In the following proposal, Associate Professor Leonie Short sets out a case for the In-house Delivery of Oral Health Training, Assessments, Care Plans and Referral Pathways in Residential and Aged Care Facilities in Australia.

Denticare – A Proposal for the In-house Delivery of Oral Health Training, Assessments, Care Plans and Referral Pathways in Residential and Aged Care Facilities in Australia

Associate Professor Leonie M. Short, CQUniversity, 28 January 2019

Gap in Service-Delivery: As a registered dental practitioner, academic, researcher and daughter of a 93 year old mother who has been in dementia care for 4 ½ years, I regularly encounter the difficulties that residents in residential and aged care facilities (RACFs) face when attempting to access oral health care and dental treatment in Australia.

Aged Care Royal Commission: Members of the dental profession, residential care managers, nursing personnel and families are already aware that oral health neglect is a common feature in Australia.

Links between oral health and general health: Oral health affects general health and, conversely, general health affects oral health. The inability of teeth or dentures to bite together and chew food has a direct impact on diet and nutrition. Sadly, decayed teeth, teeth with abscesses, loose teeth and diseased gums (periodontal disease) mean that eating and cleaning teeth can be painful or avoided. Illnesses and diseases including Arthritis and Type II Diabetes may affect a resident’s ability to hold a toothbrush or impair healing in the mouth. And prescription medicines such as antihypertensives, diuretics and analgesics may cause the discomfort of dry mouth (xerostomia).

Nursing care plans include teeth and/or denture cleaning in terms of whether the resident is able to do this independently, needs some assistance or needs full assistance. And as most of the day-to-day care in RACFs is performed by Certificate II or III trained personal care workers, it is up to these workers to manage the oral health of residents with more than one illness or disease (co-morbidities), multiple medications (poly-pharmacy) and who have generally been admitted into care with poorly maintained or neglected teeth, gums and dentures.

Managers and nursing staff in RACFs refer residents to medical practitioners and a range of allied health professionals, such as speech pathologists, physiotherapists, podiatrists, dietitians and occupational therapists, but are reluctant to refer a resident to a dental practitioner. This reluctance is due to the difficulty in accessing private dental practitioners to examine a resident in a RACF, the cost of private dental treatment for residents and their families, the cost of mobile dental equipment for dental practitioners to treat residents in-house, the cost and difficulty in transporting ambulant (those walking and in wheelchairs) and bed-bound residents to dental surgeries or clinics, large dental waiting lists in the public sector, the separation of ‘allied health’ from ‘oral health’, and phobias about dental treatment and ‘dentists’ in general.

Registered dental practitioners: As oral health and its links with general health is more than cleaning teeth or dentures, oral health care plans for residents with complex needs should be devised and performed by registered dental practitioners who can legally diagnose, manage and treat dental diseases. Dental practitioners should work within an interprofessional framework with nursing personnel, personal care workers, speech pathologists and dietitians to devise and action the oral health care plan.

Proposal for the Delivery of Oral Health Training, Assessments, Care Plans and Referral Pathways in Residential and Aged Care Facilities in Australia: This proposal is mindful that dental treatment is expensive and that the need for oral health care for residents in RACFs is high. In order to limit the costs, reduce the possibility of over-servicing, and deliver the greatest benefit for all residents, Denticare will be limited to only those oral health services that can be provided in-house and only services provided by cost-efficient, contemporary and flexible oral health therapists, dental hygienists and dental therapists with adult scope of practice. Dental prosthetists and dentists will be excluded from participating in the Denticare scheme.

Rational for Choice of Dental Practitioners in Denticare: From the Dental Board of Australia Registrant Data 1 July to 30 September 2018, there are 17,280 dentists, 1,263 dental prosthetists, 3,682 dental hygienists and oral health therapists, and 936 dental therapists - from a total of 23,165 registrants in Australia. As a small number of dental practitioners are registered in more than one category, these have been added to the main categories. Furthermore, of the 936 dental therapists who treat children and adolescents, only a small number of dental therapists with additional training for adults would be able to treat residents in RACFs. As their numbers are also small and cannot be identified in the data from the Dental Board of Australia, all dental therapists remain in one main category.

By limiting Denticare to dental practitioners with an emphasis on preventive dentistry, diet, nutrition and interprofessional clinical practice, the scheme is utilising the most appropriate, cost-effective and fit-for-purpose practitioners and, at the same time, excludes those dental practitioners who are trained to provide expensive, high-end restorative and prosthetic dentistry (full and partial dentures, crown and bridgework, root treatments, implants and surgical periodontal treatment).

Denticare - A Proposal for the In-house Delivery of Oral Health Care for residents in Residential and Aged Care Facilities in Australia:

• Oral health training for all nursing and personal care workers in the evidence-based delivery of oral hygiene techniques, prevention and treatment of dental diseases, oral pathology and referral pathways. https://agedcare.health.gov.au/publications-articles/resources-learning-training/better-oral-health-in-residential-care-training
• Oral Health Assessments of all residents including soft tissues, gums, teeth, tongue, lips, dentures, screening for oral cancer, etc. http://webarchive.nla.gov.au/gov/20140801083400/http://www.health.gov.au/internet/main/publishing.nsf/Content/ageing-better-oral-health.htm
• Oral Health Care Plans for all residents with an emphasis on prevention including individually prescribed toothbrushes, toothpastes and mouthrinses; prescribed medications for conditions such as dry mouth; toothbrushing aids for those with physical impairments; and advice on pain relief. http://webarchive.nla.gov.au/gov/20140801083400/http://www.health.gov.au/internet/main/publishing.nsf/Content/ageing-better-oral-health.htm
• Referral Pathways when required to a dental practitioner for dental treatment, to a speech pathologist for dysphagia (difficulty in swallowing), to a dietitian for dietary assistance, and to a medical practitioner / oral pathologist / oral surgeon for a suspicious lesion.
• All dental records will be entered into the patient’s notes at the RACF for other staff and for future reference.
• All treatment will be performed by registered dental practitioners, namely oral health therapists, dental hygienists and dental therapists with adult scope of practice – approximately 3,682 registrants out of a total of 23,165 registrants in Australia.

Fees:

• Training $200 per session – limit to 2 training sessions per RACF per year.
• In-house Assessment, Care Plan and Referral Pathway $150 per resident (ADA Item Numbers 011-017) – limit to 2 assessments with care plans per resident per year.
• Follow-up consultation and/or referral $100 – limit to 4 follow-up consultations / referrals per resident per year.

Eligibility: Commonwealth Seniors Health Card, Health Care Card, Low Income Health Care Card and Pensioner Concession Card https://www.humanservices.gov.au/individuals/subjects/concession-and-health-care-cards

Costing: If 50 eligible dental practitioners (3,682) participate in this scheme, and if each practitioner is able to treat 50 residents per week @ $150 per resident plus deliver one training session at $200, for 48 weeks each year, then maximum cost would be $18,480,000 per year. Total Costing: $55.44m over 3 years

Contact Details: Associate Professor Leonie M. Short

Head of Course for Oral Health, School of Health, Medical and Applied Sciences

CQUniversity Australia, Bruce Highway North Rockhampton 4702

[email protected] +61 (0)7 4923 2831 (tel) +61 (0)407 694 874 (m)