Development of practice guidelines for daily oral care in care‐dependent older adults to complement the InterRAI suite of instruments using a modified Delphi approach

Abstract Aim To develop practice guidelines for nursing assistants who provide daily oral care to older adults. Background The interRAI suite of instruments is internationally used in professional health care to assess the needs of care‐dependent older persons. An optimised oral health section was developed recently to identify care clients with poor oral health and hygiene. Internationally shared guidelines for daily oral care are needed to complement the optimised oral health section of the interRAI suite of instruments. Material and methods The modified Delphi approach started with the preparation of an initial draft. Subsequently, an online survey and a face‐to‐face discussion were conducted with international experts. Their feedback was used to revise the draft. Two additional online surveys were conducted with the experts to reach consensus agreement for each item of the revised version. The same group of experts was invited to the different study phases. Results The three surveys were completed by 26, 27 and 23 international experts, respectively. A group of 18 experts completed each survey, whereof a subgroup of 11 experts also took part in the face‐to‐face discussion. Experts were dental hygienists, dentists, nursing scientists, physicians and psychologists from 14 different countries. After the final survey, consensus agreement was reached for 54 of the 57 (94.7%) items, representing the final version of the guidelines. Conclusion Available evidence was combined with practical feedback from international experts to develop clear and concise practice guidelines for daily oral care in older adults. Implications for practice The guidelines will help to improve knowledge and reduce barriers of nursing assistants to provide daily oral care.

Aneffectivedailyoralcareisindispensabletomaintaingoodoral health. It mainly aims to prevent dental decay and gum disease by disintegration of the bacterial biofilm and application of active ingredients (Sbordone&Bortolaia,2003).Incare-dependentolderadults, preventive measures are particularly relevant as curative treatment isoftenchallengedbycognitiveandphysicalimpairment.Inaddition, evidence is available that daily oral care reduces the risk of aspirationpneumonia (Sjögrenetal.,2016;VanDerMaarel-Wierinketal., 2013).
Older persons in professional care settings often lack the ability toperformadequatedailyoralcareindependently.Thistaskisusually delegated to nursing assistants who are also called nurse's aides orhealthcareaides(Hobenetal.,2017).
• The available evidence was complemented with practice-based feedback and consensus agreement from internationalexperts.
• Contradicting national guidelines were harmonised.
What are the implications of this new knowledge for nursing care with older people?
• The guidelines will help to improve knowledge and reduce barriers of nursing assistants to provide daily oral care.
• Byfacilitatingadequatedailyoralcare,oralhealthwill improve. In turn, this will contribute to better general healthandqualityoflife.
How could the findings be used to influence policy or practice or research or education?
• The guidelines complement the optimised oral health section that recently was developed for the interRAI suite of instruments.
• The guidelines are also applicable for education and training of nursing assistants or other direct care providers.
care and palliative care versions became available. To harmonise these different versions, the interRAI suite of instruments was released in 2005. It consists of a core of common items that is com- To recruit international experts, a call was circulated among members of the European College of Gerodontology. In addition, emails were sent to dental hygienists, dentists, nursing scientists, physiciansandpsychologistswithanacademic-clinicalbackground related to oral health in care-dependent older adults. The experts had to be affiliated with an organisation located in a country where instrumentsoftheinterRAIsuitewereused.
In survey 1,quantitativeandqualitativefeedbackwasprovided by the experts. Participants indicated the extent of agreement witheachitemona5-pointLikertscale(1stronglyagree,2agree, 3 nor agree/nor disagree, 4 disagree, 5 strongly disagree). They wereinstructedtoassumethatresourcesintermsofstaffing,time and material were sufficiently available. Participants were invited to provide general and item-wise feedback and to suggest additional items.
The face-to-face discussion was conducted with a subgroup of experts during a conference meeting of the European College of Gerodontology. Items that reached only medium or low consensus on agreement in survey 1wereconsidered.Theexpertsdiscussedhow these items could be revised or whether they should be eliminated.
All qualitative feedback contributions provided by the experts in survey 1andduringtheface-to-facediscussionwereappraisedby theresearchteamandusedtorevisethedraft.Thisresultedinan interim version of the guidelines.

| Selection phase
The selection phase consisted of two online surveys (survey 2 and survey 3).Itaimedtoselectthoseitemsfromtheinterimversionthat

Phase
Step N
reached high or very high consensus on agreement among the inter- In survey 2,participantsassessedeachitemoftheinterimversion.
Items that did not achieve high or very high consensus on agreement in survey 2werere-assessedinsurvey 3.Inthislastsurvey,expertswere provided with a summary of the scientific evidence and the results of

thepreviousstepsforeachitem.Thisapproachisacharacteristicof
Delphi studies and allows participants to reconsider their responses.
The final version of the guidelines was constituted by those items that achieved high or very high consensus on agreement in survey 3 at the latest.

| Ethics
FollowingtheBelgianlaw(Wetinzakeexperimentenopdemenselijkepersoon,2004),approvalfromamedicalethicscommitteewas notnecessaryforthisstudy.Datawerecollectedanonymously,and participation was completely voluntarily. Participants provided consent that data would be used for education and research purposes.
Survey 1 was completed by 26 participants from 10 countries.
The face-to-face discussion was conducted with a subgroup of 11 participantsfrom6countries.Mostparticipantsweredentists,but otherprofessionswererepresentedaswell.Twelveitemsachieved only moderate or low consensus on agreement in survey 1. These itemswerereviewedintheface-to-facediscussion.
Qualitative feedback contributions included the concern that dailyoralcarerequiredanindividualised,client-centredapproach.In

| Selection phase
Twenty-seven experts from 12 countries participated in survey 2.

| Items not included in the final version of the guidelines
Only 3 items of the interim version did not achieve high or very high consensusonagreement.Theywerenotincludedinthefinalversion oftheguidelines.Below,reasonsfortheirinclusioninthedraftand concernsoftheexpertsaresummarised.  (Coelho et al., 2017). High-quality evidence of a reductionindentalplaqueandgingivitisisalsoavailable(Jamesetal., 2017). However, the experts in our study raised the concern that nursing assistants might misuse chlorhexidine to substitute daily oral care. Moreover, it was mentioned that brushing is possible as wellwhenchlorhexidinecanbeappliedtothemouth.Participants further emphasised concerns related to accidental swallowing and adverse effects.

| Chemical cleaning of removable dentures
The interim version included the advice 'After mechanical cleaning, the denture can be soaked in water with a denture cleanser tablet. It has an additional effect on cleanliness. Use denture cleanser tablets only outside the mouth and follow manufacturers' guidelines strictly.' The item was based on the recommendation of international experts who had considered the available evidence (Bartlett et al., 2018).
Asystematicreviewconfirmedthatthecombinationofmechanical cleaning with chemical agents resulted in optimal denture cleanliness (Papadiochou & Polyzois, 2018). The main concern of the participants in our study was that cleaning tablets might be misused to replace mechanical cleaning. It was further mentioned that clients with cognitive impairment might accidentally drink the cleaning solution.
Participantsalsoraisedtheconcernthatmanufacturers'guidelines mightnotbefollowed,causingdamagetodenturematerials. This strategy was included in a non-pharmacologic, relationshipbased intervention program that showed to be effective in a randomisedclinicaltrial(Jablonskietal.,2018).Participantsinourstudy mainlyraisedtheconcernthatitmightbenon-ergonomicanduncomfortable for the person who provides oral care.

| DISCUSS ION
Recently, an optimised oral health section was developed for the interRAI suite of instruments that is internationally used to assess needsandcapacitiesofcare-dependentindividuals(InterRAI,2020; Krausch-Hofmannetal.,2020).Whenclientswithinsufficientoral hygiene are detected, practice guidelines should be available for nursing assistants who often provide direct hygiene care tasks.
Literature shows that daily oral care is often neglected or only provided superficially in professional care settings (De Visschere et al., 2016;Delwel et al., 2018

| CON CLUS ION
Practiceguidelinesfordailyoralcareincare-dependentolderadults were developed. The available evidence was complemented with practice-basedfeedbackandconsensusfrominternationalexperts.