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Clinical Progress

Developing an instrument to support oral care in the


elderly
Yasunori Sumi1, Kazuki Nakajima2, Toshiyo Tamura2, Masahiro Nagaya3 and Yukihiro
Michiwaki 4
1
Department of Dental Surgery, The National Chubu Hospital, Obu City, Japan; 2Department of Gerontechnology, National Institute for
Longevity Sciences, Obu City, Japan; 3Department of Rehabilitation, The National Chubu Hospital , Obu City, Japan; 4Department of Oral
and Maxillofacial Surgery, School of Dentistry, Showa University, Tokyo, Japan

Abstract

Background: The dramatic increase in the number of dependent elderly in developed countries has created
a great need for their improved oral care. However, optimal oral care by caregivers is not possible because
of time constraints, difficulty involved in brushing other individuals’ teeth, lack of co-operation, and the
lack of perceived need. Therefore, the development of an effective instrument simplifying and supporting
oral care to relieve the strain on caregivers is a matter of some urgency. Purpose: In order to clean the
mouths of elderly dependent patients, we have developed a new oral care support instrument (an electric
toothbrush in combination with an antibacterial-agent supply and suction system). The purpose of the
present study was to develop and evaluate a new oral care support instrument. Methods: a) Plaque
removal study: The plaque- removing ability of this new instrument in 70 outpatients was compared with
the Plak Control D9011 (Braun Gillette Japan Inc.) as a control by means of the Turesky modification of
the Quigley and Hein plaque index. b) Clinical study: The subjects were 10 dependent elderly who received
oral care using the new oral care support instrument for two weeks. The plaque and gingival indices were
used for clinical evaluations. Results: a) Plaque removal study: Brushing with the new oral care support
instrument removed significantly more plaque than with the Plak Control D9011. b) Clinical study: The
new oral care support instrument allows a more effective removal of dental plaque and shows a significant
improvement in the gingival indices in dependent elderly. Conclusion: It is concluded that the new oral
care support instrument is effective and can be recommended for oral care in the dependent elderly.

Key words: Oral care, dependent elderly, aspiration pneumonia, oral care support instrument

Introduction
At the present time we are experiencing a dramatic for respiratory infection2. It is generally agreed
increase in the number of dependent elderly in that bacterial plaque is a common etiologic factor
Japanese society. Respiratory infectious diseases in the development of dental caries and
such as aspiration pneumonia are common and inflammatory periodontal disease, and it has been
costly especially in dependent or institutionalized suggested that dental and denture plaque serve as
elderly1. The morbidity and mortality that result a reservoir for respiratory pathogens, especially
from aspiration pneumonia are recognized as a in high-risk patients with poor oral hygiene 2,3.
major geriatric health problem. Persons with poor Recently, it was reported that good oral care is
oral health have a greater risk for colonization by important in lowering the risk of pneumonia
respiratory pathogens and therefore a greater risk among the institutionalized elderly 4. Plaque

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4 Yasunori Sumi, Kazuki Nakajima, Toshiyo Tamura, Masahiro Nagaya and Yukihiro Michiwaki

retention is a problem in elderly people who may caregivers is a matter of some urgency6,7. Our
have difficulty in mechanically removing plaque recent study showed that 96% of caregivers desired
owing to diminished manual dexterity, impaired methods for cleansing the mouth in addition to
vision, or illness. The older person’s ability to those used in current oral care, and 99% hoped for
perform self-care may gradually decrease with age, the development and dissemination of simple oral
and the role of the caregiver in daily oral care care equipment 6. Although reported results
becomes increasingly important. However, optimal underscore the importance of developing
oral care by caregivers is not always possible equipment to simplify and facilitate oral care, few
because of time constraints, difficulty involved in instruments of this kind have been proposed in the
brushing other individuals’ teeth, lack of co- literature. We have therefore developed an
operation, and the lack of perceived need. In instrument for simpler, easier oral care based on
addition, it has also been reported that while 343 an electric toothbrush (Figure 1a), then used a pilot
nursing home residents in the UK preferred clinical trial to evaluate its effectiveness.
assistance in oral care, only 94 (27%) responded New oral care support instrument
that the care-giving staff had helped them5. This The new instrument for easier oral care (Figure
suggests that oral care is given a low priority among 1a) is based on the Plak Control D9011 (Braun
many caregivers. Gillette Japan Inc.). It has a cup-shaped brush head
Since oral care by caregivers is often performed with a diameter of 13 mm. The brush head features
in such a way that the caregiver may have a narrow an oscillating/rotating movement with a free angle
field of vision or is in an uncomfortable posture, of oscillation of 60º and speed of 3,800 rpm8. The
the development of an instrument simplifying and novel brush head design incorporates an
supporting oral care to relieve the strain on antibacterial-agent (0.25% of Povidone-Iodine

Figure 1b. Round brush head in action. The new brush


head design incorporates an antibacterial agent supply
system in its centre.

Figure 1a. Overall view of the new oral care support


instrument
A: Brush head; B: Antibacterial-agent on/off switch; C:
Suction head with light fibre illumination; D: Portable Figure 1c. Structural diagram of the brush head of the new
suction device; E: Drip infusion system; F: Foot controller oral care support instrument.

Gerodontology
© The Gerodontology Association 2003
Developing an instrument to support oral care in the elderly 5

solution) supply system in its centre for effective 65 to 77 years (mean age: 70.5 years; sex: 3 male,
removal of food debris and adhesive plaque (Figure 7 female). They were screened to exclude those
1b and 1c). The antibacterial agent is supplied to with (a) fewer than 6 natural teeth and (b) acute
the brush head by a drip infusion system at the intra-oral lesions such as acute periodontitis,
rate of 5 ml/min. The remodelling of the brush head gingival abscess and acute stomatitis. They
for the clinical trial was carried out by The National received oral care using the new oral care brush
Chubu Hospital and National Institute for from a dentist once a day for 2 minutes for 2 weeks.
Longevity Sciences with the permission of Braun Oral care was performed between meals at about
Gillette Japan Inc. Suction was performed using a 10-11 a.m. Before beginning the use of the new
commercially available portable device. In this instrument, the amount of dental plaque was
study, the new oral care support instrument for the evaluated according to the Turesky modification
oral care of elderly patients was evaluated by of the Quigley and Hein plaque index9, and
dentists, not caregivers. We are at present preparing gingival inflammation was evaluated with the
a patent for this new oral care support instrument. criteria for the gingival index system of Loe-
Silness gingival index10. The lingual and buccal
Materials and Methods surfaces of each tooth were scored. The average
a) Plaque removal outpatient study index score was determined for each individual.
The newly developed oral care brush was After 2 weeks of this oral care, the same plaque
investigated with the Plak Control D9011 as a and gingival indices were scored before the oral
control. Seventy outpatients were selected with care and between meals at about 10-11 a.m. A
ages ranging from 60 to 84 years (mean age: 67.2 Wilcoxon test for matched pairs was used to
years; sex: 30 male, 40 female). They were compare data before and after oral care. Values of
screened to exclude those having fewer than 4 p<0.05 were accepted as statistically significant.
natural teeth per quadrant and acute intra-oral
lesions such as acute periodontitis, gingival abscess Results
and acute stomatitis. a) Plaque removal outpatient study
The examiner evaluated the amount of dental Figure 2 shows the results of plaque assessment
plaque according to the Turesky modification of according to the Turesky modification of the
the Quigley and Hein plaque index9. The lingual Quigley and Hein plaque index. At baseline the
and buccal surfaces of each tooth were scored. The mean plaque index was 2.29 ± 0.94 (oral care
subject’s mouth was then brushed in a split-mouth support instrument) and 2.29 ± 0.90 (the Plak
order by the examiner using the two brushes. In Control D9011), respectively. After 2 minutes of
random order, either the 1st and 3rd or 2nd and brushing, the mean scores were 0.56 ± 0.34 (oral
4th quadrants were brushed with one toothbrush. care support instrument) and 0.72 ± 0.36 (the Plak
The two remaining quadrants were then brushed Control D9011). Brushing with the oral care
using the other. The brushing time was 30 seconds support brush removed significantly (p<0.01)
per quadrant, that is, 15 seconds for the buccal and more plaque than with the Plak Control D9011.
15 seconds for the lingual surfaces. To maintain
adequate visibility for the professional brusher, no
toothpaste was used in this experiment. After
brushing, the examiner re-evaluated the plaque (the
Turesky modification of the Quigley and Hein
plaque index). The same examiner performed oral
care and evaluated the amount of dental plaque
before and after oral care. The average index score
was determined for each individual. Differences
between the plaque index end-scores of the two
brushes were tested using a repeated measure
analysis. Baseline scores were used as a covariate.
A Wilcoxon test for matched pairs was used to
compare the data for both brushes. Values of
p<0.05 were taken as statistically significant.
b) Clinical study Figure 2. Comparative results of plaque removal
between new oral care support instrument and Plak
The subjects were 10 dependent elderly in the Control D9011 according to Turesky modification of
National Chubu Hospital with ages ranging from Quigley and Hein plaque index.

Volume 20, No. 1


6 Yasunori Sumi, Kazuki Nakajima, Toshiyo Tamura, Masahiro Nagaya and Yukihiro Michiwaki

b) Clinical study reinforces the innate tendency of oral


In Figure 3a, the data on plaque assessment are microorganisms to survive i.e. their vastly greater
presented. At baseline the mean plaque index was ability to adhere tenaciously to tooth surfaces and
3.52 ± 0.82. After 2 weeks of oral care, the mean oral mucosa than other bacteria. Thus, an
score was 1.98 ± 0.62. Analysis of the data antibacterial agent supply and suction system
indicated a significant improvement in the plaque during oral care is important to remove the
index (p<0.01) over the 2-week period. microorganisms that accumulate because of a
The mean scores for gingival evaluation are person’s inability to perform oral irrigation, the
shown in Figure 3b, and an analysis of the data greater adherence of oral microorganisms to tooth
reveals a significant improvement in the gingival surfaces and oral mucosa and the presence of
index (p<0.01). At baseline the mean gingival xerostomia in older people.
index was 2.42 ± 0.31, and after 2 weeks of oral Plaque is a thin, transparent layer of bacteria
care the score was 1.71 ± 0.28. (biofilm) on the tooth surface that can only be
Representative intra-oral clinical photographs removed by mechanical cleaning. Biofilms are
(Figure 4) of a 72-year-old woman with dementia defined as matrix-enclosed bacterial populations
show the potential beneficial effects of the use of adherent to each other and/or to surfaces or
the new oral care support instrument. interfaces. It is well known that bacteria in biofilms
are much more resistant to antibiotics than are
Discussion planktonic bacteria. Biofilm cells are at least 500
Elderly people are often unable to cleanse their times more resistant to an antibacterial-agent12. It
mouth by irrigation to decrease the number of is necessary to destroy the biofilm for complete
microorganisms in the oral cavity. In addition, they removal of the plaque. Whereas one of the main
are often prescribed a variety of drugs, many of methods of oral physiotherapy is the use of the
which contribute to xerostomia, which may manual toothbrush, electric toothbrushes are
increase the risk of colonization and pneumonia perceived by the general population as an easy
because of the poor clearance of bacteria and the method of reducing plaque deposits in the mouth,
potential for bacterial aspiration11. Another factor thereby preventing dental caries and periodontal

Figure 3a. Plaque assessment before and after 2 weeks of


oral care with the new oral care support instrument.

Figure 4. Representative clinical intra-oral photographs


Figure 3b. Gingival index before and after 2 weeks of oral of a 72-year-old woman with dementia a) before and
care with the new oral care support instrument b) following 8 days use of the new oral care instrument.

Gerodontology
© The Gerodontology Association 2003
Developing an instrument to support oral care in the elderly 7

disease. Braun Gillette markets a type of electric Acknowledgement


toothbrush with a mode of action that resembles This research was supported in part by Health
that of a prophylactic instrument used Sciences Research Grants (Comprehensive
professionally in the cleansing of the teeth13. Research on Aging and Health 12-21) from the
Electric toothbrushes produce a disturbance of the Ministry of Health, Labour and Welfare, Japan.
fluid around the bristles during motion, and this
may have an additive effect on the purely
mechanical action of the toothbrush. Sahota et al.
reported that the removal process depends on the
nature of the contact and whether water is present14.
Although removal is mainly due to the mechanical
action of the bristles, there is additional removal
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Volume 20, No. 1


8 Yasunori Sumi, Kazuki Nakajima, Toshiyo Tamura, Masahiro Nagaya and Yukihiro Michiwaki

12. Costerton J W, Lewandowski A, Caldwell D Address for correspondence:


E, et al. Microbial biofilms. Ann Rev Microbiol
1995; 49: 711-745. Dr Yasunori Sumi, D.D.S., Ph.D.
Director, Division of Dental Surgery
13. Van der Weijden G A, Danser M M, Nijboer The National Chubu Hospital
A, et al. The plaque-removing efficacy of an 36-3, Gengo, Morioka
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1993; 20: 273-278. Japan

14. Sahota H, Landini G, Walmsley A D. A testing Business Phone: +81-562-46-2311 ext. 731
system for electric toothbrushes. Am J Dent 1998; Fax Number: +81-562-44-8518
11: 271-275. E-mail address: yasusumi@chubu-nh.go.jp

Gerodontology
© The Gerodontology Association 2003