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9 March 2026

Exploring Oral Health Practices and Barriers Among Nurses and Nursing Assistants in Long-Term Care Facilities: A Cross-Sectional Survey

,
and
1
Health Sciences Faculty, University Fernando Pessoa, 4200-150 Porto, Portugal
2
RISE-Health (Health Research and Innovation Unit), FP-I3ID (Instituto de Investigação, Inovação e Desenvolvimento), FP-BHS (Biomedical and Health Sciences Research Unit), Faculty of Health Sciences, Fernando Pessoa University, Fernando Pessoa Teaching and Culture Foundation, Rua Carlos da Maia, 296, 4200-150 Porto, Portugal
3
LAQV/REQUIMTE (Laboratório Associado para a Química Verde/Rede de Química e Tecnologia), University of Porto, 4050-313 Porto, Portugal
*
Author to whom correspondence should be addressed.
Oral2026, 6(2), 28;https://doi.org/10.3390/oral6020028
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Abstract

Background: Oral health (OH) is integral to general health, well-being, and quality of life; however, in long-term care (LTC) settings, it is often neglected due to residents’ functional limitations, high care dependency, and the prioritization of underlying medical conditions by healthcare staff. Previous studies have highlighted this issue and identified multiple barriers to OH promotion in institutional settings. Objectives: To assess OH practices among nurses (NUR) and nursing assistants (NA) in LTC units and to identify barriers compromising effective oral care delivery. Methods: An observational, cross-sectional, descriptive study was conducted across five LTC facilities in Porto, Portugal. A structured survey was administered to 145 healthcare workers out of a total of 259 eligible participants, yielding a response rate of 55.98%. Data were collected via Google Forms and analyzed using IBM SPSS Statistics v.26. Descriptive statistics, analysis of variance, the Mann–Whitney U test, and Chi-square tests were applied, with a significance level of 0.05. Results: The main primary barriers to OH promotion included poor patient cooperation (74.6%), lack of dentists (74.6%), insufficient material (62.7%), limited time (45.8%) and inadequate staffing (40.7%). Chlorhexidine (94.50%) and oral sponges (70%) were the most frequently used resources, whereas other methods were underutilized. No statistically significant differences were observed between professional groups, irrespective of prior training. Although 48.5% of NUR and 51.5% of NA reported not perceiving barriers, substantial gaps in practice were identified. Only 1.9% of untrained NA reported consulting evidence-based scientific sources, compared with 44.7% of untrained NUR. Conclusions: Despite limited perceived barriers, significant deficiencies in OH practices persist in LTC settings, highlighting the need for structured, interdisciplinary training programs to improve oral care delivery.

1. Introduction

Older adults residing in long-term care (LTC) facilities often present with functional limitations, cognitive impairment, and high dependency levels, which increase the complexity of care and the need for institutional support [1,2]. Ageing and multimorbidity contribute to a higher prevalence of chronic conditions, reinforcing the importance of structured care in LTC settings [2].
Oral health (OH) is a fundamental component of overall well-being and is closely linked to systemic conditions, including cardiovascular disease, diabetes, respiratory infections, kidney disease, and aspiration pneumonia [3,4,5,6,7]. Residents of LTC frequently face difficulties in performing adequate oral hygiene, which increases the risk of dental caries, gingivitis, periodontitis, and secondary infections [4,5,6,7,8,9,10,11,12,13,14].
Despite the recognized importance of OH, numerous barriers hinder its promotion in LTC. These include patient non-cooperation, insufficient knowledge and training among caregivers, limited dental materials, low prioritization of oral care, inadequate interdisciplinary communication, lack of formal OH protocols, restricted access to equipment, and limited time and staffing [12,13,14,15,16,17,18,19,20,21,22,23]. While caregivers generally demonstrate positive attitudes towards oral care, they often report a need for improvement in knowledge and practical skills [15,16,22,24,25,26]. Evidence suggests that implementation strategies can enhance caregiver knowledge and attitudes; however, these improvements do not always translate into better oral health outcomes, although interventions targeting denture plaque have shown substantial effect sizes [27].
Previous work by our group [28] focused on evaluating the knowledge and attitudes of nurses and nursing assistants regarding oral health. Building on this, the present study addresses a gap in the literature by assessing actual oral health practices and perceived barriers among healthcare professionals in LTC units in Porto, Portugal. This approach provides insight into the real-world implementation of oral care and identifies obstacles that may limit effective oral health management.
The present study aims to evaluate the oral health practices and perceived barriers of nurses and nursing assistants working in LTC units, thereby extending previous findings on knowledge and attitudes and providing actionable information to improve oral care delivery in institutional settings.
The null hypothesis of the present study states: There are no statistically significant differences in perceived barriers between NUR and NA working in long-term care units. There are no statistically significant differences in oral care practice between NUR with and without training in OH and NA with or without training, working in LTC.

2. Materials and Methods

This is an observational cross-sectional study, reported following the STROBE criteria [29] (see Supplementary Materials).
The study received approval from the University Ethics Committee (No. FCS, 11 April 2019). Before completing the online survey, each participant provided informed consent. Participants were fully informed by the researcher about the purpose and procedures of the study. They were notified that participation was voluntary, that they could withdraw at any point without any adverse consequences, that their responses would remain anonymous and confidential, and that all data would be analyzed in aggregate form, ensuring non-identifiability. Since the data collection was conducted online, informed consent was obtained electronically immediately before the survey began by selecting the option “I consent to participate in the study.”
This study targeted NUR and AHT working in five LTC units in the Greater Oporto area. Units with hospitalizations of over 90 days were considered, ensuring similar protocols. This observational study uses a convenience sample, followed a census-based sampling strategy, in which all eligible healthcare professionals from the participating long-term care units (N = 259) were invited to participate. Consequently, an a priori sample size calculation was not performed. Additionally, no previous Portuguese studies assessing oral health practices in long-term care settings were available to provide valid estimates of effect size or outcome prevalence, which are required for robust power analysis.
Eligibility was restricted to healthcare professionals directly responsible for oral hygiene and basic patient care (nurses and nursing assistants), as these professionals are primarily involved in the implementation of oral health practices in long-term care units. Staff without direct caregiving roles (e.g., administrative or non-clinical personnel) were excluded to ensure that responses reflected actual clinical practices and barriers related to oral care delivery.
A survey prepared by the author, consisting of 36 questions and divided into 4 parts, was carried out. The first part includes questions about the participants’ sociodemographic data. The second, third, and fourth parts correspond respectively to questions about the attitude, practice, and knowledge of the NUR and NA about OH. The only items allowing multiple answers concerned the barriers and tools used in OHy, whereas all other questions were limited to a single response. The questionnaire was checked for clarity and contextual relevance and was first tested by a focus group consisting of NUR and NA not related to the research site. The survey was applied through the Google Forms platform, between April 2019 and February 2020. This paper focuses on parts three and four of the survey, as the other information collected was published previously [28] as prior mention.
The IBM SPSS Statistics 26.0 software (IBM Corporation, Armonk, NY, USA) was used for statistical analysis. The descriptive statistics present the socio-demographic data of the participants’ characteristics, practices, and perceived barriers using frequencies (qualitative variables) and central tendency and dispersion statistics (quantitative data). Inferential tests (ANOVA, Mann–Whitney U, and Chi-square) were applied to explore differences between NUR and NA across the assessed variables. The Mann–Whitney U nonparametric test was used to assess the existence of a significant difference regarding the median duration of the OHy (minutes) of patients in two groups (e.g., NUR and NA, with or without training in OH, work experience) due to the non-normal distribution of the data. The Chi-square test was used to evaluate differences in responses (qualitative variables) regarding OH practices and identified barriers to OH in two groups (NUR and NA, with or without training in OH). Given the exploratory nature of the study and the absence of predefined primary or secondary outcomes, no adjustment for multiple testing was performed. All analyses were conducted at a significance level of 0.05. We acknowledge that multiple comparisons may increase the risk of type I error, which should be considered when interpreting the results.

3. Results

From a target population of 259 NUR and AHT, a total of 145 responses were collected, corresponding to a response rate of 55.98%. The participants’ characteristics are presented in Table 1. Their mean age was 34 ± 9.5 years (range: 18–59). The majority were female (83.4%), and most were nursing assistants (NA, 55.2%). Professional experience varied from 0.019 to 35 years, with a mean of 7.1 ± 5.7 years. Overall, 31% reported receiving training in oral hygiene (OH), including 40% of NUR and 60% of NA.
Table 1. Characteristics of participants (all statistics are presented as counts and % (n (%), unless otherwise stated).
Based on Table 2, a disparity is observed in the perception of barriers to oral health (OH) promotion between NUR and NA. Among NUR, only 37% reported encountering obstacles in providing OH care. The most frequently cited barriers included poor patient cooperation (74.6%), absence of dental professionals (74.6%), insufficient availability of materials (62.7%), time constraints (45.8%), and inadequate human resources (40.7%). In contrast, a majority of NA (63.0%) acknowledged facing challenges, primarily highlighting patient cooperation difficulties (87.3%), absence of dental professionals (50.9%), and lack of dental supplies (30.9%) as key impediments. When considering all respondents collectively, 31.7% identified the most significant barriers as poor patient cooperation (80.7%), absence of dental professionals (63.2%), and insufficient dental supplies (47.4%).
Table 2. Possible barriers in providing oral care (all statistics are presented as counts and % (n (%)), comparison according to professional function (NUR and NA).
Among participants without OH training (Table 2), reliance on personal knowledge (88%) and observations of other professionals (43%) were the most prevalent sources of information. Notably, statistical significance (p = 0.028) was observed between NUR and NA regarding internet-based searches (17% of NUR vs. 3.8% of NA) and evidence-based research (44.7% of NUR vs. 1.9% of NA).
The supply of dental materials in hospitals is predominantly led by chlorhexidine (90.3%), followed by sponges (81.4%), gauze (65.5%), and manual toothbrushes (37.2%) (Table 2).
All p-values presented in Table 2 and Table 3 correspond to the inferential tests specified in the table footnotes and in the Statistical Analysis section (Chi-square, Fisher’s exact test, or Mann–Whitney U, as appropriate).
Table 3. Practices in oral health (all statistics are presented as counts and % (n (%)), description according to training in OH (No and Yes), and comparison according to the professional function (NUR and NA).
Table 3 details the OH practices among caregivers. It should be noted that all findings related to prior oral health training are presented as associations only, in accordance with the cross-sectional study design, and do not imply causality or the effectiveness of training.
A majority of NA both trained and untrained (75.0% and 76.90%, respectively), do not conduct oral screenings of patients. Conversely, NUR with and without training primarily engage in oral screenings (41.50% and 50.60%, respectively) (Table 3). Among those who perform oral examinations, most report conducting them once a day using solely direct observation without internal or external palpation.
When addressing prevalent oral issues, caregivers predominantly opt for product application (55.6% of NUR and 44.4% of untrained TA) and seek communication with physicians (50.6% of NUR and 49.5% of untrained NA, 37.2% of NUR and 62.8% of trained NA) as their primary resolution methods.

4. Discussion

The null hypotheses were not rejected, as the results revealed no statistically significant differences in perceived barriers between NUR and NA in LTC, nor in oral care practices according to oral health training status among either professional group.
In long-term care (LTC) settings, oral health (OH) is a core component of daily care, largely performed by nurses (NUR) and nursing assistants (NA). The present findings reveal important gaps in oral screening and documentation practices, particularly among untrained caregivers, which may hinder the early identification of oral conditions. These results should be interpreted as observed practices rather than indicators of effectiveness, in line with the cross-sectional design. Existing European consensus documents highlight the need to strengthen OH promotion and standardization in medicalized LTC units, providing a relevant framework for contextualizing these shortcomings [30].
The limited reporting of appropriate clinical management or referrals observed in this study suggests that oral conditions may not be systematically integrated into routine clinical assessment, despite evidence supporting the importance of regular oral examinations for prevention and early diagnosis [30,31,32]. Caregivers frequently reported encountering oral health problems such as halitosis, xerostomia, gingivitis, and oral candidiasis, indicating a considerable burden of unmet OH needs among LTC residents. While xerostomia is often associated with medication, aging, or systemic conditions, the presence of gingival inflammation and candidiasis may reflect inadequate plaque control and suboptimal oral hygiene (OHy) practices [33,34].
Barriers to OH promotion identified in this study, including poor patient cooperation, lack of physician involvement, insufficient materials, and limited human resources, are consistent with previously reported structural and organizational constraints in LTC settings [35,36]. The prominence of patient cooperation as a perceived barrier, alongside the relatively low overall recognition of barriers, may also reflect gaps in knowledge and training, potentially influencing both perception and daily practices.
A notable finding was the predominant use of sponges as the main mechanical tool for OHy, despite evidence indicating their reduced effectiveness in plaque removal compared with toothbrushes [37,38,39]. This contrasts with international recommendations emphasizing mechanical plaque control as the cornerstone of oral hygiene [30,40,41]. The very limited use of suction toothbrushes, electric devices, or adapted tools further suggests that oral care practices may not be sufficiently tailored to dependent or frail patients, even though some reviews indicate that electric or adapted brushes may be more feasible for caregivers in specific contexts [42,43,44,45]. These discrepancies should be interpreted as differences in reported practices rather than as evidence of tool superiority.
The frequent use of chlorhexidine reported by caregivers indicates a reliance on chemical approaches to OHy. However, available evidence supports its use mainly as an adjunct in cases of poor plaque control and under clinical supervision, rather than as a substitute for mechanical plaque removal [39,40,46]. Additionally, the routine use of mouthwashes in frail older adults may present practical challenges, particularly in individuals with swallowing difficulties [30,47,48].
The study also showed limited adoption of interdental cleaning tools, tongue cleaning devices, and adapted denture hygiene methods. Although interdental brushes, floss, and tongue cleaning are recognized as important components of comprehensive OHy, their implementation in LTC practice appears inconsistent, possibly due to patient-related limitations and practical constraints [33,35,49,50,51]. Similarly, denture hygiene practices reported in this study diverge from recommendations advocating regular mechanical and chemical cleaning, and appropriate storage conditions to prevent microbial colonization and related complications [52,53,54,55,56].
Importantly, no significant differences were observed between trained and untrained caregivers in most practices. This finding may suggest that formal training alone is insufficient to modify daily oral care behaviors without ongoing supervision, institutional protocols, and resource availability. In this context, the absence of structured OH protocols in many LTC facilities may partially explain the persistence of heterogeneous and suboptimal practices.
Finally, external guidelines and consensus statements were retained in this Discussion to contextualize whether the reported practices of NUR and NA align with expected standards in LTC oral care. These references are used as interpretative benchmarks rather than prescriptive recommendations derived from the present study. Accordingly, all interpretations are limited to associations observed in the data and should not be construed as evidence of causality or effectiveness, given the cross-sectional and observational nature of the study.
This study presents some limitations that should be acknowledged. First, a convenience, census-based sample was used, including only healthcare professionals from five long-term care units in a single geographic region. In addition, no a priori sample size calculation was performed, as all eligible professionals were invited to participate. Although this approach reflects the total accessible population within the selected units, the absence of a formal sample size estimation may limit statistical power and should be considered when interpreting the findings, particularly in analyses where no significant differences were observed. These factors may reduce the external validity and generalizability of the results. Second, the response rate (55.98%) introduces the possibility of non-response bias, as professionals more interested in oral health may have been more likely to participate. Third, data were collected through a self-reported questionnaire, which is inherently subject to recall bias and social desirability bias, potentially leading to overestimation of good practices. Additionally, eligibility was restricted to nurses and nursing assistants directly involved in oral and basic care, excluding other staff; although methodologically justified, this may have limited the comprehensiveness of institutional perspectives. Finally, the cross-sectional design precludes causal inferences and only allows the identification of associations and reported practices at a single time point. Despite these limitations, the inclusion of multiple LTC units and a sample representing more than half of the eligible population strengthens the internal consistency and contextual relevance of the findings.
Additionally, the questionnaire was specifically developed for this study and, although pre-tested for clarity, did not undergo extensive psychometric validation, which may affect the reliability and comparability of certain constructs. Furthermore, no clinical oral examinations were performed to objectively verify reported oral health conditions or hygiene practices; therefore, the findings rely on self-reported data. Nonetheless, the instrument was grounded in existing literature and tailored to the institutional context, and self-reported measures were considered appropriate given the study’s focus on professional practices and perceived barriers within long-term care settings.
Finally, differences between nurses and nursing assistants may have been influenced by unmeasured factors such as workload, shift patterns, or patient dependency. Nevertheless, the study focused on healthcare professionals’ knowledge, attitudes, and self-reported practices, and participants were able to indicate perceived barriers to oral care, capturing contextual influences without directly measuring these factors.

5. Conclusions

The main barriers identified by the participants were poor patient cooperation, absence of attendance of MD, and lack of materials. Although 48.5% of NUR and 51.5% of NAs reported not perceiving barriers to OH practices in LTC, the present findings reveal the persistence of substantial gaps in oral care. The frequent use of ineffective tools, such as oral sponges, underscores discrepancies between reported perceptions and evidence-based care.
Despite the multiple challenges associated with providing OH care to dependent patients, caregivers should be encouraged to adopt comprehensive, evidence-based approaches tailored to individual patients’ needs. Only 1.9% of untrained NAs reported consulting evidence-based scientific sources, compared with 44.7% of untrained NURs. However, for most assessed variables, no statistically significant differences were observed between professional groups, regardless of prior training. These differences did not reach statistical significance, underscoring the need for structured, interdisciplinary training programs aimed at improving OH in LTC.
Providing effective OH care to dependent patients remains a significant challenge in LTC. The findings indicate the presence of gaps in caregivers’ evidence-based OHy practices and perceived barriers, within the context of systemic constraints such as limited resources and patient cooperation difficulties.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/oral6020028/s1, the STROBE reporting checklist.

Author Contributions

Conceptualization, A.B., S.G. and M.C.M.; methodology, A.B., S.G. and M.C.M.; validation, A.B., S.G. and M.C.M.; formal analysis, A.B., S.G. and M.C.M.; investigation, A.B.; resources, A.B., S.G. and M.C.M.; data curation, A.B., S.G. and M.C.M.; writing—original draft preparation, A.B., S.G. and M.C.M.; writing—review and editing, A.B., S.G. and M.C.M.; visualization, A.B., S.G. and M.C.M.; supervision, S.G. and M.C.M.; project administration, A.B., S.G. and M.C.M.; funding acquisition, A.B. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the University Fernando Pessoa (11 April 2019, no protocol code was issued by the institution).

Data Availability Statement

The data that support the findings of this study are available from the corresponding author, M.C.M., upon reasonable request.

Acknowledgments

The authors would like to thank all the nurses, auxiliary technicians, and the directors of all hospital units who accepted to participate in this project.

Conflicts of Interest

The authors wish to confirm that there are no known conflicts of interest associated with this publication, and there has been no financial support for this work that could have influenced its outcome. The authors report that they do not have any outside financial support or potential conflicts of interest. The foundation mentioned in the affiliation is the legal governing body of the university and does not represent a conflict of interest.

Abbreviations

The following abbreviations are used in this manuscript:
LTCLong-term care
MDDentists
NANursing assistants
NURNurses
OH Oral health
OHyOral hygiene

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