The UNC Sheps Center’s Mouth Care Without a Battle training program shows promising results after one year, underscores need to establish new standards of care for residents with dementia.

CHAPEL HILL, North Carolina (June 19, 2020) – The Cecil G. Sheps Center for Health Services Research, a leading health services research group based at the University of North Carolina at Chapel Hill, has published a paper in The Journal of the American Medical Association (JAMA) Network Open evaluating the effectiveness of its Mouth Care Without a Battle staff training program. After participating in the study for one year, nursing homes that implemented the care program saw a statistically significant 31% reduction of pneumonia cases compared to nursing homes that did not use the program.

While numerous studies demonstrate an association between mouth care and pneumonia, the Mouth Care Without a Battle implementation study is the first to examine whether a pragmatic program of mouth care (tooth brushing, flossing and gum care) provided by nursing home staff reduces pneumonia.

“We’re building a compelling case to show that mouth care is health care, that poor oral hygiene can lead to more serious health concerns, and that nursing home staff can play a key role to interrupt that cycle,” said Sheryl Zimmerman, Ph.D., Sheps Center program co-director and distinguished professor of social work and public health. “By implementing an evidence-based, compassionate approach like Mouth Care Without a Battle, nursing homes can take a meaningful step to evolve care practices. This program has incredible potential to help individuals in a variety of supportive care settings, including those living at home or in assisted living communities.”

Nearly two-thirds of nursing home residents have Alzheimer’s disease or a related dementia. When these residents resist care, their caregivers often lack the knowledge or skills to properly clean their teeth. As a result, 84% of dependent long-term care residents do not receive mouth care.

Building on its growing body of evidence-based trainings, including the nationally-adopted Bathing Without a Battle program, the Sheps Center Program on Aging, Disability and Long-Term Care designed Mouth Care Without a Battle to remove common barriers to mouth care. In addition to learning about new products and techniques, staff learn individualized care practices that improve their confidence and the care they provide.

"Many nursing home communities may not connect the dots between mouth care and pneumonia, but the results from the program speak for themselves," said Michelle Strickland, licensed nursing home administrator at Brian Center Health & Rehabilitation in Wilson. "We saw a noticeable reduction of residents being hospitalized with pneumonia, and the program continues to empower our staff and residents."

A lack of significant results in the second year of the study raises important questions about the sustainability of interventions in long-term care.

“It’s one thing to train your staff on a new procedure, and another to establish a new best practice in the long-term,” said Philip Sloane, M.D., MPH, Sheps Center program co-director and distinguished professor of family medicine. “We recommend putting safeguards in place, such as hiring an oral care aide, to help sustain a high level of oral health care.”

The paper, Effectiveness of a Mouth Care Program Provided by Nursing Home Staff vs. Standard Care on Reducing Pneumonia Incidence, was led by Zimmerman and Sloane and is available on the JAMA Network Open website. The training program is available at http://www.mouthcarewithoutabattle.org.

"This study is an exciting step forward in translating evidence into daily care practice," said Robyn Stone, Ph.D., senior vice president of research at LeadingAge. "While most frontline caregivers intuitively know that oral health is important, these findings bring the issue into focus in a way that's practical, actionable and patient-centric."

About The Cecil G. Sheps Center for Health Services Research (the UNC Sheps Center)
The Sheps Center seeks to improve the health of individuals, families, and populations by understanding the problems, issues and alternatives in the design and delivery of health care services. This mission is accomplished through interdisciplinary research, consultation, technical assistance and training that focus on timely and policy-relevant questions concerning the accessibility, adequacy, organization, cost and effectiveness of health care services and the dissemination of this information to policy makers and the general public. Within the Sheps Center, The Program on Aging, Disability, and Long-Term Care focuses on better understanding and improving the well-being of older persons and the quality of care they receive. Follow the Sheps Center on Facebook and Twitter.

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A “boots on the ground” project conducted in 22 NY nursing homes by The Foundation for Quality Care provides tips about implementing Mouth Care Without a Battle using ongoing coaching. Study details available at: Volk L, Spock M, Sloane PD, Zimmerman S. Improving evidence-based oral health of nursing home residents through coaching by dental hygienists. (2020). Journal of the American Medical Directors Association, 21(2), 281‐283.

Of more than 200 nursing home residents evaluated over two years, those who received mouth care using Mouth Care Without a Battle had significantly better plaque and gingiva. Study details available at: Weintraub JA, Zimmerman S, Ward K, et al. (2018). Improving nursing home residents' oral hygiene: results of a cluster randomized intervention trial. Journal of the American Medical Directors Association, 19(12):1086‐1091.

Given a potential link between mouth care and pneumonia, knowing which residents are at higher risk for pneumonia may help staff prioritize mouth care. Study details available at: Sloane PD, Zimmerman S, Ward K, Reed D, Preisser JS, Weber DJ. (2017). The nursing home pneumonia risk index: A simple, valid MDS-based method of identifying 6-month risk for pneumonia and mortality. Journal of the American Medical Directors Association, 18(9), 810.e11‐810.e14.

Knowing which characteristics are related to oral hygiene may help staff prioritize mouth care. Study details available at: Zimmerman S, Austin S, Cohen L, et al. (2017). Readily identifiable risk factors of nursing home residents' oral hygiene: dementia, hospice, and length of stay. Journal of the American Geriatrics Society, 65(11), 2516-2521.

In addition to the train-the-trainer version of Mouth Care Without a Battle, an in-service version is now available, in both English and Spanish.  

With the support of the Alzheimer’s Association and FutureCare of North Carolina, the program has been distributed free of charge to all North Carolina nursing homes.

The Mouth Care Without a Battle training program has been distributed to all North Carolina community colleges through a collaboration with the North Carolina Foundation for Advanced Health Programs.

Mouth Care Without a Battle helps staff provide care to persons who resist care and can be used for quality improvement; staff trained in the program report feeling more able to provide care. Study details available at: Zimmerman S, Sloane PD, Cohen LW, Barrick AL. (2014). Changing the culture of mouth care: Mouth Care Without a Battle. The Gerontologist, 54(S), S25-34.

Nursing assistants in three nursing homes using Mouth Care Without a Battle significantly improved the condition of resident’s plaque and gingivitis in as little as 8 weeks. Study details available at: Sloane PD, Zimmerman S, Chen X, et al. (2013). Effect of a person-centered mouth care intervention on care processes and outcomes in three nursing homes.  Journal of the American Geriatrics Society, 61(7), 1158-1163.