Proces- en effectevaluatie van de Oral Health Screener binnen interRAI en bijhorende opleiding: een clustergerandomiseerde gecontroleerde studie

Oral health is an important component of healthy ageing. A healthy mouth is not only necessary for adequate nutrition, but also for psychosocial reasons such as communication and comfort. Nevertheless, many care-dependent older adults experience significant oral health problems that often remain under the radar. These problems are frequently rooted in a loss of intrinsic capacity, which constrains daily oral hygiene and access to dental care. Integrating oral care into general care for care-dependent older adults is therefore of great importance. A potential strategy is to monitor oral health within the multidisciplinary comprehensive geriatric assessment. In Belgian nursing homes, this is done using the interRAI Long-Term Care Facilities instrument (interRAI LTCF). Recently, the oral health section was optimised and validated as the Oral Health Screener (OHS), an instrument designed to assess and monitor oral health by caregivers without a dental background. This doctoral research evaluated the use of the OHS in nursing homes through seven studies conducted at three levels, using both qualitative and quantitative research methods. At the level of residents, interviews showed that older adults primarily associated oral health with the ability to chew adequately, as well as with psychosocial aspects such as appearance and communication. Although most participants expressed satisfaction with their oral health, it was objectively suboptimal. Their oral care behaviour was influenced by intrinsic capacities, the physical and social environment, and motivation. Preserving autonomy emerged as an important theme. The pre-measurement study revealed suboptimal oral health, both in the proportion of individuals with oral problems and in dental indices. These outcomes were also associated with reduced cognitive and functional capacities. Longitudinal evaluation demonstrated a further decline in oral health across all groups, albeit progressing more slowly in the intervention groups, particularly when caregivers had also received on-site training within the nursing home. At the level of caregivers, focus groups showed that the OHS was perceived as feasible and valuable. The prescribed visual inspection of the oral cavity revealed problems that had previously gone unnoticed. However, follow-up actions to address these problems were often impeded by structural constraints. The e-learning module was evaluated positively. Additional on-site training was particularly useful for building confidence. The reliability study of the OHS demonstrated better reliability of caregivers' assessments compared with earlier versions of the instrument, especially when they had received the additional training. At the level of the instrument, the OHS items Oral Hygiene, Gums and Teeth were shown to have high sensitivity and sufficient accuracy for use as a screening tool for oral health in older adults. The lower specificity, particularly for Gums and Oral Hygiene, was partly expected given the high prevalence of oral problems and also reflects the deliberate choice to avoid under-detection. The Collaborative Action Points (CAPs), which support care planning, were compared with dentists' recommendations. As expected in a screening context, CAPs were activated more frequently than recommended by dentists. Analysis of these differences revealed patterns related to the differing objectives of screening (risk detection) and clinical assessment (determining urgency). This nevertheless suggests room for further refinement of the CAP algorithms. The studies conducted identified macro-level structures that are important for successful implementation of the OHS, such as government-led implementation initiatives, the facilitation of equitable access to dental care, and the strengthening of structures to support follow-up of CAPs. These findings align with international recommendations, including the WHO Framework on Integrated, People-Centred Health Services. The integration of the OHS, and more broadly of oral care, into care for nursing home residents requires interdisciplinary collaboration, for which health care education programmes must prepare professionals, as well as task shifting and alternative models of dental care beyond the traditional dental practice. However, integrating oral care into general care for older adults involves more than a set of procedures and responsibilities. It is fundamentally about healthy ageing. This requires attention to oral health from early childhood onwards, empowering individuals to adopt healthy lifestyles and habits. It also requires attention to the older person themselves and the provision of care that responds to their wishes and needs. Scientific research can make a valuable contribution in this regard. This doctoral research has shown that integrating the OHS within interRAI LTCF is a feasible and promising strategy for integrating oral care into general care for nursing home residents. Its effectiveness, however, depends on collaboration across all levels: - residents who are supported in maintaining autonomy and reporting problems, - caregivers who are adequately trained and supported, - organisations that provide clear processes and facilitate collaboration, - and policies that structurally strengthen accessibility of care and interprofessional collaboration.