Hoben M, Yoon M N, Lu L, Estabrooks C A. If we cannot measure it, we cannot improve it: understanding measurement problems in routine oral/dental assessments in Canadian nursing homes - part I. Gerodontology 2020; DOI: 10.1111/ger.12449.

Yoon M N, Lu L L, Ickert C, Estabrooks C A, Hoben M. If we cannot measure it, we cannot improve it: understanding measurement problems in routine oral/dental assessments in Canadian nursing homes - part II. Gerodontology 2020; DOI: 10.1111/ger.12467.

Poor communication and training denies opportunities for prevention.

Poor oral health among nursing home (NH) residents causes pain and discomfort, and may lead to malnutrition and respiratory disease. Altered aesthetics and speech may lead to loss of self esteem and social isolation. The Resident Assessment Instrument-MDS 2.0 (RAI-MDS2.0) is used in many countries as a validated and reliable tool to assess and monitor NH residents. However, the nine items within the instrument which assess oral health status have been shown to have limited value, recording general items such as swallowing and chewing problems, pain, presence of debris, dentures and missing teeth, broken loose or carious teeth, gum problems and daily cleaning.

In part 1, the authors compared the oral health status of a sample of residents (n=103) from four nursing homes, as assessed by 1) experienced dental hygienists (DH) and 2) research assistants (RA) specially trained in the use of the oral component of RAI-MDS2.0, with the records held by the nursing home. The number of issues identified by both DHs and RAs exceeded those recorded by the care staff. For instance, care staff had recorded no pain or gum problems and that only 1% of the residents did not receive mouth cleaning once per day. RAs found pain in 16% of residents, gum problems in 17% and no daily cleaning in 51%. DHs found higher rates of tooth problems (24% v 4%) and gum problems (75% v 0%) than care home staff. The inter-rater reliability between the RAs was generally poor but generally good for the DHs.

A lack of training and consistency is highlighted in part 2, using focus groups to unpack the issues raised in part 1. The diagnosis of pain, for instance, depended on the resident being able to verbalise it as an issue, despite many of their patients having dementia and consequently being unable to describe their problem. Oral pain, therefore, might (or might not) be recognised by a change in eating habits. One nurse reports recognising a tooth as discoloured, therefore noted it as carious. Nursing aides thought an unpleasant smell and a black appearance was a sign of dental caries. Oral problems only appear to be reported when disease was severe, thus limiting opportunities for early intervention and prevention. The authors suggest that the descriptions of mouth problems within the RAI-MDS2.0 user manual are limited and unhelpful. The need for improved standardised definitions, appropriate to non-specialist staff, and training to teach assessors exactly what to look for, would provide early warnings of oral disease and improve the accuracy and efficacy of RAI-MDS2.0.