Oral Health Care for Older Adults: Implications for U.S. Nursing Homes: A Structured Narrative Review

Abstract

Oral health in long-term care facilities, particularly in U.S. nursing homes, is an increasing concern as the older adult population continues to grow. Poor oral health among older adults is associated with adverse physical and psychosocial outcomes, yet oral care remains underprioritized in institutional settings. This structured narrative review synthesizes literature on oral health care for older adults, focusing on workforce roles and organizational practices relevant to U.S. nursing homes. Literature was identified through searches of electronic databases, including PubMed, ProQuest, and PsycINFO. The included studies examine oral health care practices, training programs, and organizational factors influencing care delivery with implications for U.S. nursing home care. Findings indicate persistent gaps in oral care for older adults due to barriers such as limited staff training, organizational constraints, and insufficient institutional prioritization. These factors align with broader social and structural determinants shaping access to and quality of oral care. Several studies highlight the potential benefits of integrating oral health education into health professional training and nursing home practice, although reported effects were mixed. Overall, the review highlights the importance of targeted staff education, organizational support, and improved funding and resources in enhancing oral health care delivery in U.S. nursing home care contexts.

Keywords

oral health care delivery nursing homes workforce organizational factors

Introduction

As the global population ages, addressing the social determinants of health (SDOH) that impact older adults is increasingly critical. Among these determinants, oral health represents a frequently overlooked yet essential component of overall well-being. Inadequate oral care and poor oral hygiene can lead to systemic conditions such as cardiovascular disease and diabetes, as well as adverse impacts on physical and cognitive health (e.g., coronary heart disease and Alzheimer’s disease) and reduced survival among individuals with head and neck cancers (Desai & Nair, 2023; Farquhar et al., 2017; Gurenlian, 2009; Li et al., 2000). Despite its importance, oral care is often undervalued in America’s healthcare culture which tends to prioritize other organs over the mouth (U.S. Department of Health and Human Services, 2000).

Oral health care is similarly overlooked in practice across long-term care facilities (LTCFs), particularly in nursing homes (NHs), where it has become a serious concern given residents’ complex health needs (R. Ettinger & Marchini, 2022). An estimated 1.7 million older adults live in long-term care nursing facilities in the U.S., but only about 17% of them are treated with dental care (Maramaldi et al., 2019). Nursing home residents, who comprise a significant subset of LTCF populations, are particularly vulnerable to poor oral health outcomes. Many NH residents are of advanced age, have multiple underlying health conditions, and experience functional limitations, which increase both their need for oral care and the risk of insufficient care (Sifuentes & Lapane, 2020). Studies have found that, in U.S. nursing homes, fewer than one-fifth of residents either receive adequate oral hygiene (e.g., had their teeth brushed and mouth rinsed) from nursing staff or report having good oral health (Coleman & Watson, 2006; Zimmerman et al., 2017). Limited staff training, workforce shortages, and lack of institutional prioritization contribute to this insufficiency, leaving residents particularly vulnerable to preventable oral diseases (Leung & Chu, 2022; Sifuentes & Lapane, 2020).

Beyond clinical risks, oral health represents a critical SDOH that influences physical, cognitive, and psychosocial well-being among older adults. Social and structural factors, such as education, insurance coverage, and socioeconomic status, impact both the access to care and oral health outcomes. For instance, data from the 2018 Behavioral Risk Factor Surveillance System (N = 155,060) show that nearly 50% of U.S. adults had lost one or more permanent teeth, with losses associated with these social factors (Gaskin et al., 2022). Limited access to oral health care is also linked to broader health outcomes, such as mental health and obesity (Nijakowski et al., 2020; Tanaka et al., 2022). Furthermore, diminished social contact and engagement have been associated with poorer oral health (e.g., fewer teeth, faster tooth loss) among older adults, in turn affecting their social connections and quality of life (Qi et al., 2023; Yoshida-Kohno et al., 2025). Poor oral hygiene can further reduce confidence, impair self-esteem, increase social isolation, and contribute to anxiety, cognitive decline, and depression (Finlayson et al., 2024; Guerrero-Escobedo et al., 2014; Palomer et al., 2024; Rouxel et al., 2017). Taken together, these findings highlight that oral health serves not only as a clinical concern but also as a social determinant influencing older adults’ overall well-being.

Despite these high stakes, oral health remains a “silent epidemic” in NHs and across LTCFs, with gaps persisting in our understanding of how workforce roles, organizational structures, and systemic barriers influence oral care delivery. NH residents are legally entitled to proper oral care under Centers for Medicare & Medicaid Services (CMS) regulations, yet deficiencies in compliance are frequently observed (Centers for Medicare & Medicaid Services, n.d). Specifically, 42 CFR § 483.55 (Dental services) mandates that all nursing facilities provide both routine and emergency dental services to meet each resident’s oral needs, with compliance monitored using F-tags (e.g., F-tag 790 and F-tag 791). Despite these regulations, research indicates that deficiencies remain common across NHs. For example, many facilities lack standardized oral care protocols, and oral assessments are often incomplete (Coleman & Watson, 2006; Sifuentes & Lapane, 2020). Implementation and monitoring remain inconsistent, putting residents’ oral health at risk.

This current study synthesizes existing research on oral health care for older adults using a structured narrative review approach, with a focus on workforce roles, organizational practices, and system-level factors that shape access to and quality of oral care. While nursing homes represent a critical setting where oral health needs are concentrated and the consequences of inadequate care are especially pronounced, relevant evidence is dispersed across studies conducted in nursing homes, as well as in broader health care, training, and policy contexts. Despite longstanding recognition of the importance of oral health and regulatory requirements in nursing homes, limited research has examined how workforce and organizational conditions influence oral health care delivery for older adults. By consolidating findings across these domains, this review aims to inform nursing home practice and policy by identifying structural and workforce-related barriers and opportunities to improve oral health care and outcomes among older adults.

Methods

Data Sources

This study uses a structured narrative review approach to synthesize literature on oral health care delivery for older adults, drawing on a structured search of electronic databases, informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Page et al., 2021). Electronic databases, including PubMed, ProQuest, and PsycINFO, were searched to identify relevant studies, with the final search conducted in November 2023. The search was limited to peer-reviewed scholarly articles published in English between 2013 and 2023, and focused on U.S. contexts, ensuring inclusion of contemporary and relevant evidence. Dissertations, systematic reviews, and meta-analyses were excluded to focus on empirical, conceptual, and commentary-based contributions relevant to the review aims.

Search Strategy

Keywords were selected to capture research relevant to oral health care for older adults, with particular attention to workforce-related factors informing care in nursing home contexts. Oral health-related terms (e.g., oral and related derivatives), population and workforce terms (e.g., staff, nurse, worker, aide), and organizational or care context-related terms (e.g., nursing home, nursing facility) were included. Additional workforce-related terms, such as training and education, were included to capture studies addressing workforce preparation, care delivery, and organizational practices relevant to oral health care. Keywords were combined using Boolean operators (AND/OR) and truncation (*) to capture relevant variations in terminology across databases. Articles were included if they examined oral health care practices, workforce roles, organizational factors, or system-level influences relevant to oral health care for older adults, with implications for U.S. nursing home care contexts. Inclusion was determined by conceptual relevance to oral health care delivery for older adults in nursing home-relevant contexts, rather than by study setting alone.

Study Selection

The search yielded 1,118 records. After removing duplicates, 1,101 articles were screened based on titles and abstracts. Twenty-two articles were assessed in full text, of which 16 were included in the qualitative synthesis. Six articles were excluded due to limited relevance to oral health care for older adults or to workforce, organizational, or system-level factors pertinent to nursing home care contexts. Figure 1 presents the study selection flow diagram. Screening and full-text review were conducted by the authors, with discussion used to resolve uncertainties or discrepancies.

Figure 1.

Study selection flow diagram.

Key findings from each included article were extracted and reviewed to identify common patterns related to workforce roles, organizational factors, and system-level influences shaping oral health care with implications for nursing home care contexts. Notes from each study were grouped into preliminary categories, which were reviewed and refined through discussion among all authors. Following iterative review and discussion, the findings were organized into three overarching themes representing the primary areas of focus across the included studies.

Results

Overview of Included Studies

The sixteen studies included in this review used a range of research approaches, including quantitative, qualitative, mixed methods, program evaluations, policy analyses, and commentary. Most studies examined oral health care practices, workforce roles, or organizational and system-level factors relevant to U.S. nursing home care contexts, while a few examined broader populations of older adults or professional training programs with implications for nursing home care contexts. Study samples ranged from nursing staff and nursing home residents to program directors and participants in interprofessional training programs. Table 1 summarizes the study designs, key findings, and implications/recommendations of the included studies.

Table 1.

Summary of Included Studies (N = 16).

Citation	Study design/method	Key findings (workforce/organizational/structural focus)	Implications/recommendations
Barrow et al. (2020)	Qualitative	Oral health underrepresented in graduate programs; interprofessional education may improve workforce competency	Fund integrated training; foster collaboration between dental & medical programs
Cadet et al. (2015)	Mixed methods	Certified Nursing Assistant training showed modest knowledge gains in select domains; no significant change in attitudes/self-efficacy	Revise training models; multiple sessions with follow-up assessments
Chávez et al. (2016)	Qualitative	Misconceptions about age-related dental disease; ageism and educational disparities	Public health campaigns; include dental benefits in Medicare Part B
Dirks (2016)	Qualitative	Nursing homes face limited funding, lack protocols, and staff negative attitudes	Leadership development; improve communication between dentists, staff, and residents
R. L. Ettinger and Cowen (2016)	Program evaluation	Student training in oral care for older adults improved understanding of residents’ complex care needs; findings suggest potential workforce preparation benefits	Implement programs teaching comprehensive oral care in long-term care settings
Hartshorn et al. (2021)	Quantitative	Mouth Care Matters training was associated with improved Certified Nursing Assistant-delivered oral care; reduced plaque and gingival scores	Expand clinical trials; secure government support for staff training
Jablonski et al. (2018)	Quantitative	Trained staff reduced care-resistant behaviors; quality more important than frequency	Explore strategies for resistant behaviors; emphasize care quality
Lee et al. (2015)	Quantitative	Older adults with cognitive impairment were less likely to receive regular dental care; gaps in access and insurance coverage	Longitudinal studies on dental care utilization; expand insurance coverage
Maramaldi et al. (2019)	Quantitative	Oral care low priority; staff lack knowledge/skills; screenings insufficient	Educational programs; enhance oral cancer screening; mobile dental teams
Nagro (2016)	Policy analysis	A substantial proportion of older adults lack dental insurance; policy initiatives such as the Action for Dental Health Act identified as potential mechanisms to address financial barriers	Expand insurance coverage; mandatory oral screenings
Saunders (2016)	Commentary	Oral health integral to overall health; funding limited	Improve oral health literacy; influence public and policy perceptions
Taverna et al. (2016)	Qualitative	Dementia complicates oral care; caregivers lack specific training	Develop oral care guides; advocate for interventions and training
Ticku et al. (2020)	Quantitative	Medical educators support integrating oral health training into medical education; potential benefits for workforce preparation	Strengthen health-dental program integration to reduce disparities
Warshaw and Bragg (2016)	Quantitative	Shortage of geriatric specialists; workforce unprepared for oral care needs	Implement training; Congress should fund workforce assessments; financial incentives for geriatrics
Weintraub et al. (2018)	Quantitative	Staff-administered oral care improved plaque, gingival, and denture hygiene	Implement structured oral care interventions
Yellowitz (2016)	Qualitative	Non-dental professionals often unaware of oral-systemic links; professional isolation reduces knowledge sharing	Promote interdisciplinary collaboration; leverage provider influence to encourage dental visits

Emerging Themes

Three overarching themes were identified across the included studies. The first theme, represented in four studies, emphasizes the significance of oral care for older adults. Studies within this theme highlighted the importance of educating caregivers about oral hygiene, underscoring their role in providing consistent care and raising awareness of the potential health consequences associated with inadequate oral care. The second theme, reflected in three studies, pertains to the integration of oral care within broader healthcare training and practice. The three studies examined the benefits of incorporating oral health education into general healthcare programs and emphasized the need for providers to understand the connections between oral and systemic health in order to deliver comprehensive care. The third theme, reflected in nine studies, focuses on barriers to oral care delivery and potential solutions. The nine studies identified structural, organizational, and workforce-related challenges, including limited staff knowledge and training, insufficient funding, and gaps in insurance coverage for residents. Proposed solutions included enhanced staff training, the development of standardized care protocols, and policy-level efforts to address gaps in funding and access to dental care.

Significance of Oral Care

Four studies underscored the significance of oral care for older adults, including those with cognitive or functional limitations, with implications for care delivery in nursing home care contexts (R. L. Ettinger & Cowen, 2016; Lee et al., 2015; Taverna et al., 2016; Warshaw & Bragg, 2016). Across these studies, oral health was closely linked to older adults’ overall health, comfort, and ability to maintain daily functioning, yet it was often overlooked in routine care. In particular, older adults with cognitive or functional impairments often face challenges such as memory deficits, communication difficulties, and care-resistant behaviors, which may contribute to poorer oral health outcomes. As a result, these individuals rely heavily on caregivers and nursing staff for daily oral hygiene and access to dental services, particularly in institutional care settings. Several studies reported gaps in caregiver training and confidence, contributing to inconsistent oral care practices and, in some cases, negative attitudes toward oral hygiene tasks. Collectively, these findings highlight the clinical importance of oral care for older adults and underscore challenges that may be particularly salient in nursing home care contexts.

Integration of Oral Care

Three studies emphasized the integration of oral health into broader healthcare education and practice as a strategy for strengthening workforce preparedness and interdisciplinary collaboration, with relevance for oral care delivery in nursing home care contexts (Barrow et al., 2020; Ticku et al., 2020; Yellowitz, 2016). Across these studies, insufficient oral health knowledge among non-dental healthcare providers was identified as a persistent challenge, largely reflecting limited exposure to oral health content during professional training. Barrow et al. (2020) reported that oral health remains underrepresented in graduate-level training programs, even in disciplines emphasizing interprofessional education, contributing to misconceptions that oral care falls outside providers’ clinical responsibilities. Yellowitz (2016) highlighted limited awareness of oral-systemic health connections among non-dental professionals and noted that professional isolation constrains interdisciplinary collaboration and knowledge sharing. Ticku et al. (2020) assessed oral health education across multiple primary care disciplines and found broad support among nurse practitioners for greater inclusion of oral health education, alongside recognition of the risks associated with inadequate training. Together, these studies suggest that integrating oral health into health professions education and clinical practice may enhance provider awareness, encourage interdisciplinary collaboration, and improve access to oral health care for older adults, which may be particularly impactful in care contexts where oral care is often deprioritized.

Barriers and Solutions

Nine studies examined barriers to oral health care delivery and evaluated potential strategies to address these challenges (Cadet et al., 2015; Chávez et al., 2016; Dirks, 2016; Hartshorn et al., 2021; Jablonski et al., 2018; Maramaldi et al., 2019; Nagro, 2016; Saunders, 2016; Weintraub et al., 2018). Across studies, barriers were consistently described at the workforce, organizational, and policy levels. Oral care was frequently reported as a low priority within nursing home routines, often overshadowed by competing demands related to nutrition, safety, and medical care (Maramaldi et al., 2019). Limited staff training, lack of standardized protocols, and negative or avoidant attitudes toward oral care further constrained consistent delivery, particularly when residents exhibited care-resistant behaviors or cognitive impairment (Dirks, 2016; Jablonski et al., 2018).

Several studies highlighted broader structural and social factors contributing to these barriers. Ageist beliefs, such as the perception that tooth loss and oral disease are inevitable aspects of aging, were identified as influencing provider, family, and societal attitudes toward oral care, reducing its perceived importance (Chávez et al., 2016; Saunders, 2016). Financial barriers were also prominent. Policy analyses documented substantial gaps in dental insurance coverage among older adults and limited Medicare benefits for dental services, constraining access to preventive and routine care for nursing home residents (Nagro, 2016).

Intervention studies reported mixed findings. Cluster randomized trials demonstrated that structured staff training programs, such as Mouth Care Matters (MCM), could improve Certified Nursing Assistant (CNA)-delivered oral care and residents’ oral health indicators (e.g., reductions in residents’ plaque and gingival scores), suggesting potential benefits of workforce-focused interventions (Hartshorn et al., 2021; Weintraub et al., 2018). However, other training efforts showed limited or inconsistent effects on staff knowledge, attitudes, or resident behaviors, underscoring challenges in sustaining change through brief or single-session interventions (Cadet et al., 2015; Jablonski et al., 2018). Collectively, these studies suggest that improving oral health care in U.S. nursing home care contexts requires multifaceted approaches that address workforce preparation, organizational support, and policy-level constraints rather than relying on workforce training alone.

Discussion

This structured narrative review synthesizes literature on oral health care delivery, highlighting key challenges and potential strategies with implications for improving oral health care practices in U.S. nursing home care contexts. Oral care was often described as underprioritized within care routines, particularly in institutional care settings, shaped by workforce, organizational, and policy-level limitations. Although this review was not explicitly designed using a social determinants of health framework, the findings align with prior work emphasizing the role of social and structural contexts in shaping health care access among older adults. These findings suggest that gaps in oral health care extend beyond individual clinical practices and reflect broader structural conditions within nursing home care contexts.

Limited training and preparation among direct care staff represent a central challenge in oral health care delivery. They are often responsible for assisting older adults with daily oral hygiene (particularly for those with cognitive or functional limitations), yet many lack the confidence or skills needed to provide such care consistently. These workforce limitations were reinforced by organizational norms in which oral care competed with other clinical demands, such as medication administration, nutrition, and safety-related tasks. As a result, oral hygiene was frequently viewed as discretionary rather than essential, contributing to variability in care practices across facilities.

The review also identified structural and policy-related constraints that shape access to oral health services for older adults. Inadequate insurance coverage and limited public funding for dental care were repeatedly cited as barriers to preventive and routine services, contributing to delayed, problem-driven dental visits rather than proactive and ongoing oral health maintenance. Viewed together, these findings are consistent with broader social and structural determinants of health, illustrating how workforce capacity, institutional priorities, and financial resources may increase older adults’ risk of inadequate oral health care and associated adverse outcomes.

Intervention studies included in this review provide insight into potential strategies for improving oral health care, while also highlighting their mixed effects. For instance, several staff-focused training programs were associated with improvements in residents’ oral hygiene outcomes. However, effects were inconsistent and appeared to vary by intervention design, duration, and implementation context. Brief or one-time training sessions tended to yield minimal or short-lived benefits, particularly in settings involving individuals with dementia or care-resistant behaviors. These findings suggest that training alone may be insufficient to produce sustained improvements when implemented in isolation. Interventions that incorporated broader organizational or interdisciplinary elements (e.g., collaboration across care roles, standardized care protocols, leadership engagement, adequate staffing and material resources) may hold additional promise, though empirical evidence remains preliminary.

This review has several limitations that should be noted. As a structured narrative review, this study did not aim to provide an exhaustive or fully systematic synthesis, and relevant studies may not have been captured. In addition, the search was limited to selected databases and articles published in English, which may have introduced selection bias and limited the comprehensiveness of the evidence base. Moreover, the included studies varied in design, sample size, and measurement approaches, which may limit the generalizability of findings and complicate direct comparisons across studies. Several studies relied on self-reported data from staff or residents, introducing potential recall or social desirability biases. Additionally, not all included studies were conducted exclusively in nursing home settings, though they were included due to their relevance to workforce, organizational, and structural factors informing care in these contexts. Nonetheless, this review offers several strengths. It highlights both persistent barriers and potential strategies for improving oral health care with particular relevance for nursing homes. Moreover, by incorporating workforce, organizational, and policy-level factors, the review allows findings to be interpreted in relation to social determinants of health, providing a contextualized understanding of the structural conditions that shape oral health outcomes in this vulnerable population.

These findings offer implications for practice, future research, and policy, particularly for efforts to improve oral health care delivery in U.S. nursing home care contexts. First, from a practice standpoint, nursing home staff may benefit from targeted education and training to improve oral health care delivery. Educational interventions should not only teach essential skills for daily oral hygiene but also emphasize the significance of oral health for residents’ overall well-being. Training programs that include hands-on practice, repeated exposure, and interdisciplinary collaboration (e.g., interprofessional education, integration with dental and primary care teams) may enhance staff competence and confidence, particularly when caring for residents with cognitive impairment or care-resistant behaviors. Embedding oral health into standard care routines, ensuring adequate staffing and resources, and promoting leadership engagement can further support sustained improvements in care quality.

Future research is recommended to evaluate multifaceted interventions that combine workforce training with organizational and policy-level supports. Larger-scale and longitudinal studies are needed to better assess the durability of training effects and their impact on resident outcomes. Research should also examine the effectiveness of interprofessional education and collaborative care models in long-term and nursing home care contexts, particularly regarding integration between nursing, dental, and primary care providers. Additionally, studies that include diverse facility types and resident populations can help clarify how structural and social determinants influence access to and quality of oral health care.

Policy efforts should expand public and private insurance coverage for dental services, increase funding for oral health programs, and incentivize nursing homes to integrate oral care into routine practices. Policies should support preventive oral health care by providing adequate funding and reimbursement so as to enable nursing homes to deliver consistent, high-quality services.

Conclusion

Oral health care in U.S. nursing home care contexts appears to remain underprioritized, with barriers at the workforce, organizational, and policy levels. Limited staff preparation, competing clinical demands, and insufficient financial and structural supports are associated with inconsistent care and increased risk of poor oral health outcomes among residents. While staff-focused training programs show some promise, lasting improvements may depend on integration with broader organizational and interdisciplinary supports.

Addressing these challenges through targeted education, supportive policies, and interprofessional collaboration may strengthen the quality and consistency of oral health care in nursing homes. Future research should focus on evaluating multifaceted interventions, assessing long-term outcomes, and examining the influence of social and structural determinants on access to care. Coordinated efforts across practice, research, and policy will be critical to ensure that nursing home residents receive the preventive and ongoing oral health care necessary for overall well-being.

Footnotes

ORCID iD

Xiaochuan Wang

Ethical Considerations

Not applicable.

Consent to Participate

Not applicable.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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