Purpose: The primary aim was to describe the effects for nursing home residents of monthly professional cleaning and individual oral hygiene instruction provided by registered dental hygienists (RDHs), in comparison with daily oral care as usual. The secondary aim was to study the knowledge and attitudes among nursing staff regarding oral health care and needs. Patients and Methods: In this randomised controlled trial (RCT), 146 residents were recruited from nine nursing homes in Regions of Stockholm and Sörmland and were randomly assigned (on nursing home level) to either intervention group (I; n=72) or control group (C; n=74). Group I received monthly professional cleaning, individual oral hygiene instructions and information given by an RDH. Group C proceeded with daily oral care as usual (self-performed or nursing staff-assisted). Oral health-related data was registered with the mucosal-plaque score index (MPS), the modified sulcus bleeding index (MSB), and root caries. The nursing staff’s attitudes and knowledge were analysed at baseline and at six-month follow-up. Statistical analysis was performed by Fisher’s exact test and two-way variance analysis (ANOVA). Results: Improvements were seen in both Group I and Group C concerning MPS, MSB and active root caries. The nursing staff working with participants in Group I showed significant improvements regarding the Nursing Dental Coping Beliefs Scale (DCBS) in two of four dimensions, oral health care beliefs (p=0.0331) and external locus of control (p=0.0017) compared with those working with Group C. The knowledge-based questionnaire showed improvement (p=0.05) in Group I compared with Group C. Conclusion: Monthly professional oral care, combined with individual oral health care instructions, seems to improve oral hygiene and may reduce root caries among nursing home residents. This may also contribute to a more positive attitude regarding oral hygiene measures among nursing home staff, as compared with daily oral care as usual.

With care dependency, untreated root caries lesions (RCLs) and irregular dental visits are common. RCLs, if left untreated, could lead to pain, tooth loss, difficulties eating, and impact on general health. Therefore, there is a need for prevention and effective treatment for RCLs, and especially in those with care dependency. The aim of this systematic review was to investigate the effect of domiciliary professional oral care on root caries development and progression, in comparison with self-performed or nurse-assisted oral care. A literature search was conducted in four databases in November 2022. Two authors independently screened the literature throughout the review process. Five of the identified studies were found to be relevant. Four of these were assessed as having moderate risk of bias and were included in the review, while one study had high risk of bias and was excluded from further analyses. Due to heterogenicity of the included studies (and of the interventions and outcomes), no meta-analysis or synthesis without meta-analysis (SWiM) was performed. The participation of dental personnel performing mechanical plaque removal and fluoride, or chlorhexidine application seems beneficial for care-dependent older adults with risk of RCLs development and progression. However, future studies are needed.

Background: With care dependency, irregular dental visits are common, leading to an increased risk of poor oral status and low oral health-related quality of life (OHRQoL). Therefore, the overall aim of this thesis was to evaluate the impact of domiciliary professional dental care on oral health and OHRQoL in care- dependent older adults, and to establish recommendations for home-based preventive care.Methods: The project was conducted between 2016 and 2024 and comprised four studies. Studies I, III and IV were randomized controlled trials. Study I followed care-dependent older adults at nursing homes for six months and investigated the effect of monthly professional dental cleaning on gingival bleeding compared with daily oral care as usual. Study II was a systematic review in which six researchers screened reports for inclusion (260 years of age and ≥1 natural tooth), intervention (professional dental cleaning at home) and outcome (root caries lesions [RCLs]), individually and in group sessions. Studies III and IV studied the additional effect of professional dental cleaning every third month on RCLs and OHRQoL among older adults with in-home care who received high- fluoride (Duraphat®) toothpaste for daily use.Results: Study I (n=124) showed less gingival bleeding and dental plaque at six months, and the intervention group (n=69) showed fewer active RCLs (p=0.05). Study II included four studies (out of 331) that showed fewer active and new RCLs at final registrations when adding fluoride products by dental personnel. Due to heterogeneity, no meta-analysis was performed. In Studies III and IV, 82 participants (intervention=50) remained at one-year registration. Progression of RCLs were seen in both groups (22%=intervention, 28%=control) without significant difference. Correlation investigation showed an association between progression of RCLs and dental plaque amount (p=0.0014). Study IV showed moderate OHRQoL at both baseline and follow-up.Conclusion: Additional sodium fluoride can prevent and arrest new RCLs. Professional dental cleaning may support oral hygiene at nursing homes but not among older adults with in-home care who use high-fluoride toothpaste daily. Therefore, preventive strategies should focus on availability and adherence to high-fluoride toothpaste for the dentate part of this population.List of scientific papersI. Girestam Croonquist C, Dalum J, Skott P, Sjögren P, Wårdh I, Morén E. Effects of Domiciliary Professional Oral Care for Care-Dependent Elderly in Nursing Homes - Oral Hygiene, Gingival Bleeding, Root Caries and Nursing Staff's Oral Health Knowledge and Attitudes. Clin Interv Aging. 2020;15:1305-1315.https://doi.org/10.2147/CIA.S236460II. Morén E, Skott P, Edman K, Gavriilidou N, Wårdh I, Domeij H. The Effect of Domiciliary Professional Oral Care on Root Caries Progression in Care-Dependent Older Adults: A Systematic Review. J Clin Med. 2023;12(7):2748. https://doi.org/10.3390/jcm12072748III. Moren E, Skott P, Gabre P, Sjögren P, Wårdh I. Impact of Home- Based Professional Dental Cleaning on Oral Health in Care- Dependent Older Adults - A Randomized Controlled Trial - Part 1: Clinical Variables. [Manuscript]IV. Moren E, Gabre P, Sjögren P, Wårdh I, Skott P. Impact of Home- Based Professional Dental Cleaning on Oral Health in Care- Dependent Older Adults - A Randomized Controlled Trial - Part 2: Self-Reported Data and Oral Health-Related Quality of Life. [Manuscript]

Objective: The trial aimed to study the additive effect of domiciliary professional dental cleaning on root caries lesions (RCLs), oral hygiene outcomes and oral health-related quality of life (OHRQoL) in care-dependent older adults with in-home care that use high fluoride toothpaste, compared with oral care as usual for a year. Basic research design: Parallel-group evaluator-blinded randomized controlled trial. Clinical settings: Participants own home in Sweden. Participants: 194 care-dependent with in-home care aged ≥65 years and ≥1 natural tooth were randomized (1:1) in blocks by computer-generated sequence. 149 were available at baseline (intervention (I) = 80, control (C) = 69). All were provided with toothbrushes and high-fluoride toothpaste (5,000 ppm F) for daily use. Intervention: Domiciliary professional dental cleaning and oral hygiene instructions by dental assistant, every third month. Main outcomes: The primary outcome was RCLs progression. Secondary outcomes were gingival bleeding, oral hygiene, hyposalivation and OHRQoL, registered at baseline and after 1 year by dental hygienists. Results: Due to high attrition (45%), 82 individuals remained (I = 50, C = 32) after 1 year resulting in an underpowered study. The number of subjects assessed with RCLs progression was 11 (22.0%) in I group and 9 (28.1%) in C. With the use of per protocol analysis, no significant differences between groups were seen for any of the outcomes. Conclusions: Domiciliary professional dental cleaning to care-dependent older adults does not seem to have any additive preventing effect on RCLs to daily toothbrushing with high-fluoride toothpaste. This suggests that focus be maintaining good daily oral health routines rather than home-care visits to maintain oral health.

Background: With care dependency, irregular dental visits are common, leading to an increased risk of poor oral status and low oral health-related quality of life (OHRQoL). Therefore, the overall aim of this thesis was to evaluate the impact of domiciliary professional dental care on oral health and OHRQoL in care- dependent older adults, and to establish recommendations for home-based preventive care.Methods: The project was conducted between 2016 and 2024 and comprised four studies. Studies I, III and IV were randomized controlled trials. Study I followed care-dependent older adults at nursing homes for six months and investigated the effect of monthly professional dental cleaning on gingival bleeding compared with daily oral care as usual. Study II was a systematic review in which six researchers screened reports for inclusion (260 years of age and ≥1 natural tooth), intervention (professional dental cleaning at home) and outcome (root caries lesions [RCLs]), individually and in group sessions. Studies III and IV studied the additional effect of professional dental cleaning every third month on RCLs and OHRQoL among older adults with in-home care who received high- fluoride (Duraphat®) toothpaste for daily use.Results: Study I (n=124) showed less gingival bleeding and dental plaque at six months, and the intervention group (n=69) showed fewer active RCLs (p=0.05). Study II included four studies (out of 331) that showed fewer active and new RCLs at final registrations when adding fluoride products by dental personnel. Due to heterogeneity, no meta-analysis was performed. In Studies III and IV, 82 participants (intervention=50) remained at one-year registration. Progression of RCLs were seen in both groups (22%=intervention, 28%=control) without significant difference. Correlation investigation showed an association between progression of RCLs and dental plaque amount (p=0.0014). Study IV showed moderate OHRQoL at both baseline and follow-up.Conclusion: Additional sodium fluoride can prevent and arrest new RCLs. Professional dental cleaning may support oral hygiene at nursing homes but not among older adults with in-home care who use high-fluoride toothpaste daily. Therefore, preventive strategies should focus on availability and adherence to high-fluoride toothpaste for the dentate part of this population.List of scientific papersI. Girestam Croonquist C, Dalum J, Skott P, Sjögren P, Wårdh I, Morén E. Effects of Domiciliary Professional Oral Care for Care-Dependent Elderly in Nursing Homes - Oral Hygiene, Gingival Bleeding, Root Caries and Nursing Staff's Oral Health Knowledge and Attitudes. Clin Interv Aging. 2020;15:1305-1315.https://doi.org/10.2147/CIA.S236460II. Morén E, Skott P, Edman K, Gavriilidou N, Wårdh I, Domeij H. The Effect of Domiciliary Professional Oral Care on Root Caries Progression in Care-Dependent Older Adults: A Systematic Review. J Clin Med. 2023;12(7):2748. https://doi.org/10.3390/jcm12072748III. Moren E, Skott P, Gabre P, Sjögren P, Wårdh I. Impact of Home- Based Professional Dental Cleaning on Oral Health in Care- Dependent Older Adults - A Randomized Controlled Trial - Part 1: Clinical Variables. [Manuscript]IV. Moren E, Gabre P, Sjögren P, Wårdh I, Skott P. Impact of Home- Based Professional Dental Cleaning on Oral Health in Care- Dependent Older Adults - A Randomized Controlled Trial - Part 2: Self-Reported Data and Oral Health-Related Quality of Life. [Manuscript]