Barriers and facilitators for provision of oral health care in dependent older people: a systematic review

  • Gerd GöstemeyerEmail author
  • Sarah R. Baker
  • Falk Schwendicke



Provision of oral health care (OHC), including oral hygiene (OH) or oral/dental treatment, to dependent older people (DOP) is frequently insufficient. We aimed to assess barriers and facilitators perceived by different healthcare professionals towards providing OHC to DOP.

Materials and methods

A systematic review was performed. Studies reporting on knowledge, attitudes, and beliefs acting as barriers and facilitators for provision of OHC were included. One database (PubMed) was searched and data extraction independently performed by two reviewers. Thematic analysis was used and identified themes translated to the domains and constructs of the theoretical domains framework (TDF) and aligned with the domains of the behavior change wheel (BCW). Analyses were stratified for the two target behaviors (providing oral hygiene and providing oral/dental treatment) and according to different stakeholders’ perspective. For quantitative analysis, frequency effect sizes (FES) were calculated.


In total, 1621 articles were identified and 41 (32 quantitative, 7 qualitative, 2 mixed method) studies included. Within these 41 studies, there were 7333 participants (4367 formal caregivers, 67 informal caregivers, 1100 managers of care, 1322 dentists, 340 DOP). Main barriers for providing OH were “lack of knowledge” (FES 65%, COM-B domain: capability, TDF domain: knowledge) and “patients refusing care” (62%, opportunity, environmental context and resources). Main facilitators were “OHC training/education” (41%, capability, skills) and “presence of a dental professional” (21%, opportunity, environmental context and resources). Main barriers for provision of dental treatment were “lack of suitable facilities for treatment/transportation of patients” (76%) and “patients refusing care” (53%) (both: opportunity, environmental context and resources). Main facilitators were “regular visiting dentist” (35%) and “routine assessment/increased awareness by staff” (35%) (both: opportunity, environmental context and resources).


A number of barriers and facilitators for providing different aspects of OHC were identified for different stakeholders.

Clinical relevance

Our findings help provide the evidence to develop implementation strategies for providing high-quality systematic OHC to DOP.


This review was registered at Prospero (CRD42017056078).


Elderly Barriers Facilitators Oral hygiene Dental care Qualitative studies 



Newcastle-Ottawa Scale


theoretical domains framework


capability, opportunity, motivation, and behavior model


oral healthcare


oral hygiene


dependent older people


frequency effect size


behavior change wheel



We appreciate the support of Prof. Gabriele Meyer (Martin-Luther-Universität Halle-Wittenberg, Germany) for her useful comments on our study and the manuscript.


This study was funded by the authors and their institutions.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

For this type of study, formal consent is not required.

Supplementary material

784_2019_2812_MOESM1_ESM.docx (652 kb)
ESM 1 (DOCX 651 kb)


  1. 1.
    Petersen PE, Kandelman D, Arpin S, Ogawa H (2010) Global oral health of older people--call for public health action. Community Dent Health 27:257–267Google Scholar
  2. 2.
    Jordan R, Micheelis W (2015) In: Jordan, Micheelis U SU (ed) Fünfte Deutsche Mundgesundheitsstudie. IDZ, KölnGoogle Scholar
  3. 3.
    Eke PI, Wei L, Borgnakke WS, Thornton-Evans G, Zhang X, Lu H, McGuire LC, Genco RJ (2016) Periodontitis prevalence in adults >/= 65 years of age, in the USA. Periodontol 72:76–95CrossRefGoogle Scholar
  4. 4.
    Lopez R, Smith PC, Gostemeyer G, Schwendicke F (2017) Ageing, dental caries and periodontal diseases. J Clin Periodontol 44(Suppl 18):S145–S152CrossRefGoogle Scholar
  5. 5.
    De Visschere LM, Grooten L, Theuniers G, Vanobbergen JN (2006) Oral hygiene of elderly people in long-term care institutions--a cross-sectional study. Gerodontology 23:195–204CrossRefGoogle Scholar
  6. 6.
    El-Rabbany M, Zaghlol N, Bhandari M, Azarpazhooh A (2015) Prophylactic oral health procedures to prevent hospital-acquired and ventilator-associated pneumonia: a systematic review. Int J Nurs Stud 52:452–464CrossRefGoogle Scholar
  7. 7.
    Sjogren P, Nilsson E, Forsell M, Johansson O, Hoogstraate J (2008) A systematic review of the preventive effect of oral hygiene on pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes: effect estimates and methodological quality of randomized controlled trials. J Am Geriatr Soc 56:2124–2130CrossRefGoogle Scholar
  8. 8.
    Desvarieux M, Demmer RT, Rundek T, Boden-Albala B, Jacobs DR Jr, Papapanou PN, Sacco RL, Oral I, Vascular Disease Epidemiology S (2003) Relationship between periodontal disease, tooth loss, and carotid artery plaque: the Oral Infections and Vascular Disease Epidemiology Study (INVEST). Stroke 34:2120–2125CrossRefGoogle Scholar
  9. 9.
    Saarela RK, Soini H, Hiltunen K, Muurinen S, Suominen M, Pitkala K (2014) Dentition status, malnutrition and mortality among older service housing residents. J Nutr Health Aging 18:34–38CrossRefGoogle Scholar
  10. 10.
    Porter J, Ntouva A, Read A, Murdoch M, Ola D, Tsakos G (2015) The impact of oral health on the quality of life of nursing home residents. Health Qual Life Outcomes 13:102CrossRefGoogle Scholar
  11. 11.
    Crocombe LA, Broadbent JM, Thomson WM, Brennan DS, Poulton R (2012) Impact of dental visiting trajectory patterns on clinical oral health and oral health-related quality of life. J Public Health Dent 72:36–44CrossRefGoogle Scholar
  12. 12.
    Chalmers JM, Carter KD, Spencer AJ (2003) Oral diseases and conditions in community-living older adults with and without dementia. Spec Care Dentist 23:7–17CrossRefGoogle Scholar
  13. 13.
    Warren JJ, Chalmers JM, Levy SM, Blanco VL, Ettinger RL (1997) Oral health of persons with and without dementia attending a geriatric clinic. Spec Care Dentist 17:47–53CrossRefGoogle Scholar
  14. 14.
    Hoben M, Clarke A, Huynh KT, Kobagi N, Kent A, Hu H, Pereira RAC, Xiong T, Yu K, Xiang H, Yoon MN (2017) Barriers and facilitators in providing oral care to nursing home residents, from the perspective of care aides: A systematic review and meta-analysis. Int J Nurs Stud 73:34–51CrossRefGoogle Scholar
  15. 15.
    Weening-Verbree L, Huisman-de Waal G, van Dusseldorp L, van Achterberg T, Schoonhoven L (2013) Oral health care in older people in long term care facilities: a systematic review of implementation strategies. Int J Nurs Stud 50:569–582CrossRefGoogle Scholar
  16. 16.
    Forsell M, Sjogren P, Johansson O (2009) Need of assistance with daily oral hygiene measures among nursing home resident elderly versus the actual assistance received from the staff. Open Dent J 3:241–244CrossRefGoogle Scholar
  17. 17.
    Bots-VantSpijker PC, Vanobbergen JN, Schols JM, Schaub RM, Bots CP, de Baat C (2014) Barriers of delivering oral health care to older people experienced by dentists: a systematic literature review. Community Dent Oral Epidemiol 42:113–121CrossRefGoogle Scholar
  18. 18.
    Frenkel H, Harvey I, Newcombe RG (2000) Oral health care among nursing home residents in Avon. Gerodontology 17:33–38CrossRefGoogle Scholar
  19. 19.
    Albrecht M, Kupfer R, Reissmann DR, Muhlhauser I, Kopke S (2016) Oral health educational interventions for nursing home staff and residents. Cochrane Database Syst Rev 9:CD010535Google Scholar
  20. 20.
    Godin G, Belanger-Gravel A, Eccles M, Grimshaw J (2008) Healthcare professionals' intentions and behaviours: a systematic review of studies based on social cognitive theories. Implement Sci 3:36CrossRefGoogle Scholar
  21. 21.
    Pearson A, Chalmers J (2004) Oral hygiene care for adults with dementia in residential aged care facilities. JBI Libr Syst Rev 2:1–89Google Scholar
  22. 22.
    Hearn L, Slack-Smith L (2015) Oral health care in residential aged care services: barriers to engaging health-care providers. Aust J Prim Health 21:148–156CrossRefGoogle Scholar
  23. 23.
  24. 24.
    Atkins L, Francis J, Islam R, O'Connor D, Patey A, Ivers N, Foy R, Duncan EM, Colquhoun H, Grimshaw JM et al (2017) A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implement Sci 12:77CrossRefGoogle Scholar
  25. 25.
    Tong A, Flemming K, McInnes E, Oliver S, Craig J (2012) Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Med Res Methodol 12:181CrossRefGoogle Scholar
  26. 26.
    Moher D, Liberati A, Tetzlaff J, Altman D (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6:e1000097CrossRefGoogle Scholar
  27. 27.
    Tran VT, Porcher R, Falissard B, Ravaud P (2016) Point of data saturation was assessed using resampling methods in a survey with open-ended questions. J Clin Epidemiol 80:88–96CrossRefGoogle Scholar
  28. 28.
    Francis JJ, Johnston M, Robertson C, Glidewell L, Entwistle V, Eccles MP, Grimshaw JM (2010) What is an adequate sample size? Operationalising data saturation for theory-based interview studies. Psychol Health 25:1229–1245CrossRefGoogle Scholar
  29. 29.
    Tran VT, Porcher R, Tran VC, Ravaud P (2016) Predicting data saturation in qualitative surveys with mathematical models from ecological research. J Clin EpidemiolGoogle Scholar
  30. 30.
    LA J, MN A (1996) Qual Health Res 6:553–560CrossRefGoogle Scholar
  31. 31.
    Noblit G, Hare R (1988) Meta-ethnography: synthesizing qualitative studies. Sage, Newbury ParkCrossRefGoogle Scholar
  32. 32.
    Michie S, van Stralen MM, West R (2011) The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 6:42CrossRefGoogle Scholar
  33. 33.
    Lau R, Stevenson F, Ong BN, Dziedzic K, Treweek S, Eldridge S, Everitt H, Kennedy A, Qureshi N, Rogers A et al (2016) Achieving change in primary care--causes of the evidence to practice gap: systematic reviews of reviews. Implement Sci 11:40CrossRefGoogle Scholar
  34. 34.
    Sandelowski M, Barroso J, Voils CI (2007) Using qualitative metasummary to synthesize qualitative and quantitative descriptive findings. Res Nurs Health 30:99–111CrossRefGoogle Scholar
  35. 35.
    Suga US, Terada RS, Ubaldini AL, Fujimaki M, Pascotto RC, Batilana AP, Pietrobon R, Vissoci JR, Rodrigues CG (2014) Factors that drive dentists towards or away from dental caries preventive measures: systematic review and metasummary. PLoS One 9:e107831CrossRefGoogle Scholar
  36. 36.
    Herzog R, Alvarez-Pasquin MJ, Diaz C, Del Barrio JL, Estrada JM, Gil A (2013) Are healthcare workers' intentions to vaccinate related to their knowledge, beliefs and attitudes? A systematic review. BMC Public Health 13:154CrossRefGoogle Scholar
  37. 37.
    Schwendicke F, Gostemeyer G (2016) Understanding dentists' management of deep carious lesions in permanent teeth: a systematic review and meta-analysis. Implement Sci 11:142CrossRefGoogle Scholar
  38. 38.
    Garrido Urrutia C, Romo Ormazabal F, Espinoza Santander I, Medics Salvo D (2012) Oral health practices and beliefs among caregivers of the dependent elderly. Gerodontology 29:e742–e747CrossRefGoogle Scholar
  39. 39.
    Gil-Montoya JA, de Mello AL, Cardenas CB, Lopez IG (2006) Oral health protocol for the dependent institutionalized elderly. Geriatr Nurs 27:95–101CrossRefGoogle Scholar
  40. 40.
    Dharamsi S, Jivani K, Dean C, Wyatt C (2009) Oral care for frail elders: knowledge, attitudes, and practices of long-term care staff. J Dent Educ 73:581–588Google Scholar
  41. 41.
    Khanagar S, Naganandini S, Tuteja JS, Naik S, Satish G, Divya KT (2015) Improving Oral Hygiene in Institutionalised Elderly by Educating Their Caretakers in Bangalore City, India: a Randomised Control Trial. Can Geriatr J 18:136–143Google Scholar
  42. 42.
    Goh CE, Guay MP, Lim MY, Lim SM, Loke SY, Toh HE, Nair R (2016) Correlates of attitudes and perceived behavioural control towards oral care provision among trained and untrained nursing home caregivers in Singapore. J Clin Nurs 25:1624–1633CrossRefGoogle Scholar
  43. 43.
    Hardy DL, Darby ML, Leinbach RM, Welliver MR (1995) Self-report of oral health services provided by nurses'aides in nursing homes. J Dent Hyg 69:75–82Google Scholar
  44. 44.
    Hasson H, Arnetz JE (2008) Nursing staff competence, work strain, stress and satisfaction in elderly care: a comparison of home-based care and nursing homes. J Clin Nurs 17:468–481Google Scholar
  45. 45.
    Reed R, Broder HL, Jenkins G, Spivack E, Janal MN (2006) Oral health promotion among older persons and their care providers in a nursing home facility. Gerodontology 23:73–78CrossRefGoogle Scholar
  46. 46.
    Reis SC, Marcelo VC, da Silva ET, Leles CR (2011) Oral health of institutionalised elderly: a qualitative study of health caregivers' perceptions in Brazil. Gerodontology 28:69–75CrossRefGoogle Scholar
  47. 47.
    Czarkowski G, Allroggen S, Koster-Schmidt A, Bausback-Schomakers S, Frank M, Heudorf U (2013) Oral health hygiene education programme for nursing personnel to improve oral health of residents in long-term care facilities 2010 in Frankfurt/Main, Germany. Gesundheitswesen 75:368–375CrossRefGoogle Scholar
  48. 48.
    Young BC, Murray CA, Thomson J (2008) Care home staff knowledge of oral care compared to best practice: a West of Scotland pilot study. Br Dent J 205:E15 discussion 450-451CrossRefGoogle Scholar
  49. 49.
    Unfer B, Braun KO, Ferreira AC, Ruat GR, Batista AK (2012) Challenges and barriers to quality oral care as perceived by caregivers in long-stay institutions in Brazil. Gerodontology 29:e324–e330CrossRefGoogle Scholar
  50. 50.
    Willumsen T, Karlsen L, Naess R, Bjorntvedt S (2012) Are the barriers to good oral hygiene in nursing homes within the nurses or the patients? Gerodontology 29:e748–e755CrossRefGoogle Scholar
  51. 51.
    Wardh I, Jonsson M, Wikstrom M (2012) Attitudes to and knowledge about oral health care among nursing home personnel--an area in need of improvement. Gerodontology 29:e787–e792CrossRefGoogle Scholar
  52. 52.
    Le P, Dempster L, Limeback H, Locker D (2012) Improving residents' oral health through staff education in nursing homes. Spec Care Dentist 32:242–250CrossRefGoogle Scholar
  53. 53.
    Stancic I, Petrovic M, Popovac A, Vasovic M, Despotovic N (2016) Caregivers' attitudes, knowledge and practices of oral care at nursing homes in Serbia. Vojnosanit Pregl 73:668–673CrossRefGoogle Scholar
  54. 54.
    Chiba Y, Shimoyama K, Suzuki Y (2009) Recognition and behaviour of caregiver managers related to oral care in the community. Gerodontology 26:112–121CrossRefGoogle Scholar
  55. 55.
    Shimoyama K, Chiba Y, Suzuki Y (2007) The effect of awareness on the outcome of oral health performed by home care service providers. Gerodontology 24:204–210CrossRefGoogle Scholar
  56. 56.
    Rabbo MA, Mitov G, Gebhart F, Pospiech P (2012) Dental care and treatment needs of elderly in nursing homes in Saarland: perceptions of the homes managers. Gerodontology 29:e57–e62CrossRefGoogle Scholar
  57. 57.
    Webb BC, Whittle T, Schwarz E (2013) Provision of dental care in aged care facilities, NSW, Australia - part 1 as perceived by the directors of nursing (care providers). Gerodontology 30:226–231CrossRefGoogle Scholar
  58. 58.
    Jablonski RA, Munro CL, Grap MJ, Schubert CM, Ligon M, Spigelmyer P (2009) Mouth care in nursing homes: knowledge, beliefs, and practices of nursing assistants. Geriatr Nurs 30:99–107CrossRefGoogle Scholar
  59. 59.
    Forsell M, Kullberg E, Hoogstraate J, Herbst B, Johansson O, Sjogren P (2010) A survey of attitudes and perceptions toward oral hygiene among staff at a geriatric nursing home. Geriatr Nurs 31:435–440CrossRefGoogle Scholar
  60. 60.
    Forsell M, Sjogren P, Kullberg E, Johansson O, Wedel P, Herbst B, Hoogstraate J (2011) Attitudes and perceptions towards oral hygiene tasks among geriatric nursing home staff. Int J Dent Hyg 9:199–203CrossRefGoogle Scholar
  61. 61.
    Webb BC, Whittle T, Schwarz E (2015) Provision of dental care in aged care facilities NSW Australia- Part 2 as perceived by the carers (care providers). Gerodontology 32:254–259CrossRefGoogle Scholar
  62. 62.
    de Mello AL, Padilha DM (2009) Oral health care in private and small long-term care facilities: a qualitative study. Gerodontology 26:53–57CrossRefGoogle Scholar
  63. 63.
    Schembri A, Fiske J (2005) Oral health and dental care facilities in Maltese residential homes. Gerodontology 22:143–150CrossRefGoogle Scholar
  64. 64.
    Hagman-Gustafsson ML, Holmen A, Stromberg E, Gabre P, Wardh I (2008) Who cares for the oral health of dependent elderly and disabled persons living at home? A qualitative study of case managers' knowledge, attitudes and initiatives. Swed Dent J 32:95–104Google Scholar
  65. 65.
    Lindqvist L, Seleskog B, Wardh I, von Bultzingslowen I (2013) Oral care perspectives of professionals in nursing homes for the elderly. Int J Dent Hyg 11:298–305CrossRefGoogle Scholar
  66. 66.
    Lewis A, Kitson A, Harvey G (2016) Improving oral health for older people in the home care setting: An exploratory implementation study. Australas J Ageing 35:273–280CrossRefGoogle Scholar
  67. 67.
    Delgado AM, Prihoda T, Nguyen C, Hicks B, Smiley L, Taverna M (2016) Professional Caregivers' Oral Care Practices and Beliefs for Elderly Clients Aging In Place. J Dent Hyg 90:244–248Google Scholar
  68. 68.
    Knevel R, Foley J, Gussy M, Karimi L (2016) Does enhancing personal care assistants' own oral health influence their attitudes and practices towards oral care for residents - a pilot study. Int J Dent Hyg 14:249–254CrossRefGoogle Scholar
  69. 69.
    Janssens B, Vanobbergen J, Lambert M, Schols J, De Visschere L (2018) Effect of an oral healthcare programme on care staff knowledge and attitude regarding oral health: a non-randomised intervention trial. Clin Oral Investig 22:281–292CrossRefGoogle Scholar
  70. 70.
    Preston AJ, Kearns A, Barber MW, Gosney MA (2006) The knowledge of healthcare professionals regarding elderly persons' oral care. Br Dent J 201:293–295 discussion 289; quiz 304CrossRefGoogle Scholar
  71. 71.
    Paley GA, Slack-Smith L, O'Grady M (2009) Oral health care issues in aged care facilities in Western Australia: resident and family caregiver views. Gerodontology 26:97–104CrossRefGoogle Scholar
  72. 72.
    Chalmers JM, Hodge C, Fuss JM, Spencer AJ, Carter KD, Mathew R (2001) Opinions of dentists and directors of nursing concerning dental care provision for Adelaide nursing homes. Aust Dent J 46:277–283CrossRefGoogle Scholar
  73. 73.
    Antoun JS, Adsett LA, Goldsmith SM, Thomson WM (2008) The oral health of older people: general dental practitioners' beliefs and treatment experience. Spec Care Dentist 28:2–7CrossRefGoogle Scholar
  74. 74.
    De Visschere LM, Vanobbergen JN (2006) Oral health care for frail elderly people: actual state and opinions of dentists towards a well-organised community approach. Gerodontology 23:170–176CrossRefGoogle Scholar
  75. 75.
    Smith BJ, Ghezzi EM, Manz MC, Markova CP (2008) Perceptions of oral health adequacy and access in Michigan nursing facilities. Gerodontology 25:89–98CrossRefGoogle Scholar
  76. 76.
    Hopcraft MS, Morgan MV, Satur JG, Wright FA (2008) Dental service provision in Victorian residential aged care facilities. Aust Dent J 53:239–245CrossRefGoogle Scholar
  77. 77.
    Nunez B, Chalmers J, Warren J, Ettinger RL, Qian F (2011) Opinions on the provision of dental care in Iowa nursing homes. Spec Care Dentist 31:33–40CrossRefGoogle Scholar
  78. 78.
    Matear D, Barbaro J (2006) Caregiver perspectives in oral healthcare in an institutionalised elderly population without access to dental services: a pilot study. J R Soc Promot Heal 126:28–32CrossRefGoogle Scholar
  79. 79.
    Thompson CA, Spilsbury K, Hall J, Birks Y, Barnes C, Adamson J (2007) Systematic review of information and support interventions for caregivers of people with dementia. BMC Geriatr 7:18CrossRefGoogle Scholar
  80. 80.
    de Lugt-Lustig KH, Vanobbergen JN, van der Putten GJ, De Visschere LM, Schols JM, de Baat C (2014) Effect of oral healthcare education on knowledge, attitude and skills of care home nurses: a systematic literature review. Community Dent Oral Epidemiol 42:88–96CrossRefGoogle Scholar
  81. 81.
    Amerine C, Boyd L, Bowen DM, Neill K, Johnson T, Peterson T (2014) Oral health champions in long-term care facilities-a pilot study. Spec Care Dentist 34:164–170CrossRefGoogle Scholar
  82. 82.
    Holm-Pedersen P, Vigild M, Nitschke I, Berkey DB (2005) Dental care for aging populations in Denmark, Sweden, Norway, United kingdom, and Germany. J Dent Educ 69:987–997Google Scholar
  83. 83.
    Zenthofer A, Schroder J, Cabrera T, Rammelsberg P, Hassel AJ (2014) Comparison of oral health among older people with and without dementia. Community Dent Health 31:27–31Google Scholar
  84. 84.
    Delwel S, Binnekade TT, Perez RS, Hertogh CM, Scherder EJ, Lobbezoo F (2017) Oral health and orofacial pain in older people with dementia: a systematic review with focus on dental hard tissues. Clin Oral Investig 21:17–32CrossRefGoogle Scholar
  85. 85.
    Dentistry AAoP (2016) Guideline on Behavior Guidance for the Pediatric Dental Patient. Pediatr Dent 38:185–198Google Scholar
  86. 86.
    Gostemeyer G, Schulze F, Paris S, Schwendicke F (2017) Arrest of Root Carious Lesions via Sodium Fluoride, Chlorhexidine and Silver Diamine Fluoride In Vitro. Materials (Basel) 11Google Scholar
  87. 87.
    Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0.
  88. 88.
    Hartling L, Hamm M, Milne A, Vandermeer B, Santaguida PL, Ansari M, Tsertsvadze A, Hempel S, Shekelle P, Dryden DM (2012) In: Validity and Inter-Rater Reliability Testing of Quality Assessment Instruments. AHRQ Methods for Effective Health Care, Rockville (MD)Google Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Operative and Preventive DentistryCharité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of HealthBerlinGermany
  2. 2.School of Clinical DentistryUniversity of SheffieldSheffieldUK

Personalised recommendations