Oral health challenges in aged care

Australians aged 65 and over had an average of 13.7 missing teeth in 2017–18, according to data from the Australian Institute of Health & Welfare. Around 59% suffered periodontitis and around 7% avoided eating some foods due to problems with their teeth, mouth or dentures.

With Dental Health Week in August (7–13), the Australian Dental Association’s (ADA) flagship oral health promotion event, it’s a great time to think about how we look after our mouths and those of older Aussies. The harsh reality is that urgent and long overdue changes are needed to improve oral health care for older Australians in aged care facilities.

With a new government in Canberra for over a year now, we at the ADA — the dental body which represents the nation’s 17,000 dentists — remain quietly optimistic that the shocking oral neglect of older Australians in aged care stands a chance of getting resolved.

We have 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” amongst the raft of concerning issues brought to its attention.

This problem is only going to get more pressing with people 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 those 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 medical issues requiring more complex care.

It also means more people have their natural teeth for longer, many with 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 adds up a perfect storm for rotten dental health for this expanding age group.

The ADA made a number of 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 come with cracked or fractured teeth, untreated gum disease, dentures that are overdue for a clean or replacement, 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.

Addressing and preventing these problems requires careful daily attention to oral hygiene as well as regular reviews by a dentist. Under the current 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 and/or 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 more older Australians.

The ADA estimates this would cost just $95m a year to administer based on a 100% uptake of the scheme, which is not likely.

The SDBS would use the existing Child Dental Benefits Schedule as the template for additional dental benefits assistance schemes 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 and included it in their set of recommendations.

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 and for GPs to include oral health in their health assessments for over 75s.

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

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 onsite rather than in an offsite dental clinic with all the logistics and transport complexities that brings.

This will not occur without direction from governments or support provided to existing facilities — but the development of a multipurpose room used by dentists and other visiting healthcare professionals would have significant cost benefits to the health system overall.

*Dr Stephen Liew graduated from the Australian Institute of Company Directors with the Order of Merit and is a recipient of the Australian Outstanding Young Dentist Award. He has chaired or served on many committees at federal and state level for over a decade, including the Australian Digital Health Agency’s Secure Messaging Steering Group and the FDI World Dental Congress 2021-3 Committee. He worked rurally in public health, volunteered in Australia and overseas, and is a Fellow of the International College of Dentists, Academy of Dentistry International and Pierre Fauchard Academy. He is the Federal ADA President.

Top image credit: iStockphoto.com/Svitlana Hulko