Clinical Oral Investigations

https://doi.org/10.1007/s00784-019-02812-4

REVIEW

Barriers and facilitators for provision of oral health care in dependent

older people: a systematic review
Gerd Göstemeyer 1 & Sarah R. Baker 2 & Falk Schwendicke 1

Received: 3 August 2018 / Accepted: 11 January 2019

# Springer-Verlag GmbH Germany, part of Springer Nature 2019

Abstract
Objectives Provision of oral health care (OHC), including oral hygiene (OH) or oral/dental treatment, to dependent older people
(DOP) is frequently insufficient. We aimed to assess barriers and facilitators perceived by different healthcare professionals
towards providing OHC to DOP.
Materials and methods A systematic review was performed. Studies reporting on knowledge, attitudes, and beliefs acting as
barriers and facilitators for provision of OHC were included. One database (PubMed) was searched and data extraction inde-
pendently performed by two reviewers. Thematic analysis was used and identified themes translated to the domains and
constructs of the theoretical domains framework (TDF) and aligned with the domains of the behavior change wheel (BCW).
Analyses were stratified for the two target behaviors (providing oral hygiene and providing oral/dental treatment) and according
to different stakeholders’ perspective. For quantitative analysis, frequency effect sizes (FES) were calculated.
Results In total, 1621 articles were identified and 41 (32 quantitative, 7 qualitative, 2 mixed method) studies included. Within
these 41 studies, there were 7333 participants (4367 formal caregivers, 67 informal caregivers, 1100 managers of care, 1322
dentists, 340 DOP). Main barriers for providing OH were Black of knowledge^ (FES 65%, COM-B domain: capability, TDF
domain: knowledge) and Bpatients refusing care^ (62%, opportunity, environmental context and resources). Main facilitators
were BOHC training/education^ (41%, capability, skills) and Bpresence of a dental professional^ (21%, opportunity, environ-
mental context and resources). Main barriers for provision of dental treatment were Black of suitable facilities for treatment/
transportation of patients^ (76%) and Bpatients refusing care^ (53%) (both: opportunity, environmental context and resources).
Main facilitators were Bregular visiting dentist^ (35%) and Broutine assessment/increased awareness by staff^ (35%) (both:
opportunity, environmental context and resources).
Conclusions A number of barriers and facilitators for providing different aspects of OHC were identified for different
stakeholders.
Clinical relevance Our findings help provide the evidence to develop implementation strategies for providing high-quality
systematic OHC to DOP.
Registration This review was registered at Prospero (CRD42017056078).

Keywords Elderly . Barriers . Facilitators . Oral hygiene . Dental care . Qualitative studies

Electronic supplementary material The online version of this article

(https://doi.org/10.1007/s00784-019-02812-4) contains supplementary
material, which is available to authorized users.
* Gerd Göstemeyer
gerd.goestemeyer@charite.de
1
Department of Operative and Preventive Dentistry, Charité –
Universitätsmedizin Berlin, corporate member of Freie Universität
Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of
Health, Assmannshauser Str. 4-6, 14197 Berlin, Germany
2
School of Clinical Dentistry, University of Sheffield, Claremont
Crescent, Sheffield S10 2TA, UK
Background
Considerable advances in prevention and management of oral
diseases have led to improved oral health in most population
groups in most high-income countries. However, in frail or
functionally dependent older people (DOP), oral health is still
frequently poor [1]. A poor oral hygiene (OH) and a high
prevalence of the main dental diseases (caries and periodontal
diseases), often with a high degree of disease severity and
extent, have been found in DOP [2–5].
 Clin Oral Invest

The consequences of poor oral health can heavily im- Methods

pact on general health. Excessive accumulation of micro-
organisms in the oral cavity due to insufficient OH can This review was registered at Prospero (CRD42017056078).
lead to an increased vulnerability to respiratory tract in- The reporting of our study is in accordance with the PRISMA
fections like pneumonia and arteriosclerosis [6–8]. and ENTREQ statement guidelines [25, 26].
Reduced chewing performance due to an insufficient
number of retained teeth and/or insufficient dentures
Eligibility criteria
can result in weight loss and, ultimately, malnutrition
[9]. Discomfort and pain and impaired dental esthetics
Original studies that aimed to assess knowledge, attitudes, and
are also associated with a lower quality of life [10].
behaviors acting as barriers or facilitators for provision of
Maintaining good oral health is based on sufficient
OHC for DOP were included into this review. Such studies
OH and regular access to dental services and, if needed,
could be interviews, focus groups, or surveys, also studies
oral/dental treatments [11]. In DOP, the capacity to per-
nested within larger studies intended for a different purpose.
form OH is often reduced, especially if burdened with
Only peer-reviewed publications were considered for inclu-
physical or psychological impairment [12, 13].
sion. No language, time, or quality restrictions were applied.
Consequently, DOP often rely on OH being provided
The following PICOS criteria for including studies were
by caregivers, who have been found to not provide
formulated:
high-quality and systematic OH in most circumstances
[5, 14–16]. Physical access to dental services also de-
creases when older people are becoming more dependent Population
and less mobile, while in older individuals, especially
DOP, the need for dental treatment is usually high [17]. Any stakeholder involved in providing OH measures or oral/
The majority of DOP have been found to not be regular- dental treatment to DOP. The DOP were defined as patients
ly examined and treated by a dentist; indeed, in most under care aged ≥ 65 years or described with terms commonly
cases, oral/dental treatment is only provided for emergen- used for this older population group (e.g., geriatric, elderly,
cies and at minimum levels of care [18, 19]. The avail- elder, old, aged).
ability of evidence-based practice information for oral
healthcare (OHC) in DOP seems not to have a sustain-
Intervention
able impact on this situation [20–22].
Given the predicted demographic changes in most
Any intervention necessary for provision of OH or oral/dental
high-income countries, the number of DOP will increase
treatment to DOP.
[23]. As discussed, these DOP will retain more teeth,
often rehabilitated with extensive restorations and pros-
theses. Consequently, the need for oral health care Control
(OHC) including high-quality systematic OH (provided
by caregivers) and dental treatments (provided by den- None (studies did not need to have a comparator as this review
tists) will increase in this group [2, 17]. A number of was not a comparative effectiveness study).
barriers seem to be in place, which hamper the provi-
sion of OHC in DOP. Understanding these barriers, and
Outcomes
also identifying facilitators for the provision of OHC,
will help to develop interventions eventually aimed at
Qualitative and quantitative data on factors (e.g., attitudes,
improving the oral health of DOP by providing them
knowledge, and beliefs of OHC professionals or environmen-
with the care they need.
tal factors influencing behavior) acting as barriers (i.e., factors
The aim of the present study was to assess the bar-
hampering provision of OHC) or facilitators (i.e., factors pro-
riers and facilitators for providing OHC to DOP using a
moting provision of OHC) for provision of OH and provision
systematic review approach. As different stakeholders
of oral/dental treatment to DOP.
with different motivations are involved in providing
OHC, we aimed to assess these barriers and facilitators
from different stakeholders’ perspectives. Our analysis Setting
was based on the Theoretical Domains Framework
(TDF) which has been shown to increase the compre- Any usual setting where provision OH and provision of oral/
hensiveness, validity, and reliability of identifying deter- dental care to DOP takes place (e.g., nursing homes, home
minants of behavior [24]. care).
Clin Oral Invest
Information sources
Electronic searches
One electronic database (PubMed via Medline) was searched
for studies published until 25 October 2016 and an update of
this search was performed on 28 February 2018. In line with
previous studies, we assumed that the number of newly iden-
tified barriers and facilitators would decrease at some point
during data extraction, i.e., saturation would occur [27, 28].
Such saturation was formally assessed after finishing the
PubMed search and including all eligible studies by randomly
plotting newly identified themes found in each new study
against the cumulative number of included studies [29]. We
assumed saturation was attained if the plotted curve showed a
plateau, which we defined as the curve area where less than
10% new themes were identified within the last 25% of new
studies. After saturation had been reached (see below), no
further databases were searched.
Search strategy
The search strategy was developed by one author (GG), who
is experienced in database search. A four-pronged search strat-
egy using the Boolean operator AND was used combining the
search terms for the four different search domains. The search
strategy was as sensitive as possible given that we expected
poor indexing (i.e., the elderly are often referred to using many
different terms, e.g., Belders,^ Baged,^ Bdependents^). The
following strategy was developed: ((((((care home) OR nurs-
ing home) OR residential)) AND ((((oral) OR dental) OR
teeth) OR denture) OR mouth)) AND attitudes) AND ((((((el-
derly) OR old) OR elder) OR seniors) OR senior) OR aged).
Selection process
Two authors (FS and GG) independently screened titles and
compared findings. There was no disagreement in study se-
lection. Full texts were assessed by both researchers indepen-
dently. No duplicative studies were identified. Studies were
included if both authors agreed. No disagreements occurred.
Data items
Data management
A piloted spreadsheet was used for data extraction and
management. The spreadsheet was developed by all au-
thors (FS, GG, SB) according to relevant data for extrac-
tion for our analyses.
Data collection process
Data extraction was performed independently by FS and GG.
Disagreements were resolved in discussion.
Data items
The following data were collected: authors; location; year of
study and publication; assessment method (e.g., survey, inter-
view); stakeholder (e.g., nurses, dentists, managers of care);
setting (e.g., care facility, home care); oral care procedures (if
specified); target behavior (provision of OH or provision of
dental treatment); items for knowledge, attitudes, beliefs, and
barriers and facilitators related to OHC. Depending on study
method (qualitative or quantitative), different strategies were
used for collection of these items: For qualitative studies (i.e.,
interviews, surveys with open questions), all identified themes
stated by interviewees were abstracted and extracted. Themes
reflecting interpretations of the interviewer were not included.
In order to avoid including data based on interpretation of
interviewers, we exclusively extracted factors that were re-
ferred in the study from the original statement of the inter-
viewees. For quantitative studies (i.e., surveys with closed
questions), we only extracted themes reported for the majority
of participants (> 50%).
Data was eventually organized according to the stake-
holders involved in providing OH and/or dental treatment to
DOP:
& Formal caregivers, which could be or were described as
nurses, nursing assistants, nursing auxiliaries, residential
care aid members, nursing aides, medical responsible
nurses, care providers, and non-nursing staff of care
homes
& Informal caregiver, which could be or were described as
family members providing care and informal (non-family)
caregiver
& Managers of care, which could be or were described as
directors of nursing homes, managers of residential
homes, clinical nurse leaders, facility director, oral health
educator, caregiver manager, case manager, and care
manager
& Dental care professionals, which could be or were de-
scribed as general and specialized dentists, dental nurses,
hygienists, therapists, etc. Note that only dentists were
eventually mentioned in the included studies.
& DOP themselves.
Data synthesis
In an iterative approach of theme and category development,
relationships between themes and concepts were independently
 Clin Oral Invest

identified by all reviewers (FS, GG, SB) [30]. Afterwards, the

reviewers compared their findings and jointly grouped and
translated them into the domains and constructs of the theoret-
ical domains framework (TDF) [24, 31, 32]. Themes and con-
cepts were further classified as barriers (−) or facilitators (+) for
healthcare provision, or as conflicting (?) (i.e., uncertain as to
their effect on the target behavior) (provision of OH or provi-
sion of dental treatment) [31, 33]. To improve the applicability
of findings for implementation, TDF domains were aligned
with COM-B domains (capability, opportunity, motivation, be-
havior) of the Behavior Change Wheel (BCW) to facilitate the
deduction of future interventions [32].
A qualitative meta-summary approach was used to synthe-
size findings from the included qualitative and quantitative
studies. To assess the relative importance of the identified
themes, their frequency effect size (FES) was calculated by
calculating the number of studies mentioning a specific theme
and dividing this number by the total number of relevant stud- Fig. 1 Flow of the search
ies [34, 35]. Overall FES were calculated for the two target
behaviors (provision of OH and provision of OHC) and also studies (n = 31) had a cross-sectional design, eight studies
estimated for the different groups of stakeholders. had a longitudinal design, and two were randomized con-
trolled trials. Thirty-two studies had a quantitative study de-
Quality assessment and confidence in data sign (i.e., surveys were used as the assessment tool), seven
studies used a used qualitative approach (i.e., interviews, fo-
Quality assessment of the included studies was based on the cus group discussions), and two studies used mixed methods
adapted Newcastle-Ottawa Scale for cross-sectional studies (i.e., both approaches). In 33 studies, data were collected for
[36, 37], which was further modified for the scope of our study DOP living in long-term care facilities (e.g., nursing homes,
(Appendix Table S1). FS and GG independently assessed the hospitals); in four studies, DOP received home care and four
quality of each study. Disagreements were resolved by discus- studies collected data from both settings. Most of the included
sion. If disagreements could not be resolved, a third reviewer studies were conducted in high-income countries (n = 36),
(SB) was consulted and a final decision was made. Studies four trials in upper middle-income countries and one in a
with 0–3 of the maximum 8 NOS points were judged to have lower middle-income country (as per the World Bank
high risk of bias, those with NOS 4–6 to have moderate risk of Classification; https://data.worldbank.org).
bias, and those with 7–8 to have low risk of bias [37].
Study quality assessment
Results
The quality of included studies according to the modified
Newcastle-Ottawa Scale is shown in Table S4. Overall 19
Search and included studies
studies were judged to have a high risk of bias (NOS 0–3),
while 21 studies had a moderate (NOS 4–6) and one study had
We identified 1621 articles via PubMed (Fig. 1). After screen-
a low risk of bias (NOS 7–8). Most of the included studies had
ing of titles and abstracts, 62 articles were screened in full text,
a high risk of bias for the domains Bconsideration of sample
and finally 41 studies (36 from the original search and 5 from
size^ (32 studies) and Bassessment of confounding factors^
the updated search) were included. Excluded studies and rea-
(22 studies). Twenty studies had not been conducted with a
sons for exclusion can be found in the Appendix (Tab. S2).
representative sample. However, most studies (36 studies)
The data saturation curve found that within the last entered
used a validated survey instrument and described the assess-
25% (n = 10) studies, only 8% (n = 5) new themes were iden-
ment tool or made it available.
tified; saturation was thus assumed (Fig. S1).
The included studies were published between 1995 and
2018 (mean 2010) (Tab. S3). The sample size ranged between Barriers and facilitators
10 and 863 participants. Overall, 7333 participants were in-
volved (4367 formal caregivers, 67 informal caregivers, 1100 A number of barriers, facilitators, and conflicting themes for
managers of care, 1322 dentists, 340 DOP). Most of the the two target behaviors were identified and translated to the
Clin Oral Invest
constructs and domains of the TDF and to COM-B domains.
These were further recorded separately for the different stake-
holders (Tables 1 and 2). For provision of OH, the majority of
themes were reported from the formal caregivers’ perspective,
followed by the perspective of managers of care and the in-
formal caregivers’ perspective. Except for Bmotivation
(COM-B): reinforcement/sanctions, punishment (TDF)^ and
Bmotivation: memory attention and decision process
optimism/decision process pessimism^ all aspects of the
TDF domains/constructs were covered. For the provision of
oral/dental treatment, the majority of themes were identified
for the managers’ of care perspective, followed by dentists’,
formal caregivers’, informal caregivers’, and DOP perspec-
tive. All aspects of the TDF domains/constructs were covered
by the identified items except of Bmotivation: memory atten-
tion and decision process optimism/decision process
pessimism.^ Possible interactions between these domains are
summarized in Fig. 2 and in Appendix Figures S2 and S3.
Frequency effect size
A total of 67 barriers, facilitators, or conflicting themes were
identified (29 for provision of OH, 38 for provision of oral/
dental care) (Table S5, Fig. 3).
Main barriers for provision of OH were Black of
knowledge^ (overall FES, 65%; COM-B domain: capability,
TDF domain/construct: knowledge/knowledge of the condi-
tion, scientific rationale) followed by Bpatients refusing care^
(62%; opportunity, environmental context and resources/
stressors, resources, organizational culture), Black of skills/
experience^ (47%; capability, skills/procedural knowledge,
skills, competence, ability), and Black of time^ (44%; oppor-
tunity, environmental context and resources/stressors, re-
sources, organizational culture) (Table 1, Fig. 3a). Having
received OH Btraining/education^ (44%; capability, skills/
procedural knowledge, skills, competence, ability) and
Bpresence of a dental professional^ (21%; opportunity, envi-
ronmental context and resources/stressors, resources, organi-
zational culture) were the main facilitators. There was ambi-
guity (i.e., some studies reported an item as a barrier and
others as a facilitator) as to the role of Bbeliefs about
importance/beneficial consequences of OH/oral health care^
(56%; motivation, beliefs about consequences/outcome ex-
pectancies), which is why we assumed this to be a conflicting
theme.
Most frequently identified barriers for provision of OH
from formal caregivers were Black of knowledge^ and
Bpatients refusing care^ (both FES 55%) followed by Black
of time^ (FES: 41%) and Black of skills/experience^ (FES
28%). Most frequent facilitators for these stakeholders were
BOH training/education^ (FES 44%), Bpresence of a dental
professional^ (FES 14%) and Bown OH awareness.^ BLack
of skills/experience^ was the most frequently identified
barrier for manager of care followed by Bunclear responsibil-
ity for oral care^ (FES 67%). BLack of knowledge^ and
Bpatients refusing care^ (both FES 56%) were also the most
frequently identified barriers for the manager of care. Most
important facilitators were BOH training/education,^
Bpresence of a dental professional^ (both FES 33%) and Bage
(younger managers of care)^ (FES 11%). For informal care-
givers, the only identified barriers were Black of knowledge^
(FES 50%) and Black of skills/experience^ (FES 50%).
Furthermore, we Bfound informal caregivers performed OH
more frequently than formal caregivers^ (FES 50%) as the
only facilitator for these stakeholders.
Main barriers for provision of oral/dental treatment were
Black of suitable facilities for treatment/transportation of
patient^ (overall FES 76%; COM-B domain: opportunity,
TDF domain/construct: environmental context and re-
sources/stressors, resources, organizational culture) and pa-
tients refusing care (53%; opportunity, environmental context
and resources/stressors, resources, organizational culture).
From the dentists’ perspective, Binconvenience of leaving
practice/preference to treat in practice^ was found to be an-
other main barrier (47%, opportunity, social role/professional
identity, confidence). The items Bregular visiting dentist^
(35%), Broutine assessment/increased awareness by staff^
(35%; both opportunity, environmental context and re-
sources/stressors, resources, organizational culture), and
Breducing costs for dental treatment^ (18%; motivation, rein-
forcement/rewards, incentives) were identified as main facili-
tators. BCaregivers who are anxious about dental attendance^
(12%; opportunity, social influence/social pressure, norms,
support, modeling) and Bself-reported adequate knowledge^
(6%; capability, knowledge/knowledge of condition, scientific
rationale) were identified as conflicting themes.
From the formal caregivers’ perspective, the most frequent-
ly identified barrier was Black of initial/routine examinations^
(FES: 30%). Other barriers were Black of knowledge,^ Blong
waiting time,^ Bnon-cooperative family,^ Bhigher certification
of caregiver,^ and Black of information on service availability/
lack of available service^ (all FES 10%). The only identified
facilitators for these stakeholders were Bregular visiting
dentist^ (FES: 30%) and Broutine assessment/increased
awareness by staff^ (FES: 20%). For managers of care most
frequently identified barriers were Black of suitable facilities
for treatment/transportation of patient^ (FES 78%), Bfinancial
constraints of residents/family^ (FES 67%), and Bpatients re-
fusing care^ (FES 67%). BRoutine assessment/increased
awareness by staff,^ Bguidelines/information about oral care
in patients with dementia,^ Bprosthesis, hygienists, domicili-
ary dentists,^ and Bdentists in rural regions more interested^
were the only reported facilitators (all FES 11%). From the
dentists’ perspective, most frequently identified barriers were
Binconvenience of leaving practice/preference to treat in
practice^ (FES 100%) followed by Black of suitable facilities
Table 1 Barriers and facilitators to provide oral hygiene aligned with COM-B and TDF domains

COM-B domain TDF domain TDF construct Identified enabler (+) or barrier Formal caregiver Managers Informal
(definition in brackets) (-) or conflicting theme (?) of care caregivers
Studies where factor was identified (References)

Capability (psychological Knowledge Knowledge of (-) lack of knowledge [38, 39-53] [48, 54-56] [38]
and physical capacity condition, (?) (self reported) adequate knowledge/skills [40, 43, 47, 58-61] [56]
to engage in the activity scientific rationale
(?) level of education [57]
concerned)
Skills Skills, competence, (-) lack of skills/experience [38, 39, 43, 44, 47, 48, [49, 54-56, [38]
ability 50, 52] 62-64]
(-) lack of training/education [40, 49, 65]
(?) OH training/education [40, 52, 65, 66] [65]
(+) OH training/education [41, 42, 45-48, 53, [48, 57, 63]
55, 60, 67-69]
(+) age (younger caregiver [54]
manager were aware knowledge
and skills for providing OH are needed)
Opportunity (all the factors Social influence Social pressure, norms, (+) being the contact person for client/family [65]
outside of the individual support, modelling
that makes behaviors Social role Professional identity, (-) home caregivers rated knowledge [44]
possible or prompt it) confidence more often as insufficient compared to
nursing home caregivers
(?) attitude/beliefs of hospital vs. [70]
nursing home nurses
(?) knowledge/beliefs of informal [38] [38]
vs. formal caregivers
(+) informal caregivers performed OH more [38] [38]
frequently
compared to formal caregivers
Environmental context Stressors, resources, (-) lack of time [39, 40, 43, 46-51, 61, [48, 63, 64]
and resources organizational 63, 65]
culture (-) patients refusing care [39, 40, 42, 43, 45, 46, [48, 54, 57, 62,
48-51, 58-62, 65] 65]
(-) unclear responsibility for oral care [45, 48, 50, 51, 62, 65] [48, 57, 62-65]
(-) lack of organization / no OH program [40, 48, 51, 61, 62] [48, 62, 64, 65]
available
(-) lack of supplies/equipment/financial [50, 58] [62]
resources
(+) presence of a dental professional [40, 49, 61, 69] [56, 62, 65]
(+) providing OH after bath time [49, 62]
Motivation (processes that Beliefs about capabilities Self-confidence, (-) insufficient own resources [40, 42, 46, 50, 59]
energize and direct competence, control
behavior Beliefs about Outcome expectancies (-) fear of causing damage/injury/bleeding [58-60]
not just goals and consequences (-) fear of getting bitten [45]
conscious
[55, 62, 64, 65] [38, 71]
decision making)
Clin Oral Invest
Clin Oral Invest

for treatment/transportation of patient^ (FES 80%). Other rel-

evant barriers were Bpatients refusing care,^ Binsufficient OH
caregivers
Informal
provided by nursing staff,^ Bdisinterest of dentist,^ Bno/low
financial incentive,^ Black of knowledge,^ and Bincreased
Studies where factor was identified (References)

time needed/lack of time^ (all FES 60%). The only identified

facilitators for the dentists’ perspective were Bguidelines/infor-
mation about oral care in patients with dementia,^ Buniversity
Managers

education in geriatric dentistry,^ Bbeing aware of ADA nurs-

[63, 65]
of care

ing home dental scheme,^ Bmale dentists,^ and Byounger

dentists^ (all FES 20%). From the informal caregivers’ per-
[40, 45, 50, 51, 59, 60,
spective, the only identified barriers for provision of oral/
[38, 40-42, 45-47, 51,
54, 58, 62, 65, 71]

dental care were Black of suitable facilities for treatment/

Formal caregiver

[40, 46, 49, 68]

transportation of patient,^ Bpatients refusing care,^ Bstaff and

time constraints,^ and Blong waiting time^ (all FES 50%).
[42, 68]

Most important facilitators were Bregular visiting dentist^

65]
[40]

[51]

and Breducing costs for dental treatment^ (both FES 100%).

The only identified barriers for the caretakers’ perspective
were Black of suitable facilities for treatment/transportation
of patient,^ Bfinancial constraints of residents/family,^ and
Bstaff and time constraints^ (all FES 50%). BRoutine
(+) recognition or award for providing OH

assessment/increased awareness by staff^ was the most fre-

consequences of OH/Oral health care
(?) beliefs about importance/beneficial

quently identified facilitator. The other facilitators were

(-) lack of empathy of nursing home
(-) perception of providing OH as a
(+) material incentives during OH

Bregular visiting dentist,^ Breducing costs for dental

Identified enabler (+) or barrier

treatment,^ and Btreatment room in facility/mobile dental

unpleasant/repulsive task
(-) or conflicting theme (?)

unit^ (all FES 50%).

(+) own OH awareness

education sessions

Sanctions, punishment none identified

none identified

Discussion
personal

This review identified several factors acting as barriers or

facilitators for provision of OH and oral/dental treatment.
We identified these factors from the perspectives of different
stakeholders as we aimed to draw a comprehensive picture on
Rewards, incentives

Decision process,

where barriers and facilitators in this field exist. This is impor-

TDF construct

pessimism

tant, as a number of different healthcare professionals are in-

volved in OHC for DOP.
Affect

Provision of OH

For provision of OH, Black of knowledge^ was identified as

Memory attention and
decision process,

one main barrier. One might assume that improvements in

Reinforcement

knowledge might easily be obtained by just performing edu-

TDF domain

optimism

cation, which is also partially reflected by the identification of

Emotion

BOH training/education^ as a main facilitator. However, FES

for this facilitator was low, indicating that only a small pro-
portion of stakeholders believe training and education would
improve OH. BOH training/education^ was also often report-
(definition in brackets)
Table 1 (continued)

ed as a conflicting theme. This is in line with another review

showing that improving knowledge in healthcare personal
COM-B domain

does not necessarily improve oral health in those receiving

care [15]. Knowledge itself seems to be a minor cognitive
factor for predicting behavior and intention. However, mea-
sures for increasing knowledge and skills might strengthen
Table 2 Barriers and facilitators to provide oral/dental treatment aligned with the COM-B and TDF domains

COM-B TDF domain TDF construct Identified enabler (+) or barrier Formal Manager of Dentists Informal DOP
domain (-) or conflicting theme (?) caregiver care caregiver
Studies where factor was identified (References)

Capability Knowledge Knowledge of condition, (-) lack of knowledge [72] [72-74]

scientific rationale (?) self-reported adequate knowledge [75]
(+) university education in geriatric dentistry [74]
Skills Skills, competence, ability (-) lack of experience [73]
(-) inadequate training in geriatric dentistry [76] [76]
(+) being aware of ADA nursing home dental [72]
scheme
Opportunity Social influence Social pressure, norms, support, (?) Caregivers who are anxious about dental [41, 70]
modelling attendance
(+) staff should act upon family request [71]
Social role Professional identity, confidence (-) inconvenience of leaving practice/ [57, 76, 77] [72-74, 76,
preference to treat in practice 77]
(-) dental specialists [75]
(+) prosthesis, hygienists, domiciliary dentists [76]
(+) male dentists [72]
(+) younger dentists [74]
Environmental context Stressors, resources, (-) increased time needed/lack of time [77] [72, 74, 77]
and resources organizational culture (-) lack of suitable facilities for [56, 57, 63, 72, [72, 76, 77] [71] [71]
treatment/transportation of patient 75-77] [74]
(-) insufficient OH provided by nursing staff [72, 76, 77] [57] [72, 76, 77]
(-) patients refusing care [57, 63, 72, 76, [73, 76, 77] [71]
77]
(-) apathy of dentists, nursing staff, [75]
administration
(-) non-cooperative family [62] [62]
(-) staff and time constraints [56, 77] [77] [71] [71]
(-) long waiting time [61] [57, 63] [71]
(-) lack of initial/routine examinations [47, 56] [56]
(-) lack of information on service [47] [63]
availability/lack of available service
(+) regular visiting dentist [46, 47, 62] [71, 78] [71]
(+) dentists in rural regions more interested [76]
(+) treatment room in facility/mobile [71] [71]
dental unit
(+) routine assessment/increased awareness [56, 66] [66] [71] [71]
by staff [66]
(+) guidelines/information about [57] [74]
oral care in patients with dementia
Motivation Beliefs about capabilities [57, 63, 76] [73, 76]
Clin Oral Invest
Clin Oral Invest

DOP
one’s own beliefs about capabilities and consequences, which

[71]

[71]
have been shown to be most consistently associated with pre-
diction of healthcare professional’s behaviors [20].
The second main barrier was Bpatients refusing care.^
caregiver
Informal

[71, 78]
Rejection of care by DOP occurs most often in patients with
Studies where factor was identified (References)

dementia. Caregivers can be trained in handling situations

[73, 74, 76]

[74, 76, 77]

where the caretaker refuses provision of care. However, it is
Dentists

[76, 77]
not clear how to best train caregivers in this aspect [79].
[76]

[77]

[74]
Attending to patients refusing care is often time-consuming,
something that adds up to the frequently perceived Black of

[64, 72, 76, 77]

time,^ which is another common barrier reported from the
Manager of

[56, 75, 76]

[56, 57, 76]
[57, 63, 72,

[72, 75-77]
perspective of formal caregivers but also from managers of
75-77]

[56, 64]
care. Interestingly, Bpatients refusing care^ was not reported
care

[75]

from the informal caregivers’ perspective. Given that informal

caregivers are often less trained than formal caregivers, this
caregiver

might indicate that the effectiveness of providing care tasks to

Formal

patients refusing care depends less on the training, but more

[67]

on the setting and the relationship between DOP and caregiver

(-) complex medical conditions/treatment needs

[38]. In fact, social professional role and identity, moral norm,

(-) perception that needs of patients are met

and emotion are cognitive factors that are frequently being

(-) financial constraints of residents/family
(-) disinterest of resident/residents’ family

identified as drivers for intention to behavior and might result

(+) reducing costs for dental treatment

(-) intervention into privacy of patient

in a more elaborative attempt (at least for informal caregivers

(-) higher certification of caregiver
Identified enabler (+) or barrier

who are relatives of the DOP) to assess patients refusing care

(-) no/low financial incentive

(-) obtaining patient consent

(-) or conflicting theme (?)

[20]. However, due to the limited number of informal care-

givers included in the studies within the review, the conclusion
(-) disinterest of dentist

that Bpatients refusing care^ seem to be less important to in-

formal caregivers should be treated with caution.
none identified
of patients

BLack of skills/experience^ was identified next often as a

barrier to providing OH, most often reported by managers of
care, and to a far lesser extent by formal caregivers, indicating
there are differences in how different stakeholders perceive
their own skills. This is corroborated by the fact that the theme
Decision process, pessimism

of Bself-reported adequate knowledge/skills^ was reported

competence, control

Sanctions, punishment

both as barrier and facilitator, i.e., ambiguously. Skills could,

Outcome expectancies
Rewards, incentives

theoretically, be easily improved by practical training and ed-

Self-confidence,
TDF construct

ucation. Nevertheless, it remains unclear if such training truly

has an impact on the behavior of caregivers [15, 38]. Evidence
exists that OHC education improved knowledge and attitudes
Affect

towards OH provision to care home residents. However, this

does not necessarily result in an improvement in OH care
skills [80]. As to the limited direct impact of education alone
Memory attention and decision

on behavior change, further studies should assess which edu-

Beliefs about consequences

cational techniques might improve the motivation to provide

OH to DOP.
process, Optimism

BUnclear responsibility^ was a frequently reported barrier,

mainly reported by managers of care and to a lesser extent by
Reinforcement
TDF domain

Motivation

formal caregivers. This might indicate a lack of organizational

Table 2 (continued)

structure in care facilities and is again partly reflected by iden-

tification of Black of time^ as a common barrier mainly from
the caregivers’ perspective. Care facilities should establish
clear care plans including high-quality and systematic OH,
COM-B
domain

with sufficient time slots being allocated, and clear responsi-

bilities to overcome lack of organizational structure and time

Fig. 2 Factors shaping the provision of oral and dental treatment from the
perspectives of dentists and formal caregivers. Interactions of COM-B
domains [32] (capability: white boxes on top; opportunity: light gray
boxes at the bottom; motivation: dark gray boxes in the middle; behavior:
black box in the center) are shown. As an example, from the dentists’
perspective, education/training in geriatric dentistry (capability) impact
on competence on treating patients and responsibility/own preferences
constraints. Clear responsibilities may also increase the adher-
ence of formal caregivers to proposed care plans [15]. These
care plans should be tailored individually to the organizational
structures of the care facilities, as the availability of evidence-
based practice information for oral healthcare alone seems not
to have a great impact on OH provision [20–22].
We identified fewer facilitators than barriers for the provi-
sion of OH. The Bpresence of a dental professional^ was the
most frequently reported facilitator, mainly by managers of
care and to a lesser extent by caregivers. It is perceivable that
the regular presence of a dental professional—a hygienist,
dental nurse, or dentist—could work as both motivator (Bcare
champion^) and as regulatory element (as dental professionals
would identify lack of care issues, implementing an element
of quality control). The regular presence of a dental profes-
sional in long-term care facilities seems also sensible to im-
prove the provision of oral/dental care to DOP. This is sup-
ported by the results from a recent pilot study, which demon-
strated that support from a Bdental hygiene champion^ work-
ing in collaboration with OHC professionals positively im-
pacted oral health of DOP [81].
Provision of oral/dental care
For this provision, Black of suitable facilities/transportation of
patients^ was the most frequently found barrier, reported from
dentists, managers of care, informal caregivers, and DOP. This is
consistent with the finding that Binconvenience of leaving
practice^ was the most common barrier stated by dentists.
Another review also identified the lack of adequate equipment
in a care home as a main barrier for dentists to provide dental
Clin Oral Invest
(opportunity) impact on the provision oral and dental treatment, but also
indirectly by influencing the motivation (e.g., by increasing competence
on treating patients with complex conditions). It can also be seen, that the
factors shaping the behavior towards provision of oral/dental care are
different between dentists and formal caregiver. Additional interactions
of factors for the other stakeholders’ perspectives and for provision of OH
are shown in the Appendix
care [17]. It seems highly important to support provision oral/
dental care for dentists by establishing suitable facilities, e.g., by
providing mobile dental units, treatment rooms located at the
nursing homes, or organization of transportation [1]. However,
it should be noted that habitual behavior performed in a stable
context is difficult to change [20]. Therefore, the availability of
suitable facilities alone might not have a strong effect on provi-
sion of OHC by dentists. Further studies should assess which
additional factors can facilitate dentists’ behavior towards pro-
viding oral care in other environments than their practice.
From the dentists’ perspective, Black of knowledge,^
Bincreased time needed/lack of time,^ and Bno/low financial
incentives^ were identified as further barriers. Education in
dentistry for the elderly should therefore be expanded both
at under- and post-graduate level. Policymakers should devel-
op systems allowing sufficient remuneration for in-house
visits to DOP, as remuneration will be closely associated with
the time allocated to such visits. Sufficient payment for such
visits will also help to tackle the barrier of Bfinancial
constraints,^ which was frequently mentioned by both man-
agers of care and DOP. In another review, reimbursement for
OHC was also reported to be an important factor associated
with access to OHC for DOP in Europe [82].
In line with our findings regarding the provision of OH,
Bpatients refusing care^ was another main barrier for provid-
ing dental/oral treatment, reported by dentists, managers of
care, and informal caregiver. This is worrisome, as especially
patients with dementia frequently suffer from poor oral health
and come with a high demand for oral/dental treatment [83,
84]. It seems urgently necessary to train dentists in how to deal
with such patients and to establish strategies for managing
Clin Oral Invest
Fig. 3 Frequency effect sizes (FES) of identified factors influencing the
provision of oral hygiene (a) and the provision of oral/dental treatment
(b). Overall FES of the identified barriers (−), facilitators (+) and
them; adapting such strategies from pediatric and special
needs dentistry seems sensible [85]. These strategies should
be disseminated appropriately, as Bguidelines/information
about oral care^ were identified as a facilitator for oral/
dental treatment. Given the limited access to patients refusing
care for complex dental treatments, application of non-
operative interventions seems highly relevant here.
However, the evidence as to which preventive and non-
invasive measures are effective in DOP remains limited [86].
Limitations
This study has a number of limitations. First, data on
barriers and facilitators from some stakeholders’ perspec-
tives were based on a limited number of studies and
conflicting themes (?) are given. Additionally, FES of the most common
barriers and facilitators are shown separately for the different healthcare
professionals’ perspectives
participants. Similarly, our semi-quantitative approach to
gauge the relative importance of identified barriers and
facilitators should be treated with caution, especially in
subgroups of stakeholders, as it is based on only a few
studies, and does not indicate the importance of each
theme bu t rather how often it w as men tione d.
Furthermore, it is likely that our approach of calculating
the FES might have resulted in an overestimation of the
importance of barriers and facilitators that often come up
in surveys (e.g., the factor knowledge), as they are more
easily assessable. On the other hand, less frequently
identified factors, which are more complex to assess
might be more important than indicated according to
their calculated FES. Additionally, factors from surveys
which were indicated as relevant for less than 50% of

participants were not considered by this study. We set
this (somewhat artificial) cutoff point in order to identify
factors that were clearly important for the majority of
surveyed stakeholders as it was our scope to give a
broad overview on where relevant barriers and facilita-
tors are for the different stakeholders. Nevertheless, some
of the identified factors might be relevant in specific
circumstances (e.g., in a specific setting or for a specific
group of stakeholders). Future studies should assess in
more detail, which barriers and facilitators exist for each
domain and construct of the TDF and which impact the
identified factors might have on the behavior of different
stakeholders. Second, searching of included studies was
only performed in one database, as we found data satu-
ration had occurred indicated by the calculated data sat-
uration curve. For performing comparative effectiveness
research within systematic reviews, it is generally recom-
mended to search different databases to ensure identifi-
cation of all relevant studies for a certain topic [87]. For
the scope of our study, we were rather interested in
learning new themes; following qualitative research
methods, where it is of interest to know the point when
collection of new information will produce little or no
change of the overall finding (i.e., data saturation) [27],
we also reached a point of data saturation after collection
of factors from an increasing number of included studies.
Our approach of assessing on whether to continue or to
stop data collection might therefore be pragmatic but
suitable for the scope of our study [27, 29]: The time-
consuming data extraction and synthesis from additional-
ly included studies probably would not have led to a
considerably different overall picture of barriers and fa-
cilitators. Nevertheless, it is conceivable that searching
further databases (e.g., EMBASE or PsycINFO) might
have led to the identification of different studies and
some new themes. Also, the perspectives of other stake-
holder (e.g., dental hygienists, dental auxiliaries, dental
students) might have been considered. Future studies
may search additional databases to increase the compre-
hensiveness of identified barriers and facilitators. Third,
our analysis did not allow us to discriminate between
different countries or healthcare systems, although it is
likely that barriers and facilitators will vary considerably.
As we found most of the included studies were conduct-
ed in high-income countries, our findings might not be
generalizable outside of these settings. Before planning
interventions to improve OHC for DOP for a certain
setting, generalizability of our findings should be criti-
cally evaluated. Lastly, we used the Newcastle-Ottawa
Scale for cross-sectional studies for quality assessment,
which is a common tool used for quality assessment in
non-randomized trials [88]. We further modified this tool
in order to increase its applicability, also to qualitative
Clin Oral Invest
studies. This was necessary as there is no validated in-
strument for quality assessment available, which can be
used for quantitative as well as for qualitative studies.
We found nearly all studies to yield a moderate or high
risk of bias, which likely leads to some distortion of
findings.
Implications for further research
Our study displays a comprehensive picture which barriers
and facilitators in the field exist and, to some degree,
shines a light on their possible relevance. Further studies
should perform more in-depth analyses using qualitative
methods to identify setting-specific barriers and facilita-
tors for different healthcare professionals [80]. Further
studies should also assess how interactions between the
different stakeholders with their different roles might in-
fluence the execution of the target tasks. Based on such
analyses and any insights gained, concepts for improving
OHC provision to DOP should be developed, considering
the identified barriers and enablers in each specific setting.
Linking the TDF to the BCW and the associated behavior
change, techniques can be helpful here [32].
Conclusions
Based on this review and within its limitations, many
different barriers and facilitators exist for provision of
OHC to DOP. These are not necessarily identical in dif-
ferent stakeholders and for different target behaviors,
namely providing OH and providing oral/dental treatment.
Our study provides information to inform further research
aiming at facilitating development of interventions for
improving OHC for DOP. These interventions should be
tailored for individual settings and pre-tested appropriate-
ly prior to implementation.
-Acknowledgements We appreciate the support of Prof. Gabriele Meyer
(Martin-Luther-Universität Halle-Wittenberg, Germany) for her useful
comments on our study and the manuscript.
Funding This study was funded by the authors and their institutions.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval This article does not contain any studies with human
participants or animals performed by any of the authors.
Informed consent For this type of study, formal consent is not required.
Clin Oral Invest
Abbreviations NOS, Newcastle-Ottawa Scale; TDF, theoretical do-
mains framework; COM-B, capability, opportunity, motivation, and be-
havior model; OHC, oral healthcare; OH, oral hygiene; DOP, dependent
older people; FES, frequency effect size; BCW, behavior change wheel
Publisher’s note Springer Nature remains neutral with regard to juris-
dictional claims in published maps and institutional affiliations.
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