Evaluating the effectiveness of fluoride varnish in preventing caries amongst Long‐Term Care Facility Residents

: Objective To evaluate the effectiveness of professionally applied fluoride varnish on the incidence of dental caries amongst older adults resident in LTCFs in Northern Ireland. Background The oral health status of older adults within Long-Term Care Facilities (LTCFs) is significantly worse than their community living peers. Whilst evidence suggests an important role for fluoride varnish in preventing caries in this population, very few studies have evaluated this intervention. Materials and Methods A quality improvement project was undertaken with dentate residents (n = 190) in nine LTCFs who had fluoride varnish applied by Dental Care Professionals on two separate occasions during a 12-month period (intervention group). Nine LTCFs were chosen as matched controls (control group) with comparable numbers of residents of similar medical status (n = 217). For the intervention group, oral hygiene training was also provided for the care home staff. Results A total of 407 patients (n = 271 female) were included in the analyses (mean age [SD]: 84.1 [6.6] years). After 12 months, the intervention group recorded a significant reduction in mean number of carious teeth (mean [95% CI]: −0.85 [−1.12, −0.58]; P < .001). Patients in the control group had significant increases in the mean number of carious teeth (mean [95% CI]: 0.21 [0.05, 0.37]; P = .012), mean plaque score (mean [95% CI]: 1.16 [0.28, 2.04]; P = .010) and mean DMFT score (mean [95% CI]: 0.13 [0.04, 0.22]; P = .004). Conclusions This the potential role of fluoride varnish in with oral hygiene training for staff in the prevention arrest of carious lesions among Abstract Objective: To evaluate the effectiveness of professionally applied fluoride varnish on the incidence of dental caries amongst older adults resident in LTCFs in Northern Ireland. Background: The oral health status of older adults within Long- Term Care Facilities (LTCFs) is significantly worse than their community living peers. Whilst evidence suggests an important role for fluoride varnish in preventing caries in this population, very few studies have evaluated this intervention. Materials and Methods: A quality improvement project was undertaken with dentate residents (n = 190) in nine LTCFs who had fluoride varnish applied by Dental Care Professionals on two separate occasions during a 12- month period (intervention group). Nine LTCFs were chosen as matched controls (control group) with comparable numbers of residents of similar medical status (n = 217). For


| INTRODUCTION
The World Health Organisation (WHO) has projected a rapid worldwide increase in the number of older people, defined as those aged 65 years and over, from approximately 5.24 million in 2010 to almost 1.5 million by 2050. 1 These changing population demographics are accompanied by concurrent trends of increased retention of natural teeth among older adults. 2,3 In 1979, 33% of the Northern Irish adult population were edentulous, compared to an estimated 4% in the most recent UK Adult Dental Health Survey. 3 Edentulism among adults aged seventy-five and over has fallen from 74% to around 40% within the same period. 3 Increases in the number of natural teeth retained and the number of sound, untreated teeth have also been noted, with more pronounced improvements identified among older age groups.
While these developments enable a greater proportion of adults to preserve a lifetime functional dentition, significant challenges exist in maintaining this dentition against the background of chronic dental diseases. 4 This holds true, in particular, for older adults residing in Long-Term Care Facilities (LTCFs). The annual dental caries increment among LTCF residents is more than double that of equivalent community-dwelling older adults, whilst for those suffering from dementia, it is more than twice the rate again. 5 In the United Kingdom, it is reported that more than half of older adults who live in LTCFs experience dental caries, in comparison to 40% of over 75s who live independently. 6 There is now acknowledgement of the inequalities in oral health provision experienced by LTCF residents, accompanied by calls for immediate action by relevant stakeholders to address these disparities. 7 Within the United Kingdom, the National Institute for Health and Care Excellence (NICE) publishes evidence-based guidelines on all aspects of health care. In 2016, NICE published "Oral health for adults in care homes (NG48)" which included a series of recommendations for LTCFs including improving access to dental services for LTCF residents, improving the oral health knowledge and skills of care home staff and the implementation of oral health assessments, mouth care plans and daily oral care for all residents. 6 Whilst the guideline development committee reviewed all available evidence on oral health of LTCF residents, they acknowledged a lack of good quality data on the effectiveness of oral health interventions for LTCF residents and identified this as a priority area for future research.
The role of fluoride in the prevention of dental caries and the mechanisms through which this preventative effect is achieved have been well described; however, the vast majority of studies investigating the effects of fluoride interventions have been carried out in children. 8,9 Studies including adults have shown that fluoride is an effective caries preventative measure across all age groups, whilst a review of fluoride interventions to prevent root caries in adults found that the regular application of topical fluoride was effective in achieving this. 10

| Inclusion and exclusion criteria
Nine LCTFs agreed to be part of the QI project. All residents within these LTCFs were patients who were already receiving oral health care from the CDS. All dentate residents within the nine LTCFs who provided verbal consent for oral examination and the application of fluoride varnish were included (n = 190). Edentulous residents (n = 121), those unable to co-operate or provide consent for examination or fluoride varnish application, were excluded (n = 44).
Residents who were unable to consent and had no registered power of attorney were deemed to have not consented and were therefore excluded. Residents with a medical history which precluded the application of fluoride products or those with facial or oral infections were also excluded (n = 1).

| Delivery of the intervention
Oral health assessments of the residents within the nine LTCFs recruited to the QI project were carried out by three calibrated senior dentists (Senior Dental Officers) from the CDS between January and The oral health assessments by the same three senior dentists from the CDS were repeated 12 months following the initial assessment. The assessment was undertaken according to the same clinical procedure described for the baseline assessment, and all examinations were undertaken within the LTCFs.

| Control homes
In order to evaluate the intervention provided as part of the QI programme, the oral health of residents within the programme was In the matched LTCFs, oral health assessments of the residents were also carried out by the same three calibrated senior dentists (Senior Dental Officers) from the CDS between February and March 2017 (CMG, JMG, GQ). This was a baseline assessment of oral health status with data collected including a plaque score and hard tissue charting to generate a DMFT Score. 12 Assessments were carried out within the LTCFs with residents sitting in an upright chair and illumination provided by a mobile light. Data were collected on specifically designed data collection sheets, and all examinations were undertaken within the LTCFs. Treatment was provided for patients by the Senior Dental Officers to render the patients dentally fit at baseline. All dentate residents within the matched LTCFs were included (n = 217) with only edentate residents (n = 151) and those unable to co-operate or provide consent for examination (n = 58) excluded.
None of the activities of the extended preventative QI programme were delivered within the control LTCFs as they continued to operate under usual practices during the 12-month period. The oral health assessments by the same two senior dentists from the CDS were repeated twelve months following the initial assessment.
The assessment was undertaken according to the same clinical procedure described for the baseline assessment, and all examinations were undertaken within the LTCFs.

| Data analysis
The data collected for each resident were anonymised, cleaned and entered into an electronic database in preparation for statis- therefore, logistic regression analysis was not untaken with this variable.

| Ethical considerations
Ethical

| RESULTS
A total of 407 older adults were included in the study (n = 217 in the control group; n = 190 in the intervention group). The entire patient sample was 71% (n = 291) female with a mean (SD) age of 84.  Table 2, similar results were observed using LOCF approach for dealing with missing data (only lost to follow-up participants had missing data at 12 months).
The impact of fluoride varnish application on change in oral health measurements over 12 months is shown in

| DISCUSSION
This analysis has demonstrated a statistically significant reduction (P < .001) in the incidence of carious lesions amongst dentate LTCF residents who received professionally applied fluoride varnish com-  Note: Data presented as mean (SD) or a frequency (%). Differences between the intervention and control groups were analysed using independent samples t-test for continuous variables   Control (n = 217) -0.08 (0.03, 0.13) ** a Within group differences analysed using paired samples t-test and only significant results are presented.
b Differences between control and intervention groups were analysed using ANCOVA, adjusting for baseline measurements and gender, age and number of teeth at baseline.
c Adjusted for baseline DMFT score also. Abbreviations: DMFT, decayed, missing and filled teeth; LOCF, Last observation carried forward.

Study
Commission "Smiling matters: oral health in care homes" reviewed 100 care homes in England and concluded that the majority of people living in care homes were not being adequately supported to maintain and improve their oral health. 17 The report found that 73% of care plans did not or only partly addressed oral health, while 52% of care homes did not have an oral care plan for residents and 47% of care home staff had not received any oral health training. The findings of this study identified poor levels of oral hygiene among LTCF residents in both intervention and control groups, with high plaque scores recorded for the majority of participants at both baseline and follow-up oral health assessments. This occurred despite the delivery of oral health training for care home staff among the intervention group, as part of the wider QI project. While the oral healthcare training of care home staff has been rightly identified as a priority area, this finding suggests that careful consideration should be given to underlying factors that may prohibit the success of this approach, as an isolated measure. High staff turnover, in combination with staff shortages, a reluctance among care home staff to undertake oral hygiene practices for residents, and a lack of understanding regarding the importance of oral health and its impact on general health have been cited as barriers to the provision of effective oral care in care homes. 18 In addition, the importance of high levels of dietary intakes of refined carbohydrates by dentate residents within LTCFs cannot be overstated.

| CONCLUSIONS
This study has provided encouraging evidence on the effectiveness of professionally applied fluoride varnish in combination with a staff training programme on caries incidence amongst LTCF residents. A statistically significant reduction in mean numbers of carious teeth was observed between baseline and 12-month follow-up for patients who received two applications of fluoride varnish compared with controls who did not (P < .001). The study outcomes should be interpreted with caution given the manner of data collection and the high rates of patients lost to follow-up. Further attention still needs to be drawn to providing effective training packages for LTCF staff as oral cleanliness did not improve for residents despite training being provided.