Older people are representative of a vulnerable population group who suffers greatly from oral diseases.¹⁾ In 2017, the number of individuals over the age of 60 years exceeded 962 million, twice as large as in 1980.²⁾ The population is ageing in both high-income countries (HICs) and low- and middle-income countries (LMICs), however, by 2050, 80% of the population will be living in LMICs.³⁾ According to the census 2011, the proportion of the older adults in India is 8.6%.⁴⁾ The rising ageing population will significantly affect healthcare systems, as the older adults are susceptible to frailty and care dependency. When the older adults become frail and in need of complex care, they may be admitted to old age homes.⁵⁾

Increasing age is one of the strongest risk factors for poor oral health.⁶⁾ In India, the only national oral health survey shows that the prevalence of oral diseases such as dental caries, periodontal disease, oral mucosal lesions, and extraoral lesions among the older adults aged between 65 and 74 years for 2002–2003 is 85% and 79.9%, 10.3% and 2.8%.⁷⁾ The 12.3% of older adults reported complete tooth loss⁸⁾ and it found that older adults who reported tooth loss were 2.38 times significantly more likely to have poor Self-Rated Health (SRH) (95% confidence interval [CI] 1.99–2.83). Dental care and treatment are a greater problem for the institutionalized older adults, which increases the prevalence of oral diseases. Institutionalized older adults have poorer oral health status than non-institutionalized older adults.⁹⁾ A meta-analysis revealed that institutionalized older adults have a greater prevalence of edentulousness (odds ratio=2.28, 95% CI 1.68–3.07) and a higher number of decayed teeth (mean difference [MD]=0.88, 95% CI 0.71–1.05) and missed teeth (MD=4.58, 95% CI 1.89–7.27).⁹⁾ Edentulism is related to the inability of an older adult to carry out social activities such as talking with peers and participating in support networks.¹⁰⁾

Older adults populations with non-communicable diseases (NCDs) are also at a higher risk of experiencing oral health issues, and those with inadequate oral health are more likely to struggle with managing their NCDs effectively.¹¹⁾ Poor oral health also raises healthcare costs and is linked to increased risk for malnutrition,¹²⁾ pneumonia,¹³⁾ respiratory disease,¹⁴⁾ diabetes¹⁵⁾ and cardiovascular disease¹⁶⁾ and also affects the quality of life.¹⁷⁾ Functional limitations related to impairments associated with chronic disabling health conditions often result in this population requiring high levels of support from others with eating or drinking and daily oral care.¹⁸⁾ Reliance upon others to maintain a clean mouth and the presence of dysphagia impact oral health considerably.¹⁸⁾

Oral health can be determined by different factors among the older adults, especially those who have limited functional or self-care ability.¹⁹⁾ Providing oral care to institutionalized older adults is a complex and challenging care task.²⁰⁾ Lack of knowledge and training in providing proper oral care to residents, non-professional and unregulated workforce, high workloads and frequent interruptions throughout their process of care, general dislike of oral care, general difficulties in providing oral care and lack of staff are contributing factors that deteriorate the oral health of the older adults.²⁰⁾ Oral health of institutionalized older adults, where there were no routine dental check-ups or oral care provisions, had a greater risk of poor oral health. Dental professionals visit old age homes not just to examine or treat a resident, but to teach caregivers simple oral hygiene techniques that can minimize oral health problems for the people in their care.²¹⁾ Unlike countries like Brazil, Japan, Thailand, and the United States, there is no formal training for geriatric dentistry in India, and geriatric dentistry is not recognized as a specialty. Rather than, “free denture” services by some district health cells and dental schools, there is no specific oral healthcare policy for older adults.²²⁾ Even-though many qualitative studies have been conducted in countries like Australia,²³⁾ Brazil,^24,25) Sweden,²⁶⁾ there is a lack of data from the perspective of caregivers of old age homes in India. Against this background, studies have been planned to explore caregivers’ perception in providing oral healthcare services to institutionalized eldelry.

A mixed method study was conducted from June 1, 2019 to October 30, 2019 in various old age homes in Bengaluru. The quantitative component involves assessing the oral health status and caregivers’ perceptions regarding the oral health status of institutionalized older adults. The qualitative part entails evaluating caregivers’ perceptions in providing oral healthcare services for institutionalized older adults. The participants signed a written informed consent form and the study was approved by the Ethics Committee (MSRUAS/UECHT/2018-20/32). This study complied with to be the ethical guidelines for authorship and publishing in the Annals of Geriatric Medicine and Research.²⁷⁾

Quantitative data collection includes the sociodemographic details of the caregivers and data on caregivers’ perceptions of the oral health of inmates, including the frequency of teeth cleaning (e.g., “How often do you clean his/her teeth?”), were collected. Additionally, the oral health status of institutionalized older adults was assessed using “World Health Organization (WHO) oral health performa-2013.”

A convenience sample of 54 institutionalized older adults and 54 caregivers, assigned to the selected institutionalized individuals, were enrolled for quantitative data. With assistance from caregiv­ers, oral health status was assessed. For qualitative data collection, the purposive sampling method was utilized. After obtaining per­mission from the administrators of four different old age homes, it was decided to interview a minimum of 12–15 caregivers from each home. However, due to data saturation, the final sample com­prised 12 caregivers. Participants who had been working as care­givers for at least 6 months or more at the time of data collection were included in the study.

For qualitative data, a research team consisted of two dental public health specialist (S.K.M. and P.K.) and a post graduate student of Public Health Dentistry (A.J.). The author (A.J.) conducted in-depth interviews and primary data analysis. The other two authors (S.K.M. and P.K.) were involved in the study design and review of the analysis. Researchers decreased bias by refraining from reading relevant literature during data collection and analysis and avoiding discussions about their opinions. Furthermore, the researchers had no personal interest in the result. The principal investigator (A.J.) prepared the Key Informant Interview (KII) guides based on the literature review and brainstorming with the research team.

The questionnaire includes sociodemographic details about the caregiver, followed by questions such as: How important is oral health for the older adults? What oral health services are provided at this institution? What are the barriers to providing oral health services or maintaining oral health for institutionalized older adults? What services would be useful for improving the oral health of institutionalized older adults? Do you have any further suggestions for improving oral healthcare? Is there anything else that you would like to add?

The qualitative data collection involved conducting face-to-face in-depth interviews (IDIs) with caregivers at the old age homes. The interview questions delved into the caregivers’ perceptions of providing oral healthcare services to institutionalized older adults. Participants were given advanced notice before the interview, a broad outline of the subject to be discussed, an indication of the type of information required of the participant, the reasons why the research was being carried out and how the information they provided would be used. An initial interview with a few opening questions was conducted to develop rapport-building between the investigator and the participant. The in-depth interviews ranged in duration from 30 to 45 minutes. All interviews were digitally recorded with the participant’s consent. Initially, the data underwent transcription in Kannada and were sent to participants for member checking. Subsequently, an expert translated the data into English with a clear understanding of both languages.

Quantitative data were collected and analyzed using the SPSS (Released 2023, IBM SPSS Statistics for Windows, Version 29.0.2.0; IBM Corp., Armonk, NY, USA). Sociodemographic variables, perceptions and practices of caregivers, and oral health status of institutionalized older adults were presented descriptively.

For qualitative data, the recording was transcribed into verbatim. Initially, verbatim was read thoroughly. The translated document underwent data analysis through coding using the inductive method. Primarily, manual coding was conducted by two coders. Qualitative research data analysis occurred concurrently following each interview. The investigators then jointly compared the emerging themes and re-examined the data to achieve consensus and confirm thematic saturation using a code-recode strategy.

Among 54 caregivers, 41 (75.9%) were females and 13 (24.1%) were males. More than 50% caregivers aged above 35 and 70.4% rendered their services to inmates’ full-time employment (Table 1). More than 50% of caregivers perceived that the oral health status of institutionalized older adults was fair (Table 2), 87% of the caregivers did not provide any support for brushing the teeth of institutionalized older adults. Mean DMFT (decayed, missing, filled teeth) was 15.52±8.23. The prevalence of periodontal pocket and loss of attachment among institutionalized elderly was 76% and 64.8% respectively (Table 3).

Twelve in-depth interviews were conducted with the caregivers. Among the participants eight were female and four were male. The participant’s age ranged from 35 to 53 years (Table 4).

This study aimed to examine the oral health status and explore perceptions of oral health services in old age homes using a mixed method approach. This type of research offers valuable insights into the fundamental conceptual processes and operational dynamics often disregarded by more quantitative approaches. Even though our results showed that oral health condition of institutionalized older adults is poor, consistent with the study conducted by Bhadauria et al.²⁸⁾ and Prasad et al.,²⁹⁾ caregivers perceived the oral health of older adults as fair which indicates lack of knowledge or awareness about the oral health condition. Nearly 50% of caregivers do not provide support to older adults for oral hygiene care. These results are consistent with the findings by Dharamsi et al.³⁰⁾

After interviewing 12 caregivers of institutionalized older adults in Bangalore, we have gained some understanding of the barriers in providing timely oral healthcare for institutionalized older adults and suggestions that need to be adopted.

Barriers in providing oral healthcare services were

(1) Autonomy/lack of cooperation: The oral health services for older adults with mental or physical impairment are often neglected by the caregivers according to the findings by the Lindqvist et al.²⁶⁾ The lack of co-operation by the older adults was the most common obstacle reported by caregivers. Negative attitudes and bad moods are disincentives to those who have to carry out oral care, leading to inadequate service.^23,24,31,32)

(2) Difficulty to travel: The caregivers mentioned that lack of appropriate transport or inability of inmates to travel alone impedes their ability to seek dental care outside of their immediate environment. De Mello and Padilha²⁴⁾ also agreed that difficulty in moving is one of the barriers to providing oral healthcare.

(3) Lack of financial support: The high cost of dental care poses a substantial barrier, particularly for inmates who lack the financial means to meet their dental needs. This underscores a notable inequality in accessing essential healthcare services within the incarcerated population. The observation highlights the need for targeted interventions, including exploring more affordable dental care alternatives and implementing financial assistance programs. Findings from grounded theory analysis by Paulsson et al.³¹⁾ and qualitative study by Paley et al.²³⁾ was consistent with our findings.

(4) Lack of knowledge: Caregivers frequently possess limited knowledge and education regarding oral hygiene care and dental diseases, which constrains their capacity to offer suitable assistance to residents. Reis et al.³²⁾ evaluated the caregivers’ perceptions of the oral health of institutionalized older adults and found that the majority believed that loss of teeth was part of the ageing process, corroborating our findings. A study by Wardh et al.³³⁾ stated that 35% of nursing home personnel had no formal education in oral healthcare.

(5) Lack of time: Caregivers identified conflicting priorities in their daily work routines lack of time as serious factors for not providing oral care for older adults. Rushed care from lack of time is an especially important trigger of responsive behaviors.²⁰⁾ Findings from other studies also support the evidence.^23,31,32) To overcome this barrier, there is a critical need for streamlined care protocols, ensuring that sufficient time is allocated to address the dental needs of institutionalized older adults individuals. By recognizing the importance of oral health within the broader spectrum of care, institutions can foster a more holistic approach, ultimately enhancing the overall well-being.

The data demonstrated that a combined strategic approach is needed at the macro and process levels to address the identified barriers. Firstly, oral health education explicitly targeted at the older adults is crucial. Older adults can be empowered to maintain oral health by tailor- made oral health education. Pam­phlets, brochures, and visual aids can serve as valuable resources for oral health education by reinforcing key messages and promoting oral care practices. Monthly visits by dentists can facilitate early detection of dental issues and ensure timely intervention. Additionally, the personal interaction with a dentist can help build trust and alleviate any concerns, contributing to a positive attitude towards oral health. Portable dental chair services further enhance accessibility by bringing dental care directly to the older adults in institutionalized settings. This innovation addresses mobility challenges and ensures on-site treatment and preventive care. Portable dental services or on-site treatment rooms were suggested to facilitate regular on-site visits.²³⁾ Collaboration with dental clinics and colleges extends the reach of specialized care to old age homes. This partnership not only benefits the institutionalized older adults but also provides practical training opportunities for dental students. The provision of oral hygiene aids is a simple yet effective strategy. Ensuring that residents have access to toothbrushes, toothpaste, and dental floss encourages regular oral care practices.

Enhancing the standard of oral health services within the institution could be achieved through an ongoing evaluation of the oral care provided to the older adults. This assessment should consider the involvement of inmates, caregivers, and administrators, prioritizing clinical effectiveness and efficiency and factors such as quality of life and autonomy. Integrating the promotion, prevention, and recovery of oral health into the regular care routine of institutions is essential for fostering sustained improvements in oral healthcare.

In conclusion, perceptions of caregivers about the oral health of institutionalized older adults is fair, even though the oral health status is poor. Barriers to oral health services include autonomy, difficulty to travel, and lack of financial support, lack of knowledge and time. Suggestions for improving oral health services for institutionalized older adults include oral health education for older adults and caregivers, monthly visit of dentist to the institution, utilization of portable dental chair services, collaboration with dental colleges/dental clinics, distribution of oral health education materials and provision of oral hygiene aids. To provide comprehensive oral healthcare services in old age homes, there is a need to develop an institutional policy by collaborating with the dental colleges. Additionally, it’s time for a realistic strategic action plan from Dental Public Health professionals to address the unique challenges and strive towards promoting better oral health outcomes and overall well-being among institutionalized older adults.