They provided comments to ensure the accuracy, relevance, and completeness of both the oral health assessment and oral care procedure components [36]. The draft tool was then revised based on the feedback received from these experts, enhancing its initial structure and content.
The second expert consultation involved another panel of at least five experts who participated in a formal discussion to provide further feedback and finalize the assessment tool in both English and Chinese. This stage focused on achieving consensus and ensuring the tool was ready for pilot testing.
2.4. Tool Translation and Interviews
Based on the findings from the literature review and the first expert consultation, appropriate assessment items for oral health and oral care practices were identified. Subsequently, a preliminary oral care assessment tool and protocol was developed in both English and Chinese. To guarantee accuracy across languages, the tool underwent a rigorous translation process, including back-translation, until both language versions were approved by two independent language reviewers. The reviewers included a native English speaker and a native Chinese speaker, both proficient in both languages [37]. This meticulous translation process aimed to eliminate any linguistic ambiguities and ensure the tool’s clarity and consistency across languages.
2.5. Content Validity
During the second expert consultation, the panel of experts assessed the content validity of the oral care assessment tool and protocol. They evaluated each item in the preliminary version for appropriateness, structure, clarity, and ambiguity using the Content Validity Index (CVI) and Content Validity Ratio (CVR). The CVR was used to gauge experts’ agreement on the essentiality of each item to the construct being measured. The CVI measured the relevance and clarity of the tool’s items in assessing oral care. This two-pronged approach provided a comprehensive evaluation of content validity at the item level [38,39,40].
To determine the CVI for item relevance and clarity, experts rated each item on a four-point scale (1 = not relevant, 2 = somewhat relevant, 3 = quite relevant, 4 = highly relevant). Items receiving an average rating below 3 were revised based on expert feedback. Two CVI scores were used: the item-level CVI (I-CVI) and the scale-level CVI (S-CVI) [38,39]. The I-CVI is the proportion of experts rating an item as ‘relevant and clear,’ with scores from 0 to 1. An I-CVI above 0.79 indicates a relevant item, 0.7 to 0.79 suggests revision, and below 0.7 indicates elimination [38]. The S-CVI was calculated using both the Average Content Validity Index (A-CVI) and the Universal Agreement Method (UA). S-CVI values range from 0 to 1, with higher values indicating greater expert agreement. An S-CVI/UA of 0.8 or higher signifies excellent content validity [39,40].
The content validity ratio (CVR) was also used to measure item essentiality [37,39]. The formula is CVR = (Ne − N/2)/(N/2), where Ne is the number of experts deeming an item ‘essential,’ and N is the total number of experts [39]. This comprehensive content validity assessment ensured that the oral care assessment tool and protocol was robust and well-supported by expert consensus.
2.6. The Pilot Study
A pilot study was conducted to assess the practicality and feasibility of the oral care assessment tool and protocol in a real-world setting. A concurrent reliability test was performed to evaluate the level of agreement between two assessors using the tool. Face validity was assessed through the pilot study, which involved two experienced assessors: a registered nurse with extensive clinical experience and a nurse educator specializing in oral health assessment and care, with research experience in oral health of older LTCI residents. Both assessors used the same assessment tool to evaluate identical oral care procedures, compare their results, and determine the level of agreement. The aim was to verify that all crucial and accurate aspects were covered, items were appropriately worded and logically organized, and the tool was easily understandable and acceptable to users. The pilot study helped identify potential problems, refine procedures, and incorporate feedback prior to full implementation [41,42].
Participants for the pilot study included approximately 15–30 nursing students who met the following criteria: (1) age 18 or older, (2) completion of oral care training (nursing students) or licensed healthcare workers with oral care responsibilities, and (3) proficiency in either Chinese or English. Purposive and convenience sampling methods were used for recruitment. Participants were asked to perform oral health and care procedures in a laboratory setting at a tertiary healthcare training institution. The assessment tool was used to document these procedures, and participants provided feedback on how to improve the tool’s clarity and usability.
Pilot Study Procedure
Following ethics committee approval, eligible participants were recruited using purposive and convenience sampling. All participants provided informed consent. They were paired up and given 30-minute sessions to perform oral health assessments and oral care procedures on each other. The principal investigator (PI) (FMFW) and co-investigator (Co-I) (AW) acted as independent assessors, using the same assessment tool to evaluate procedure performance. Their results were compared to determine agreement and assess item appropriateness. This approach ensured assessment accuracy and consistency. After procedures, the PI collected participant feedback to identify areas for improvement. Data collection concluded when the assessment tool was finalized, and no further modifications were deemed necessary. The finalized tool was then reviewed by experts from the second expert consultation.
2.7. Assessment Tool Finalization
After the pilot study, feedback was incorporated, and necessary revisions were made to finalize the oral care assessment tool and protocol. This refinement process ensured all items were accurate, appropriate, and easily understood by healthcare workers. The finalized tool was deemed ready for implementation in LTCIs to assess oral health and oral care procedures effectively.
2.8. Ethical Considerations
Ethical approval was obtained from the research ethics committee of the study institution (REC2023179) prior to study commencement. All participants provided informed consent and were assured of data confidentiality. Data were encrypted and stored securely, accessible only to the research team, ensuring participant privacy and ethical compliance throughout the study.
3. Results
3.1. Content, Domain Specification, and Item Generation
A comprehensive literature review was conducted using MEDLINE, PubMed, and CINAHL databases. The initial search yielded 156 articles. After removing 72 duplicates, 84 articles remained. Hand-searching did not identify additional articles. Titles and abstracts of the 84 articles were screened for relevance to developing the oral care assessment tool and protocol. Based on this screening, 22 articles were selected for full-text review. Two independent reviewers assessed these 22 articles against inclusion criteria and resolved disagreements through discussion. Ultimately, eight quantitative studies were chosen for detailed content review, domain specification, and item generation. The article selection process is detailed in Figure 1.
Figure 1. Flow of searching and Inclusion of relevant articles.
The developed oral care assessment tool and protocol is presented in two parts in both English and Chinese. Part I focuses on oral health screening for older LTCI residents, informed by the literature review. Several oral health assessment tools were identified, including the Oral Health Assessment Tool (OHAT), the Kayser-Jones Brief Oral Health Status Assessment (BOHSE), and other modified tools. OHAT was particularly influential in determining oral health conditions in the reviewed studies. BOHSE items were similar to OHAT. Thus, the oral health assessment tool was developed by WKL and FMFW based on OHAT and BOHSE. The appropriateness of items from the articles, essential elements for oral health screening, and applicability for LTCI healthcare workers performing regular oral health assessments were considered. The initial draft of Part I included sections assessing lips, oral mucosa, teeth, tongue, and oral-related conditions. It recommended reporting any abnormalities (pain, color changes, dryness, swelling) to the in-charge nurse and arranging a dental consultation. Part II was designed to assess oral care procedures, ensuring proper techniques to maintain resident oral health. This part included essential steps for each stage of the oral care procedure, serving as a checklist to guide healthcare workers systematically. It functions as a self-evaluation tool for healthcare workers and a skill evaluation checklist for trainees. Unsatisfactory or incomplete items require review and improvement. Part II complements Part I, reminding healthcare workers to conduct oral health assessments to identify potential problems early.
3.2. Two-Stage Expert Review
Two expert reviews ensured the applicability and appropriateness of the oral care assessment tool and protocol. In the first review, six experts (two dentists, one geriatric nurse, one nurse educator, and two dental hygienists) reviewed English and Chinese drafts of the assessment tool. Feedback was provided via email or phone, and modifications were made to align the tool with essential criteria for assessing oral health conditions and current oral care practices. For example, Item 2, ‘Use standard precautions and appropriate infection control measures during oral care’, was moved to the beginning of the checklist to emphasize infection control. Item 5, ‘Ensure the oral cavity is visible under appropriate lighting for oral care and assessment’, was highlighted for its importance. Item 10, ‘Ensure safety during oral care to all parties involved’, underscored safety precautions.
In the second review, another six experts (a community dentist, a geriatric nurse, a nurse educator, two dental nurses, and a residential home nurse) independently evaluated the tool. They assessed appropriateness, structure, clarity, and ambiguity using the preliminary CVI. CVR scores were calculated based on experts’ ratings of item relevance. Using a four-point scale, they reviewed all 23 items (seven oral health assessment, sixteen oral care procedures). Scores ranged from 3 to 4, indicating high relevance. Narrative comments led to modifications for clarity and precision, such as changing ‘whiteness’ to ‘pale’ for lip and mucosa color description. The residential home nurse suggested adding items on oral hygiene conditions like food debris and bad breath to Part I for enhanced practicality.
All six experts rated all items as ‘very relevant,’ resulting in an I-CVI score of 1.0 for each item, indicating excellent agreement on relevance and clarity. The CVR was also 1, showing all experts considered all items essential. The S-CVI/UA, calculated as the proportion of items rated ‘very relevant’ by all experts, also indicated excellent agreement.
The developed oral care assessment tool and protocol demonstrated excellent content validity. Table S1 shows expert review results, and Table S2 shows CVR and I-CVI results.
3.3. Tool Refinement
The Delphi method, using two rounds of evaluations [39], was used for tool refinement. In the first round, items were rephrased for clarity, repositioned for better flow, or removed if redundant or non-essential. Five items in Part I and eight in Part II were rephrased. One item was added to Part I, and three to Part II. Two items in Part II were repositioned. After CVI calculation and cognitive interviews, 21 items were included in the final tool (Table S1).
3.4. The Pilot Study
A pilot study assessed the applicability and feasibility of the oral care assessment tool and protocol. Participants were asked about any difficulties understanding or using the items. Twenty subjects (nursing students or enrolled nurses with oral care training) participated, 40% female, mean age 24.2 (SD 3.74). All had at least one year of oral assessment and care procedure training and were in their second year of nursing programs (higher diploma for enrolled nurse licensure or bachelor’s degree for registered nurse licensure).
Participants performed an oral health assessment and oral care procedures. They received Parts I and II beforehand for preparation. Assessments and procedures were conducted in the tertiary healthcare training institution’s laboratory. Participants paired up and performed assessments and procedures on each other. Informed consent was obtained. Two assessors independently evaluated and rated all oral care procedures using ‘unsatisfactory’, ‘satisfactory’, and ‘not done’ categories.
After procedures, participants completed Part I and provided feedback. Four subjects noted the lack of a ‘normal’ condition option in Part I for resident oral conditions. A ‘normal’ option was added to each item in Part I to address this. A footnote was added to the denture assessment for clarity on denture use and fit. The third reviewer (LWK) recommended adding a description for Item 9 of Part II for clarity on denture cleaning. Assessors recommended adding two items to Part II: ‘Maintain communication with the older resident during the procedure’ and ‘Provide brief education and/or oral condition information to the older resident after the procedure’. The finalized oral care assessment tool and protocol is shown in Table S3.
4. Discussion
Older residents often experience poorer oral health due to self-care limitations and inadequate care from healthcare workers [28]. This is concerning because poor oral health can lead to serious health problems, including non-communicable diseases and nutritional deficiencies [6,9,10]. Therefore, healthcare workers need proper training, guidance, and monitoring in oral health assessment and care.
This study developed an oral care assessment tool and protocol with two sections specifically for healthcare workers providing oral care to older residents. The study focused on the content validity and applicability of the items in these sections. Items were structured based on literature review and expert advice [39,40]. The structured sections were finalized through multiple refinement stages, including expert verification. Part I comprehensively assesses resident oral conditions. Part II provides a systematic oral care procedure for healthcare workers.
Expert reviews from dental and nursing professionals ensured the accuracy and applicability of the oral care assessment tool and protocol. Their input enhanced the tool’s relevance and feasibility for healthcare workers.
Content validity, assessed using I-CVI, S-CVI, and S-CVI/UA scores, confirmed item relevance and clarity [38,39]. The tool enables healthcare workers to effectively assess older residents’ oral conditions. It recommends detailed documentation of abnormalities and reporting to supervisors and seeking dental advice.
Pilot study participants, trained in oral health assessment and care, provided crucial feedback. Comments from an LTCI nurse improved content reliability and applicability. The pilot study confirmed item accuracy and tool feasibility [39,41]. Independent assessor evaluations further enhanced tool accuracy and applicability. The assessment tool typically takes about 10 minutes to complete.
Part I (oral health assessment) and Part II (oral care procedure) are designed to be used together, ensuring oral health assessments are not overlooked. The tool provides step-by-step guidance for healthcare workers and reminds them of essential precautions (e.g., infection control).
The finalized oral care assessment tool and protocol, developed through expert consensus and pilot testing, increases healthcare worker confidence in providing oral care. It serves as a self-evaluation or training evaluation checklist. Addressing unsatisfactory performance is crucial for resident oral health. Healthcare workers with consistently unsatisfactory ratings should receive further oral health training.
The oral health assessment and oral care procedure sections are interconnected. Oral health assessment during procedures identifies dental consultation needs, and evaluation determines assistance needs for daily oral care [29].
This oral care assessment tool and protocol is not limited to LTCIs and can be used in various clinical and community settings. Healthcare providers, including nurse assistants and nurses, require training in effective oral health assessments and care procedures [29] to prevent complications from poor oral health in dependent clients.
This study highlights the importance of oral care assessment tools and protocols for healthcare workers. Increased focus on oral health, especially for older populations, is evident in initiatives like Hong Kong’s Outreach Dental Care Programme [6,43]. This validated tool is crucial for identifying oral problems and should be used regularly. Governments should allocate resources for oral health and skill training. LTCI management should ensure adequate oral health assessments and care procedures are performed. This assessment tool should become standard in daily oral care practice in LTCIs to maintain older residents’ oral health.
4.1. Future Directions for Research and Tool Refinement
Future research should focus on further validating oral care assessment tools and protocols, especially for denture-related issues and oral health complication risks. Customizing tools based on resident care dependence levels is essential. Adapting tools to different care settings will enhance their practicality. Comparative studies of existing tools can guide further refinement. Longitudinal studies with larger samples are needed to assess long-term impacts of oral care practices and tool effectiveness.
Integrating technology, like mobile apps for data collection and personalized feedback, can improve assessment accuracy and efficiency. Collaboration with dental, geriatric, and nursing professionals is crucial for comprehensive evaluation. Standardizing assessment tools and protocols across healthcare settings will improve data comparability and promote evidence-based oral care practices.
4.2. Strengths and Weaknesses
This study successfully developed and validated an oral care assessment tool and protocol specifically for older residents’ oral health and healthcare worker procedures. This addresses a gap in oral health assessments for this population, offering a systematic approach for healthcare workers to improve daily oral care practices. The tool benefits healthcare professionals and caregivers, providing a standardized approach to oral health assessment and training.
However, the study did not include older residents directly due to practical and ethical constraints. Future studies should include residents for more comprehensive validation. While designed for older populations, modifications and revalidation are needed for use in other populations. Factor analysis was infeasible due to small sample size; larger studies are needed for robustness.
5. Conclusions
This oral care assessment tool and protocol is a significant advancement in oral health care for older populations. It uniquely combines oral health and oral care procedure assessments, developed through a rigorous process of literature review, expert input, and pilot testing. The tool demonstrates high content validity and applicability across settings, benefiting research and practice. It can evaluate staff training and performance. The oral health assessment form guides comprehensive assessments for dental management, while the procedure checklist evaluates healthcare worker performance. Using this tool can enhance oral care quality for older residents, improving their overall well-being. Government support and resources for training are essential for successful tool implementation, leading to better oral health and quality of life for older adults.
Acknowledgments
We extend our gratitude to the students in the Higher Diploma in students and Bachelor of Health Science (Major in Nursing) (Hon) programs for their invaluable support and assistance during the pilot study phase.
Supplementary Materials
The following supporting information can be downloaded at https://www.mdpi.com/article/10.3390/healthcare12050558/s1, Table S1: Expert review results for relevancy check and comments, Table S2: The CVI and CVR results, Table S3: Assessment tool for oral health and oral care procedures.
healthcare-12-00558-s001.zip (112.5KB, zip)
Author Contributions
Conceptualization, F.M.F.W.; methodology, F.M.F.W.; validation, F.M.F.W. and A.W.; formal analysis, F.M.F.W.; investigation, F.M.F.W.; resources, F.M.F.W.; data curation, F.M.F.W. and A.W.; writing—original draft preparation, F.M.F.W.; writing—review and editing, F.M.F.W., A.W., and W.K.L.; visualization, F.M.F.W., A.W., and W.K.L.; supervision, F.M.F.W.; project administration, F.M.F.W. and A.W. All authors have read and agreed to the published version of the manuscript.
Institutional Review Board Statement
The study was conducted in accordance with the Declaration of Helsinki and approved by the Research Ethics Committee of Tung Wah College (ethics application number: REC2023179 and 11 October 2023).
Informed Consent Statement
Written informed consent was obtained from all participants involved in the study.
Data Availability Statement
The data presented in this study are available on request from the corresponding author. The data are not publicly available due to participants’ confidentiality.
Conflicts of Interest
The authors declare no conflicts of interest.
Funding Statement
This research received no external funding.
Footnotes
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.
References
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
healthcare-12-00558-s001.zip (112.5KB, zip)
Data Availability Statement
The data presented in this study are available on request from the corresponding author. The data are not publicly available due to participants’ confidentiality.
