Hopes were high for a government program designed to train aged-care nurses to better manage oral health in the elderly. So a decade on, have things improved? Cameron Cooper reports
Checking the teeth and oral hygiene of older people living in residential care, Jayne Braunsteiner doesn’t like what she sees.
Oral thrush. Teeth and dentures that have not been brushed or cleaned for days or weeks. And, in extreme cases, dental care neglect that could lead to life-threatening health conditions such as aspiration pneumonia.
“It’s pretty dire,” says Braunsteiner, a dental hygienist at Residential Care by Montefiore in Randwick, Sydney. Her assessment comes a decade after the Australian Government launched the Better Oral Health in Residential Care Training program, an initiative designed to improve training for aged-care nursing teams so they could better manage the oral health of the elderly.
“After 10 years I’ve seen no improvement and it’s still a low priority among carers and nursing staff. It’s really frustrating,” Braunsteiner comments.
The unmet oral and dental care needs of the elderly population can seriously compromise their general health.
With that reality top of mind, in December 2009 the Australian Government rolled out the residential care training program in aged-care homes nationally. The aim? To provide increased awareness of oral hygiene issues for staff in daily contact with elderly residents. From 2009-12, about 400 workshops were delivered around the country, with more than 4800 people trained across 2809 aged-care homes and other services.
For all the intent, however, a question hangs in the air—has the program achieved much? Australian Dental Association president Dr Carmelo Bonanno says in addition to improved training, it produced some “fantastic” educational resources and an oral health assessment tool, known as the OHAT. The tool was intended for use by non-dental professionals, trained in its use, to check for potential problems that would inform care planning and trigger referrals to a dentist for a full dental examination and any necessary treatment.
“[But] although high-quality training resources developed for the program are still available, the positive short-term outcomes from the program haven’t been sustained over the long-term in many residential aged-care facilities,” Dr Bonanno says.
He cites two key reasons. First, the increasingly inadequate staff-to-resident ratios of most facilities apparently leave insufficient time to look after oral care. Second, low pay and poor working conditions have led to rapid staff turnover, making it difficult to keep educating new employees.
“As those who received the initial training a decade ago have progressively left the sector, the knowledge and skills have gone with them,” Dr Bonanno comments.
To help embed better practices, the ADA believes dentists must be an integral part of the aged-care workforce. Dr Bonnano adds: “You also need to ensure that personal care staff have accredited educational qualifications that have included oral health provision for older people and dementia patients as part of the curriculum, before they start working for aged-care service providers.”
“I’ve seen many forms filled out where they’ve commented that a resident’s teeth look amazing, and I’ll go and check them and they have dentures. They can’t even tell the difference.”
Jayne Braunsteiner, dental hygienist, Residential Care by Montefiore
Braunsteiner argues that OHAT has become part of the problem rather than part of the solution because general nurses and lay people are carrying out the assessments.
“They actually don’t know what they’re looking at,” she says. “I’ve seen many forms filled out where they’ve commented that a resident’s teeth look amazing, and I’ll go and check them and they have dentures. They can’t even tell the difference.”
Professor Ian Meyers, a general dental practitioner and honorary professor at The University of Queensland School of Dentistry, treats many geriatric patients and believes the residential care population has split into the “haves and have nots”, often because of their financial status.
With people living longer and preferring to keep their teeth rather than having dentures, he says they often struggle to look after their own teeth as their cognitive and physical abilities wane. Professor Meyers advocates higher staff-to-resident ratios in aged-care facilities so that staff have time to dedicate to daily oral healthcare, along with a scenario whereby “travelling” dentists or hygienists visit homes regularly, with costs to be paid through normal residential care payments.
“Residents pay for all sorts of things when they go into a nursing home. The fee covers food, activities and entertainment, and it would be easy to include a small oral healthcare component.”
While more geriatric dentistry specialists are required, Professor Meyers notes that private general dentists provide much of the treatment of the elderly.
“From a business perspective many private practitioners find it’s difficult to run a profitable practice if you are only treating the elderly.” It takes much longer to do procedures on the elderly, and additional resources are frequently required, so income generated from these patients is much less compared with other patients.
The ADA stresses that while there has been a rapid drop in the proportion of older Australians who are toothless or who wear full dentures, there is no room for complacency.
“As a nation, we could do a lot better for our senior citizens in this area,” Dr Bonanno says, noting that many older people have poor oral health long before they ever access residential or home-based aged-care services. Reasons can include long waiting lists in the public dental system, increasingly unaffordable and low-value private health insurance cover for dental care, and a lack of government schemes to support older people paying for private dental care.
Braunsteiner believes aged-care centre managers also need to step up and make oral hygiene part of the culture at their facilities. That could include upgrades to nurses’ curriculum to ensure they understand the importance of oral care to the overall health of the elderly.
What is clear, she says, is that change needs to occur. “Ten years on, we’re basically in the same situation.”
ADA president Dr Carmelo Bonanno outlines three ways active adult communities and other retirement centers can help older people with their dental care and oral hygiene.
1. To prevent the very poor oral health seen in so many older Australians when they first access aged-care services, it’s critical to take a prevention-focused approach via better funding for affordable access to dental services for seniors so they can get the care needed before they access aged care.
2. Ensure that nurses and personal carers have more time and are better skilled at helping residents who need assistance with daily oral hygiene and can recognise when a referral to a dentist is needed.
3. Dentists should be engaged to examine and develop oral-care plans for older people accessing higher-needs aged-care services, and each older person should have a referral pathway to a dentist or dental service established for them when they first access aged care.
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