Fixing oral health in aged care

Dental Health Week (1-7 August), the Australian Dental Association’s annual nationwide oral health campaign, is just around the corner.


It’s a good time to look at the long overdue changes needed to improve oral healthcare for older Australians in aged care facilities.


ADA President Dr Mark Hutton


With a new government in Canberra since June, the Australian Dental Association (ADA) is quietly confident that the shocking oral neglect of older Australians in aged care may now stand a chance of getting resolved.


The peak dental body, which represents the nation’s 17,000 dentists, has seen some terrible oral neglect of our oldest citizens – so it came as no surprise that the Royal Commission into Aged Care Quality and Safety nominated  ‘insufficient attention to oral health, leading to widespread malnutrition, excruciating dental and other pain, and secondary conditions’  amongst the raft of glaring issues brought to its attention.


The inquiry put into sharp focus the urgent need to address how we tackle the health needs of our senior citizens, whether independent or no longer living at home.


This is only going to get more pressing with Aussies living longer. Between now and 2050 the number of  Australians aged 65 to 84 years is expected to more than double, while the number of Australians aged 85 years and over is expected to more than quadruple to 1.8 million by 2050.


With it comes challenges for healthcare service delivery - as people age, they have poorer mobility and more complicated multifactorial medical issues requiring more complex care.


What does that mean for mouths? It means more people have their natural teeth for longer, and many have had complex and sophisticated restorations to keep those teeth, as well as a much higher risk of degenerative problems like decay and fracture.


Almost non-existent provision of oral care for those in aged care coupled with long waiting lists in the public dental system and poor value for money for private health insurance cover for dental work means that you have a perfect storm for rotten dental health for this rapidly expanding cohort.


The ADA made several recommendations to the Aged Care inquiry and central to this is the need to tackle the oral healthcare of seniors not only within aged care, but in the years before they enter the system. Yet the health assessments done by GPs for the over 75s don’t currently include oral health.


Indeed many older people enter aged care with poor oral health because they only go to the dentist when in pain, or they have reduced manual dexterity (ergo failure to brush twice a day or floss) due to arthritis, or perhaps dementia is a contributory factor.


So they enter an aged care facility with cracked teeth, fractures in their teeth, untreated gum disease, dentures that are overdue for a clean or a new set, or ulcerated tongues caused by broken teeth to name a few problems.


Coupled with this are the many complex health conditions older people suffer and associated medications which can result in reduced saliva flow, increasing the risk of dental caries and gum disease. Indeed Australian Institute of Health and Welfare statistics show that over half of people over 65 have gum disease.


Addressing and preventing these problems requires careful daily attention to oral hygiene, which can be difficult as manual dexterity declines, as well as regular reviews by a dentist. Under the current aged care system, none of this happens.


Studies have also shown that high levels of plaque accumulate on residents’ natural teeth and dentures, which places them at high risk for developing aspiration pneumonia, a commonly occurring event which can be fatal and necessitates immediate transfer to an acute care facility.


Several reviews found that daily brushing of nursing home residents’ teeth / dentures could dramatically reduce that pneumonia risk – in one study by almost 40% for pneumonia and almost 60% for fatal pneumonia.


Knowing what a difference even basic oral hygiene steps can make is one of many incentives to resolve this issue of understaffed residential homes where carers have not received appropriate training.


In our Aged Care Commission submission, the ADA proposed a national funding model – the Seniors Dental Benefits Schedule (SDBS), to make dentistry accessible to older Australians.


The ADA estimates this would cost just $95m a year to administer based on a 100% uptake of the scheme – a small figure in comparison to the overall annual health budget of $80bn a year.


The SDBS would use the existing Child Dental Benefits Schedule as the template for dental benefits assistance for population groups with poor oral health and unmet dental treatment needs, including Commonwealth Seniors Card and Pensioner Concession Card holders.


Thankfully, the Aged Care Commissioners agreed with the adoption of this scheme and included it in their set of recommendations.


Before the Federal election earlier this year, the ADA pushed hard for all the major parties to act swiftly by adopting an SDBS system to fund dental care provided by dentists working in either the public or private system.


Other urgent measures the ADA is advocating for to fix the broken system:

  •  the Certificate III Aged Care qualification to include oral care as one of its core units of study,
  •  for GPs to include oral health in their health assessments for over 75s, and
  •  for clinical indicators for oral health be included in Aged Care Quality Standards.


It remains to be seen if the recommendations, once adopted, will ensure enough nursing staff and personal care workers, not least when there is already a national shortage of fully-trained nurses and while aged care workers are notoriously underpaid.


Lack of an appropriate type of dental chair, x-ray facilities and other dental equipment at aged care facilities are undoubtedly also barriers to providing quality care.


But these issues could be addressed if such facilities were incorporated into the design of new aged care homes so dental professionals could treat more complex cases on site rather than in an off-site dental clinic with all the logistics and transport complexities that may bring.


This will not occur without direction from governments or support provided to existing facilities   - but the development of a multi-purpose room that can be utilised by dentists and other visiting healthcare professionals would have significant cost benefits to the health system overall.


These measures will both enable allied health services to support aged care residents in their day-to-day healthcare needs and ensure that healthcare professionals can effectively and safely perform their work when they needed.


There is much to do to improve the oral care of seniors in residential care but with the new Labor Government working with peak health bodies like the ADA and the AMA, as well as significant changes to funding models, staffing levels and training, those much needed improvements could well be within our sights.


27 July 2022.