Importance of oral health and access to dental services for aged care residents - Archana Pradhan Lantern Project 7 July, 2017
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Importance of oral health and access to dental services for aged care residents Archana Pradhan BDS, BScDent(Hons), PhD, DClinDent (Special Needs Dentistry) Fellow of Special Care Dentistry (USA) Lantern Project 7 July, 2017
Recently two dignified old homeless gents quietly queued for a meal in our Loaves & Fishes Free Restaurant. Curiously though, when they took their seats only one of them ate. The other patiently waited. As we watched this we wondered what was going on. Why wasn’t the other man eating? His meal was going cold. What happened next shocked us. When the first man finished his meal he had a drink of water to clean his mouth. Then he took out his dentures and passed them to his mate who put them in and Source: https://www.exodusfoundation.org.au/2017/03/20/sharing-dentures/ finally, was able to enjoy his meal. These two homeless Australians were sharing one set of dentures! The fact that this can happen in Australia is astounding. Thankfully, my Exodus Foundation team was able to help. We took both men to our free dentist where they were given individual sets of dentures. Now, these old mates can eat their meals together. Reve. Bill Crews
Woman found with maggots in her mouth at Raymond Terrace nursing home Anita Beaumont 9 May 2017, noon A PORT Stephens woman whose mother was found with maggots in her mouth at a Raymond Terrace nursing home the day before she died has called for an inquiry into the aged care sector. Jayne Carter has raised serious concerns about the standards of aged care facilities after she was told by staff at the Opal Raymond Terrace Gardens nursing home that they found maggots in her mother Shirley’s mouth. Shirley died at the nursing home in October 2016. Ms Carter told the ABC that she wanted justice for all people in aged care, and thinks an inquiry into the sector is “imperative.” “Opal say they are experts in dementia and care for the aged, and I think the entire aged care system needs a bit of shake up because this is happening too often to too many people,” she said.
Ill-fitting denture/oral problem Weight loss/Frailty/Falls*/Death Ability to (enjoy) eating Risk of malnutrition+ + Malnutrition is strongly associated with poor OHRQoL (Hugo et al. 2016) * In Australia, maxillofacial fractures are the third most common trauma in falls in the elderly after neck of femur and upper limb fractures (Cripps & Carman 2001).
The Steering Committee acknowledge that dietitians do not act alone in either the detection or treatment of malnourished patients, considered important to consult with a wide range of health professionals and consumers of health services. The March 2008 version (DAA 26th National Conference 2008) was circulated by DAA for multidisciplinary feedback to: (Watterson et al. 2009) Australian New Zealand Society for Geriatric Medicine Australasian Podiatry Council Speech Pathology Australia Australian Association for Exercise and Sports Science Royal College of Nursing Australia Australian Association of Occupational Therapists Australian Association of Gerontology Australian Physiotherapy Association Aged Care Association Australia (ACAA) Australian Association for Quality in Health Care (AAQHC) Services for Australian Rural and Remote Allied Health Australian College of Health Service Executives (ACHSE) (SARRAH) Australian Association of Social Workers Australian Psychology Society Institute of Hospitality in Healthcare Australian General Practice Network DENTAL? Australian Meals On Wheels Australian Society of Special Care in Dentistry (ASSCID) Society of Hospital Pharmacists of Australia Australia and New Zealand Academy for Special Needs The Royal Australasian College of Physicians Dentistry (ANZASND)
Why is dentistry relevant for older adults? 1. Increase in the proportion of older adults 2. Substantial reduction in edentulism (increase in retained teeth) (Slade et al. 2007) 3. Increase in demand for regular dental care ‘Consequences of success’ • More COMPLEX Dentistry • More challenging for the ageing population with special needs The Silver Tsunami
Oral health of older adults Poor oral health with high levels of : • Dental caries experience (decayed teeth and roots) • Periodontal disease (gums and supporting tissues) • Xerostomia (dry mouth) • Traumatic ulcers • Tooth loss • Oral cancer
Dental caries • ‘Complex’ or ‘multifactorial’, not amenable to simple prevention - elimination of ‘one type of organism’ or enhancing ‘tooth resistance’ (Fejerskov 2004) • Despite regular fluoride use, caries lesions can still develop with more than six dietary sugar exposures per day (Duggal et al. 2001, Ccahuana-Vasquez et al. 2007). • Traditional epidemiological measures of dental caries do not adequately reflect its social impacts, economic costs, and health care system effects.
Oral health of older adults Precipitating factors: • Poor oral (and denture) hygiene • Prolonged use of multiple anticholinergic drugs • Delayed clearance from the mouth of medications sweetened with sugar (MacEntee 2006, Chew et al. 2006, Maguire & Baqir 2000) Before toothbrushing After toothbrushing Most oral health problems are preventable and reversible.
Impacts of oral disease on general health Strong associations between: • Periodontal disease and diabetes • Tooth loss and poor nutrition (Kandelman et al. 2008) • High levels of plaque on residents’ natural teeth and dentures, & aspiration pneumonia (Chalmers et al. 2002, Mehta et al. 2013; Barnes 2014), one of the major causes of hospitalisation and death of patients with dementia in nursing homes • Elderly patients with no oral care had triple the risk of mortality from pneumonia, compared to those who had an oral hygiene aide (Bassim et al. 2008) • Oral health care (tooth brushing after each meal, cleaning dentures once a day, and weekly professional oral health care) : best intervention to reduce the incidence of aspiration pneumonia (Maarel‐Wierink et al. 2013).
Inquiry into Dental Services for Older South Australians - 2010 • Disturbingly, there may be a 'reasonable percentage of people dying in aged care facilities from aspiration pneumonia' in which poor oral health is implicated. • Some people avoid eating particular foods because of oral health problems and, in more severe cases; shun all social interactions because of embarrassment about their dental appearance. • Departnent of Health noted that dental diseases rank amongst the highest in terms of 'avoidable' hospital admissions.* • Improving the oral health of the community will significantly reduce costly and entirely avoidable hospital admissions. *hospitalisation is thought to be potentially avoidable if preventive care and early disease management are applied.
Oral effects of medical conditions • Stroke • Parkinson’s Disease • Dementia • Motor neurone disease (MND) • Multiple sclerosis (MS) - Trigeminal Neuralgia; orofacial pain • Inability to self-care • Difficulties in speech • Impaired communication, low self-esteem and well-being • Difficulties in swallowing • Risk of aspiration
Oral effects of medical treatment •Radiotherapy (RT) •Chemotherapy (CT) mucositis •Medication-related osteonecrosis of the jaws (MRONJ) Osteonecrosis of jaws
Oral health related quality of life can be improved • Post head and neck cancer/Osteonecrosis of jaws - Obturator • Post stroke - Palatal-lift • Oro-motor therapy
National Oral Health Priority • National Oral Health Plan (2004-2013): Action Area Three: Older People • National Oral Health Plan (2014-2023): Priority population 4 People with additional or specialised health care needs 1. People living with mental illness 2. People with disabilities 3. People with complex medical conditions 4. Frail elderly Goal • Improve oral health outcomes and reduce the impact of oral disease. Key strategies • Enhance skills & competencies of oral heath workforce to meet the needs of Priority Populations • Ensure capacity of oral health workforce to work as part of multidisciplinary teams • Collaborate with peak bodies to include comprehensive oral health components in accreditation
Good practice examples Response to National Oral Health Plan (2004-2013) Better oral health in residential care: final report. South Australian Dental (Fricker & Lewis 2009) Resource portfolios were used for national use. Key processes • Oral Health Assessment Tool (OHAT) – oral health screening • Oral Health Care Plan (OHCP) • Daily oral hygiene maintenance • Timely dental treatment Key findings • Oral Health Assessment by non-dental professional does not replace a dental examination; can be successfully used by GPs & RNs to identify residents requiring a dental referral. • Residents’ oral health improved with the implementation of the project. Result 2010: implementation of model in the first Australia-wide Nursing Home Oral and Dental Plan 396 workshops : 4,885 people trained from 2,809 aged care homes, multi-purpose services and Indigenous flexible care services.
Caring for oral health in Australian residential care (Chalmers et al. 2009) - Investigated role of carers in Australian residential care facilities - Three aspects of best practice: 1. Development of comprehensive and appropriate oral and dental care policies and procedures, - Commonwealth Residential Aged Care Standards 2. Train carers in Oral Health Assessment Tool (OHAT) - Assessed reliability & validity of carers’ use of OHAT in assessing residents’ oral health 3. Use Oral Hygiene Care Plan (OHCP) as an evidence-based oral health protocol for carers of dependent older adults (Blanco & Chalmers 2001). Focus group discussions • Completion of the OHAT and OHCP are practical and easy to use (8 minutes). • ‘We are now doing a dental audit for all new residents’. • ‘Everyone knows it is an issue that needs to be looked at’.
Nursing home care program • Collaborative partnership between: 1. South Australian Dental Service 2. Australian Dental Association (SA Branch) 3. private dental practitioners • Great initiative, but problems include: 1. Exclusion of facilities when funding level hits its max, and private dentists are unable to access equipment 2. New adequately trained specialists in SND are unable to enter the market (Pradhan et al. 2016)
Inter-professional education programs Steffens M, Pradhan A, Aldenhoven S, Boylan J, Harding G. Community Outreach Dental Program: Nursing Homes Inter-professional Care An Obligation – Not an Option. 2014 Location: Aged Care Homes (ACH) Group Residential – Highercombe, South Australia Aims: 1. Expose medical (MBBS IV) & dental students (BDS V, BOH III) to healthy aging at nursing homes 2. Increase students’ interest in caring for older residents, in response to the aging population Methods: Shared lecture on frailty and healthy aging Dental students provided Oral health assessments and education to residents Results Attitudes: “The positive environment definitely reduced some of the stigma of elderly facilities.” Learning opportunity: “I have never had this opportunity before.” “Would like to do more- “adopt a resident program would be good” Urgent need: “Always had an interest, but this has showed how much help they need!”
Good practice examples Inter-professional education programs Dental screening program with nutrition and dietetics students at Ave0 (Queensland) 2017- Onsite dental screening, preventive dental services, appropriate referrals
Conflicting priorities • Oral healthcare for frail elders are frequently neglected and receives lower priority compared to other more threatening disorders. • Role of nurses and carers for oral care needs of frail elders is limited by other priorities (MacEntee et al. 1999, Thorne et al. 2001) • Practical routine for helping frail people with their oral hygiene is a constant challenge in most facilities (Sjogren et al. 2008). • Oral health is ignored by most and dental care is sought only when one is in obvious distress. Anderesson et al. (2007) reported a Swedish physician state: ‘‘Problems with swallowing are my department while problems with chewing are the dentist’s department’’. • Efforts to address the neglected oral hygiene of frail elderly by educating nurses and carers have had little sustained effect.
Accreditation standards for aged care • Health and personal (oral?) care : Promote and achieve care recipients’ physical and mental health in partnership with each care recipient (or his/her representative) and (oral?) health care team • Nutrition and hydration: Care recipients receive adequate nourishment and hydration (good teeth/dentures?) • Behavioural management : Manage needs of care recipients with challenging behaviours (undiagnosed dental pain?) • Clinical care: Care recipients receive appropriate clinical care (oral?) • Other health and related services: Referral to appropriate health specialists (dental?) • Medication management: Care recipients’ medication is managed safely and correctly (drug interaction/oral implications?) • Pain management: All care recipients are as free as possible from pain (dental and oral?) • Palliative care : Maintain comfort and dignity of terminally ill care recipients (identity?) • Oral and dental care: Care recipients’ oral and dental health is maintained
Integrated care for adults and older people Speech pathologist British Society for Disability and Oral Health 2012
‘Muted dental voices’ on inter-professional healthcare teams • Representatives from the dental professions rarely contribute to inter-professional healthcare. • Barriers: - Limited experience of dental personnel on healthcare teams - Ignorance of other team members about the significance of oral health • What is needed? The concept of inter-professionality is accepted by educators, practitioners, professional organisations, and the public (MacEntee 2011).
Questions? firstname.lastname@example.org Thank you!
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