Oral health care in residential aged care services: barriers to engaging health-care providers.

CSIRO PUBLISHING

Australian Journal of Primary Health, 2015, 21, 148–156 http://dx.doi.org/10.1071/PY14029

Review

Oral health care in residential aged care services: barriers to engaging health-care providers Lydia Hearn A,B and Linda Slack-Smith A A B

School of Dentistry M512, University of Western Australia, 35 Stirling Highway, Crawley, WA 6009, Australia. Corresponding author. Email: [email protected]

Abstract. The oral health of older people living in residential aged care facilities has been widely recognised as inadequate. The aim of this paper is to identify barriers to effective engagement of health-care providers in oral care in residential aged care facilities. A literature review was conducted using MEDline, CINAHL, Web of Science, Academic Search Complete and PsychInfo between 2000 and 2013, with a grey literature search of government and non-government organisation policy papers, conference proceedings and theses. Keywords included: dental/oral care, residential aged care, health-care providers, barriers, constraints, and limitations. A thematic framework was used to synthesise the literature according to a series of oral health-care provision barriers, health-care provider barriers, and cross-sector collaborative barriers. A range of system, service and practitioner level barriers were identified that could impede effective communication/collaboration between different health-care providers, residents and carers regarding oral care, and these were further impeded by internal barriers at each level. Findings indicated several areas for investigation and consideration regarding policy and practice improvements. While further research is required, some key areas should be addressed if oral health care in residential aged care services is to be improved. Additional keywords: health policy, primary care. Received 10 February 2014, accepted 17 July 2014, published online 26 August 2014

Introduction Concerns about the oral health of older Australians in residential care has led to pressure being placed on dental practitioners and policymakers to address the health and socioeconomic impacts on patients and the community (Australian Institute of Health and Welfare 2012; Hopcraft et al. 2012). The increasing number of permanent aged care residents is adding to these concerns. From 1999 to 2011, the number of permanent aged care residents in Australia increased by 25% to a total of 185 482, and the number of residents aged 85 years and over rose by 45%, as did their length of stay (Australian Institute of Health and Welfare 2012). Oral diseases often develop when frail and dependent older adults are living in the community and become exacerbated following admission into residential care (Australian Institute of Health and Welfare 2010). These oral diseases may impact on their eating ability, diet, weight, speech, hydration, behaviour, appearance and social interactions (Sheiham 2005). Moreover, older adults with poor oral health may be more prone to preventable systemic diseases (Kandelman et al. 2008), including cardiovascular disease and stroke (Mattila et al. 2005). When combined with failing health and complex medical treatment (Berkey and Scannapierco 2013), poor oral health can affect nutritional status and quality of life (Ettinger 2010; Van Lancker et al. 2012), particularly among those who are dependent on others for care. Journal compilation Ó La Trobe University 2015

As Australia develops a new 10-year National Oral Health Plan, increasing emphasis is being placed on the role of health-care providers (HCPs) in the effective prevention, early intervention and management of oral health of those in residential care (Calache et al. 2013). Recommendations for better oral health care have focussed on: oral health screening on entrance to residential aged care facilities (RACFs); a simple oral health plan for each resident; maintenance of oral hygiene; and timely dental treatment (Fricker and Lewis 2009). In practice, the proposed framework has several limitations (Fricker and Lewis 2009), including a shortage of geriatric-specialised dental healthcare providers (Slade et al. 2007; Chrisopoulos and Teusner 2008) and lack of access to affordable oral health services (Hopcraft et al. 2008). This means the most vulnerable may receive inadequate care, particularly those in rural and remote areas (Tham and Hardy 2013). There is considerable empirical evidence illustrating inadequate dental hygiene and oral care among older people in RACFs (Coleman and Watson 2006; Samson et al. 2009). Many strategies have been developed and evaluated to promote compliance with guidelines and protocols (Australian Department of Health and Ageing 1997; Weening-Verbree et al. 2013), yet evidence about key barriers to better collaboration between HCPs to improve oral health in RACFs is limited (Miegel and Wachtel 2009). www.publish.csiro.au/journals/py

Oral health care in residential aged care services

What is known about the topic? *

Oral health is an important determinant of general health and quality of life of older people, but too often it is considered as a separate and isolated concern.

What does this paper add? *

Despite numerous barriers to effective engagement of health-care providers, research indicates that a more comprehensive approach could be facilitated through collaborative models of delivery at the system, service and practitioner levels.

Australian Journal of Primary Health

149

The literature search for barriers was conducted using five electronic black literature databases: MEDline, CINAHL, Web of Science, Academic Search Complete and PsychInfo, covering articles from 2000 to 2013. Keywords included: dental/oral care, residential aged care, health-care providers, barriers, constraints, and limitations. A grey literature search of government and nongovernment organisation policy papers, reports and conference proceedings was undertaken through Google and key network websites. These were supplemented with a secondary search of the references cited in the identified studies. The search was restricted to publications in English. Parallel evidence from published articles in other public health-care areas was also compiled. A thematic framework was used to present the findings under three sub-themes for synthesis. The initial synthesis reviewed barriers to oral care provision and described them as organisational; geographic and environmental; patient health, access and equity; HCPs’ attitudinal knowledge, skills and training; and research and resource barriers. A second synthesis of the literature focussed on internal barriers to oral care confronted by RACF managers, dentists, oral health practitioners, nurses and aged care assistants, and family/carers. Finally, the literature was synthesised according to system, service and provider level barriers that impede effective communication, engagement and action between multi-level HCPs.

For national policy to be translated into effective service delivery, dental professionals and HCPs require information on why there is a need for action, evidence on what action is effective, how it is best delivered and by whom. This needs to take into account the contextual setting, feasibility of implementation and sustainability (Rychetnik and Wise 2004; Mays et al. 2005). This article summarises the findings of a literature review aimed at identifying barriers to effective communication, collaboration and action between HCPs at the policy, service and practitioner levels. The goal of this review is to understand how best to engage HCPs in the provision of oral health in RACFs and propose ways in which health policies and programs in Australia could ensure better oral health for aged care residents. For the purposes of our review, HCPs include RACF managers, nurses, nurses’ aides, allied care providers, dentists, oral health practitioners (dental hygienists, dental therapists and oral health therapists), general practitioners, dietitians, family and community care providers, health education/promotion specialists and regional/national policymakers.

The literature search identified 56 primary papers that reported on barriers to oral health care in RACFs (three government reports, two non-government reports and 51 peer-reviewed journal articles). These papers focussed on single risk factors and highlighted barriers to provision of oral care, health-care provider barriers and cross-sector collaboration barriers.

Methods

Oral care provision barriers

A key question for this review was ‘what type of information do policymakers need to inform collaborative practice’? While randomised controlled trials are invaluable as a means of appraising the efficacy of interventions, such studies are less able to shed light on a host of additional social; economic; organisational; and knowledge, skills and practical issues that create barriers to enhancing collaboration between HCPs. Nor do they drive effective oral health programs for RACFs in different environmental and geographic settings. Therefore, this narrative review builds on process, impact, and parallel evidence, as suggested by Rychetnik and Wise (2004) and Mays et al. (2005), which is aimed at improving our understanding of research evidence for informing public health policy and practice based on beliefs and behaviour, rather than positivist biomedical models focussed on treatment (Watt 2007). The approach involved refining research questions then synthesising and appraising the literature against these questions, with the goal of developing new explanations to inform best practice. In addition, data were extracted from different sources to identify patterns and directions in findings regarding barriers. An algorithm of the overall review process outlining the research questions is presented in Fig. 1.

Although the National Oral Health Plan 2004–2013 (National Advisory Committee on Oral Health 2004) and subsequent educational strategies (Fallon et al. 2006; Chalmers et al. 2009) recognised the critical roles that could be played by HCPs in providing oral health care in RACFs, our review indicated a series of policy/protocol, educational, attitudinal, geographic/ environmental, health, access/equity, research and resource barriers that limit effective communication and collaboration between HCPs (Table 1). Although the literature indicates that most HCPs agree that dental care is essential for the health of residents and are aware of their responsibility to provide oral care, in practice, it receives low priority in the face of competing demands (Paley et al. 2004; Hopcraft et al. 2008; Wårdh et al. 2012; Webb et al. 2013). Limitations of public dental support and private health insurance, together with the lack of cost regulation, means that private dental providers operate in an unregulated, competitive market where they can choose which patients to treat and at what cost (Grytten and Golst 2013). The situation is exacerbated by difficulties in transporting frail residents to dental facilities (Chrisopoulos and Teusner 2008; Chalmers et al. 2009; Tham and Hardy 2013), and the lack of referral

Results

150


L. Hearn and L. Slack-Smith

Fig. 1. Algorithm of review and synthesis process.

pathways and information on their past dental history (Miegel and Wachtel 2009; Paley et al. 2009; Tham and Hardy 2013).

HCP level further limits the capacity for improved collaboration (Table 2). Barriers to RACF managers

Health-care provider barriers A second synthesis of the literature indicated that despite the need for greater collaboration between HCPs, internal issues at each

Directors of Nursing in RACFs operate in environments where much of their time is spent in: developing detailed external information to meet the requirements for funding and



151

Table 1. Types of barriers that affect engagement between dental professionals, aged care providers, family carers and residents HCFs, health-care providers; RACFs, residential aged care facilities Policy/protocol and attitudinal barriers (Frenkel et al. 2002; Paley et al. 2004; Chalmers and Pearson 2005; Nicol et al. 2005; Preston et al. 2006; Reed et al. 2006; Chalmers et al. 2009; Paley et al. 2009; De Visschere et al. 2011) Lack of legal/contractual protocols and guidelines together with trained staff to fully implement oral health-care policies Lack of oral health assessments conducted on or before admission to RACFs Lack of routine, ongoing assessment and documentation to maintain/manage residents’ oral health Staff restrictions and fragmented work shifts mean daily oral health is not enforced particularly at weekends Lack of experience and negative attitudes (fears, unwillingness, revulsion and nausea) of many personal care assistants towards cleaning residents’ teeth *

*

*

*

*

Operational/educational barriers (Coleman and Watson 2006; Fallon et al. 2006; Reed et al. 2006; Rivett 2006; Peltola et al. 2007; Chrisopoulos and Teusner 2008; Miegel and Wachtel 2009) Aged care workers see dental health as a low priority in the face of competing demands Tradition based on responsive approach addressing dental care only when problem arises Educational programs for RACF staff have shown to improve oral care, yet one-off usage limits impact Increasing number of residents together with lack of resources and support staff mean there are few opportunities for oral health counselling and management Multiple mini work shifts and contractual agency staff limit responsibilities for oral care in RACFs Lack of coordination between dental and aged care sector leads to confusion over responsibility for residents’ oral health care Limited collaboration between dentists and aged care workers as they come under the jurisdiction of different federal/state government departments Confusion over how to obtain informed consent from residents with cognitive impairment limits dental professionals involvement Dental professionals lack training and support to undertake geriatric dentistry despite increasing patient loads Administrative demands, patient consent, etc. reduces willingness to attend to residential oral health needs *

*

*

*

*

*

*

*

*

*

Access/equity barriers (Hopcraft et al. 2008; Chalmers et al. 2009; Miegel and Wachtel 2009; Slack-Smith et al. 2010; Grytten and Golst 2013; MacEntee 2013; Tham and Hardy 2013; Webb et al. 2013) Lack of geriatric-specialised portal domiciliary dental services Lack of suitable space to enable safe/effective oral examinations and treatment Lack of access to practical and affordable dental equipment Complex treatment often requires extensive time and higher level skills/facilities Long waiting list to attend public dental services Competitive, unregulated private dental environment limits access to a large percentage of frail residents Dearth of ambulant transport for frail, bed-ridden residents to attend dental care centres and hospitals (especially in rural/remote areas) Need for HCPs to work across numerous residential aged care facilities creates an unhealthy, stressful work environment *

*

*

*

*

*

*

*

Geographic and environmental barriers (Cane and Butler 2004; Fallon et al. 2006; Hopcraft et al. 2008; Paley et al. 2009; Tham and Hardy 2013) Oral health services in rural areas limited by workforce shortages Geographic distances and transport difficulties limits access to oral health services Limited or no access to affordable domiciliary/outreach oral health services Long waiting lists to attend public services *

*

*

*

Research and resource barriers (Sheiham 2005; Petersen et al. 2010; Benzian et al. 2011) Research conducted primarily by dental professionals in isolation of other key HCP stakeholders Resistance to adoption of research findings due to lack of managerial support, time constraints and limited knowledge and skills Focus on individual duties and functions rather than broader organisational change and problem solving Limited focus on strengthening collaboration between policymakers, service providers and practitioners in RACFs *

*

*

*

accreditation (Gaskin et al. 2012); administrating operational records for quality assurance; managing staff turnover, time restraints, workloads, and budgets (Fallon et al. 2006); and addressing resident carer concerns (Webb et al. 2013). While the need for oral hygiene was acknowledged widely by RACF managers (Reed et al. 2006; Hopcraft et al. 2012), the shortage of oral hygiene aides (Coleman and Watson 2006), lack of dental facilities and ambulant transport (Chalmers et al. 2009) or ‘champions’ of oral care (Miegel and Wachtel 2009) limited the ability to provide care. Communication with dentists was also perceived to be cumbersome due to the lack of interest of many dentists in treating residents (Paley et al. 2004; Gaskin et al. 2012). Barriers to dentists Dentists currently have a strong market demand in urban practices and most are reluctant to deliver services away from

their well-equipped dental surgeries (Hopcraft et al. 2008). In addition to the lack of financial remuneration and portable dental equipment (Grytten and Golst 2013), a lack of education in geriatric or special care dentistry has been another significant barrier (Chalmers et al. 2009; MacEntee 2013). Furthermore, the need to work across numerous RACFs, together with difficult working conditions for dentists in RACFs, have created an unhealthy, stressful and isolated work environment that does not attract dental professionals (Hopcraft et al. 2008; Grytten and Golst 2013). Dentists are also reluctant to attend to residents who are unable to sign approval for dental care (Tham and Hardy 2013). Even where geriatric dental education is provided, training has given priority to treatment rather than prevention of oral disease (Petersen et al. 2010). There has been little focus on a more holistic approach to oral health that aims to strengthen the ability to work collaboratively with RACF managers and other HCPs, including dietitians (Miegel and Wachtel 2009), as

152



Table 2. Barriers to involvement of aged care facility managers, dentists, dental hygienists, nurse care providers and family/carers in oral health care Barriers to residential aged care facility managers’ involvement (Paley et al. 2004; Nicol et al. 2005; Vanobbergen and De Visschere 2005; Fallon et al. 2006; Reed et al. 2006; Miegel and Wachtel 2009; Cornejo-Ovalle et al. 2013; Webb et al. 2013) Low priority in face of competing demands Lack of legal/contractual protocols and guidelines on cross-sector collaboration Lack of support for protocols from dentists Too much time spent on institutional factors (e.g. workload, protocols, staff motivation, appropriate working conditions, etc.) Limitations exacerbated by financial pressures to maximise productivity Barriers to providing training and financial support to staff to influence higher oral health values Limits of referral to specialists or hospitals because of concern for patient compensation from public health and long waiting lists for treatment Lack of dental facilities, ambulant transport, or ‘champions’ of oral health limit commitment Communications with dentists cumbersome *

*

*

*

*

*

*

*

*

Barriers to dentists’ involvement (Hopcraft et al. 2008; Chalmers et al. 2009; Miegel and Wachtel 2009; Petersen et al. 2010; Grytten and Golst 2013; Webb et al. 2013) Reluctance to treat frail and functionally dependent elderly Inconvenient to provide dental care away from their clinics Lack of portable equipment, financial remuneration and geriatric dental education Limited time or skills in how to collaborate with RACF managers and other staff to improve quality of life, well-being and function Too much emphasis on individual treatment rather than broader socio-ecological prevention ethos *

*

*

*

*

Barriers to dental hygienists’ and oral health therapists’ involvement (Baltutis et al. 2000; Hopcraft et al. 2008; Blinkhorn et al. 2012) High demand and remuneration has resulted in overwhelming propensity to work in general private practice Roles are focussed primarily on individual duties and functions rather than on health education and promotion, self and family preventative care, regular screening care and referral Traditional dentist-auxiliary hierarchy with importance placed on direct dentist supervision rather than hygienist is counterproductive in engaging hygienists in optimal care Lack of collaboration and support from dentists and residential nurses Lack of parallel education to facilitate collaboration and encourage synergistic relationships to influence legislative change Lack of involvement for fear of litigation due to misdiagnosis *

*

*

*

*

*

Barriers to nurse care providers’ involvement (Paley et al. 2004; Chalmers and Pearson 2005; Nicol et al. 2005; Fallon et al. 2006; Reed et al. 2006; Miegel and Wachtel 2009; Wårdh et al. 2012; Yoon and Steele 2012; Cornejo-Ovalle et al. 2013) Oral health of the elderly seen as not one of their daily priorities Oral health-care activities for elderly considered an unpleasant task Time restraints, excessive work demands, shift work rotations and staff turnovers limit their involvement Unaware of existence of institutional protocols/guidelines and hence fail to implement support policies Models of care discussed at upper levels of management without age care assistants’ involvement to ensure translation into practice Lack of training and knowledge regarding their training needs Australian universities/colleges have underestimated the importance of oral health at all levels of nursing education Motivation an additional barrier to performing oral health care *

*

*

*

*

*

*

*

Barriers to family/carers’ involvement (Chalmers and Pearson 2005; Chalmers et al. 2009; Paley et al. 2009; Cornejo-Ovalle et al. 2013; Somkotra 2013) High cost of accessing oral health services, including transportation Reluctance by residents to allow carers to provide oral health care Lack of support by aged care staff to empower family members/carer in dealing with their partners’ oral health care Lack of awareness of oral health problems especially among residents with severe dementia *

*

*

*

well as skills in dealing with patients with dementia (Webb et al. 2013).

direct supervision rather than on guidance and support, and this has been counterproductive to engaging oral health practitioners in optimal care (Blinkhorn et al. 2012).

Barriers to oral health practitioners Oral health practitioners could play a valuable role in promoting oral health and education for RACF staff and in containing costs while meeting service standards (Baltutis et al. 2000; Blinkhorn et al. 2012). Yet, the literature suggested they are under-utilised in the oral care of elderly residents (Hopcraft et al. 2008). Despite legal changes introduced in 2010 to limit the direct supervision of oral health practitioners by dentists in RACFs (Dental Board of Australia 2010), in practice, the traditional dentist–oral health practitioner hierarchy has continued (Petersen et al. 2010). The emphasis has been on

Barriers to nurses and aged care assistants Studies indicated that most nursing home personnel viewed oral health as important but did not see it as a daily priority (Paley et al. 2004; Miegel and Wachtel 2009), with time restrictions, staff turnovers, shift rotations, and lack of training identified as key reasons (Fallon et al. 2006; Cornejo-Ovalle et al. 2013). Many staff found assisting residents with toothbrushing to be difficult and unpleasant, especially in the case of unhealthy mouths (Frenkel et al. 2002; Paley et al. 2004; Chalmers and Pearson 2005; Nicol et al. 2005). The majority were sceptical that



even if their attitudes and skills were improved, the oral health of residents would not be any better because of uncooperative residents and their refusal of oral care. Furthermore, they felt limited access to dental care, together with the backlog and long waiting lists for dental treatment (Miegel and Wachtel 2009; Paley et al. 2009; Tham and Hardy 2013), the lack of support from dentists (Wårdh et al. 2012), and family inability and/or willingness to access private services had further contributed to poor oral health care (Chalmers et al. 2009; Paley et al. 2009; Tham and Hardy 2013). Nurses also acknowledged that residents’ oral health problems were often not visible (Yoon and Steele 2012). Motivation was another major issue, with up to one-third of aged care assistants working in RACFs out of employment necessity rather than affinity (Cornejo-Ovalle et al. 2013). Moreover, literature indicated that many were unaware of the institutional protocols/guidelines (Paley et al. 2004; Reed et al. 2006; Miegel and Wachtel 2009) and felt that even if these were discussed at the upper managerial levels, they were not translated into practice as nurses and staff at the ground level were not involved in their development (Western Australian Department of Health 2012). Barriers to family/carers The family/carers of residents noted a lack of dental check-ups and specialised professional oral care, particularly in high-care facilities (Paley et al. 2009). The need for dental treatment was a low priority compared with other disorders, especially among residents with severe dementia (Chalmers and Pearson 2005). The high cost of dental care was also a major barrier, especially among those with a lack of private dental insurance (Paley et al. 2009). Family/carers showed concern that RACF staff rarely assessed oral health, were reluctant to meet oral health-care needs, and overlooked potential problems (Chalmers et al. 2009; Miegel and Wachtel 2009; Paley et al. 2009). Similarly, they felt that RACF staff were reluctant to empower them to assist in dealing

with their family/partners’ oral health care (Cornejo-Ovalle et al. 2013). Cross-sector collaborative barriers The literature indicated that barriers to oral health care in RACFs occurred at practitioner, service, and system level (Table 3). System level barriers were compounded by incompatibility between federal, state and local level policy and protocols; lack of commitment to address service provision provided in silos; lack of continuity of oral health care during transition to RACFs; limited financial support and legal/contractual practices to enhance cross-sector collaborative engagement; and too much focus on treatment rather than on issues of prevention and quality of care (Petersen et al. 2010; MacEntee et al. 2012). Service level barriers included lack of resources; different priorities, commitments and philosophies between sectors; power relations between private and public aged care agencies and service providers; limited geriatric oral health support staff; high level staff turnover hampering continuity of care; and limited opportunities to develop sustainable collaborative initiatives (Fallon et al. 2006; Hopcraft et al. 2008; Miegel and Wachtel 2009; Paley et al. 2009; Grytten and Golst 2013; Webb et al. 2013). Practitioner issues included powerlessness in dealing with competing demands under increasing time pressures; pessimism towards success in preventing and managing the oral health of frail elderly with deteriorating overall health; isolated work environments and lack of knowledge of what other service providers were doing; and the need for appropriate information and training to help broach the issues and counsel residents and caregivers (Hopcraft et al. 2008; Chalmers et al. 2009; Miegel and Wachtel 2009; Paley et al. 2009; Cornejo-Ovalle et al. 2013). Without collaborative efforts to improve the standards of oral care in RACFs and geriatric hospitals, it will be difficult to improve oral health in RACFs (Gluhak et al. 2010).

Table 3. Barriers to cross-sector collaboration RACFs, residential aged care facilities System level

*

*

*

*

*

*

*

*

Service level

*

*

*

*

*

*

Practitioner level

*

*

*

*

*

*

*

153

Incompatibility between federal, state and local level policy and protocols Lack of commitment to address siloed service provision Lack of continuity of oral health care during transition to RACFs Lack of financial commitment to support collaborative approaches Individual treatment rather than broader socio-ecological prevention ethos Limited advocacy to address multi-sector social determinants Limited evidence to guide cross-sector practice Lack of legal/contractual protocols for funding and implementation of collaborative initiatives Different priorities, commitments and philosophies between sectors Power relationships between agencies and service providers Lack of resources Limited geriatric oral health support staff High staff turnover hampering continuity of care Limited opportunities to develop sustainable collaborative initiatives Not perceived as core focus of job Powerlessness in dealing with competing demands under increasing time pressures Pessimism towards success in preventing and managing oral health of frail elderly Isolated work environment and lack of knowledge of what other service providers are doing Lack of training in how to liaise with other sectors and/or agencies Lack of resources for commitment to collaborative initiatives Sensitivity and poor attitudes to providing dental care

154


Discussion This review revealed a range of barriers that have prevented the effective engagement of HCPs to improve access to oral health care for the elderly in RACFs. While barriers sometimes varied between high-level and low-level care facilities (Paley et al. 2004; De Visschere et al. 2013) and between urban and rural care facilities (Tham and Hardy 2013), many issues were similar. The literature has emphasised the value of improved oral health education and improved administrative procedures for residential care staff (Chalmers and Pearson 2005; Fallon et al. 2006; Rivett 2006; Peltola et al. 2007; Chalmers et al. 2009), although recent studies have inconsistent findings (Wårdh et al. 2012; CornejoOvalle et al. 2013; De Visschere et al. 2013; Somkotra 2013). Also concerning is the segregation of dentistry, oral health, medicine and aged care nursing in Australia and other countries (Petersen et al. 2010; MacEntee et al. 2012; De Visschere et al. 2013). As our ageing population are increasingly retaining their teeth (Australian Institute of Health and Welfare 2010), many are caught in the cycle of dental treatment that only alleviates the immediate problem through surgical management (Calache et al. 2013). Yet, the admission of frail elderly into RACFs could offer a window of opportunity for a more integrated systematic approach to oral health care. It requires a paradigm shift from solely restorative management to developing partnership and collaboration between dental professionals and residential HCPs, and requires major changes at the organisational, policy and infrastructure levels (Miegel and Wachtel 2009; CornejoOvalle et al. 2013; De Visschere et al. 2013). Emphasis needs to be placed on a patient-oriented approach with the resident at the centre of a triangle made up by the dental care professionals, the RACF staff, and the GP/geriatric team collaboratively providing care (Nitschke et al. 2010). This requires inter-professional support for oral hygiene for residents with decreased functional ability and may require greater emphasis on preventative measures such as sensitive dietary advice and topical fluoride applications (McHarg and Kay 2009; Hellyer 2011). Within this context, oral health for older people has become a priority area for the World Health Organization (WHO), with primary oral health care, disease prevention and oral health promotion a major plan for action (World Health Organization 2002; Petersen 2009; Petersen et al. 2010). Similarly, the National Oral Health Plan 2004–2013 emphasised a population-based approach focussed on the WHO’s five principles of building healthy public policy, creating supportive environments, strengthening community action, developing personal skills, and re-orienting health services to geriatric oral health promotion (National Advisory Committee on Oral Health 2004). Essential elements of primary health care addressed both the level of care and the approach to oral care, with emphasis on prevention, health promotion, access to equitable care, coordination and continuity of care, multidisciplinary and inter-sectoral approaches. Dentists, oral health practitioners, medical GPs, and Directors of Nursing in RACFs have an influential role in providing both scientific evidence-based information and practical advice to policymakers, aged care nurses, and residents’ caregivers. Nevertheless, as outlined in this review, unresolved barriers to oral health care have left many HCPs at all levels resigned and


sceptical, and this has hindered efforts to enhance their engagement to improving oral health in RACFs through the adoption of a primary care approach (Calache et al. 2013). In particular, the current model of oral health service that focuses on treatment with user payment, cost recovery, private insurance and public–private partnerships means the market organisation drives patient selection (Grytten and Golst 2013). This, in turn, limits elderly people’s access to services in RACFs, especially those from lower socioeconomic groups, those living in rural/ remote areas, or those who are mentally or physically frail (Cane and Butler 2004). While primary health care and dental teams are pivotal in creating a more dynamic inter-professional approach to oral health services, very little attention has been given to how oral health for the elderly could be integrated as a component of Australia’s primary health-care network. Like other chronic diseases, risk factors for oral disease in the elderly include an unhealthy diet, tobacco use and harmful alcohol abuse, yet prevention and early intervention of oral health are not perceived core business for the more clinically trained dental HCP (Petersen et al. 2010). Thus, there is an urgent need to review geriatric education in the dental undergraduate and postgraduate curricula of all dental professionals, with emphasis on the psychological and social factors of elderly patients (McHarg and Kay 2009). Importantly, oral health is associated with general health and quality of life of older people, but too often it is considered as a separate, isolated concern (Grytten and Golst 2013; Somkotra 2013). Maintaining the oral health of residents in RACFs should no longer be the role largely left to dentists. It requires the nursing team (including RACF managers, nurses and care providers) to take responsibility for daily oral health care through primary and secondary prevention; the dental team (including dentists, oral hygienists and oral therapists) to offer not only treatment but also public health education and continuous specialist advice and training; and medical doctors to oversee, coordinate and direct the overall health, including the oral health of their patients (Nitschke et al. 2010). The appointment of local oral care ‘champions’ could also play a crucial role in improving knowledge, motivation and commitment to standards of care (Fallon et al. 2006; Rivett 2006). Through greater community integration, the champions could strengthen oral health policies across a life course to maintain good quality oral health during the transition to residential care (Somkotra 2013). Research is required to assess the risks, quality, costs, accessibility and impact of innovative collaborative models of delivery in alternative settings of Australia, with special emphasis on patient-centred care focused on prevention rather than restoration (Calache et al. 2013). Their relevance, feasibility and applicability needs to be assessed in different local contexts with consideration of different socioeconomic, cultural and geographical influences. Conclusions In conclusion, the findings of this study highlight the numerous barriers to effective engagement of HCPs in the promotion of oral health care among elderly people in RACFs. While significant


challenges exist to addressing these barriers, the growing number of permanent aged care residents, together with our increased older dentate population, offers an opportunity for HCPs to advocate for changes to improve oral health care practice. As MacEntee (2013) suggests, there is an urgent need for an international review of where we are, where we should refocus oral health, and what impedes us from managing the special needs of older people, especially those in RACFs (MacEntee 2013). As he points out ‘We are part of a vibrant and globally connected inter-professional health-care team, yet there is little global unity or vision to propel our interests. Meanwhile, the patient-load grows, suffering continues, whilst other dental interests have never been better’ (MacEntee 2013, p. 89). This review has set the agenda for future action towards greater attention to cross-sector engagement between RACF managers and HCPs. A more comprehensive approach could be facilitated by increased collaboration between both public and private dental and other health care sectors, promoted at service, administration and education levels. Policy systems are also needed to clearly redefine dental teams clarifying roles and best practices to engage HCPs so that consistency and continuity of support is available across the later life course. Conflicts of interest None delcared. Acknowledgements We acknowledge Julie Pegrum and Dr Anne Read for advice on this manuscript. Our study was funded by the Australian Primary Health Care Research Institute, supported by a grant from the Australian Government Department of Health and Ageing. While the information and opinions do not necessarily reflect their views, we gratefully acknowledge their contribution.

References Australian Department of Health and Ageing (1997) Aged care client record. Commonwealth of Australia, Canberra. Australian Institute of Health and Welfare (2010) Age and the costs of dental care. Research report series no. 48. Cat. no. DEN 203. Australian Institute of Health and Welfare, Canberra. Australian Institute of Health and Welfare (2012) Residential aged care in Australia 2010–11: a statistical overview. Cat. no. AGE 68. Australian Institute of Health and Welfare, Canberra. Baltutis LM, Gussy MG, Morgan MV (2000) The role of dental hygienist in the public health sector; an Australian perspective. International Dental Journal 50, 29–35. doi:10.1111/j.1875-595X.2000.tb00543.x Benzian H, Hobdell M, Holmgren C, Yee R, Monse B, Barnard J, van Palenstein Helderman W (2011) Political priority of global oral health: an analysis of reasons for international neglect. International Dental Journal 61, 124–130. doi:10.1111/j.1875-595X.2011.00028.x Berkey DB, Scannapierco FA (2013) Medical considerations relating to oral health of older adults. Special Care in Dentistry 33(4), 164–176. doi:10.1111/scd.12027 Blinkhorn F, Weingarten L, Boivin L, Plain J, Kay M (2012) An intervention to improve the oral health of residents in an aged care facility led by nurses. Health Education Journal 71(4), 527–535. doi:10.1177/0017896911 412127 Calache H, Hopcraft J, Martin J (2013) Minimum intervention dentistry – a new horizon in public oral health care. Australian Dental Journal 58 (Suppl. 1), 17–25. doi:10.1111/adj.12046


155

Cane RJ, Butler DR (2004) Developing primary health clinical teams for public oral health services in Tasmania. Australian Dental Journal 49(4), 162–170. doi:10.1111/j.1834-7819.2004.tb00068.x Chalmers JM, Pearson A (2005) A systematic review of oral health assessment by nurses and carers for residents with dementia in residential care facilities. Special Care in Dentistry 25, 227–233. doi:10.1111/j.17544505.2005.tb01654.x Chalmers J, Spencer A, Carter K, King P, Wright C (2009) Caring for oral health in Australian residential aged care. Dental statistics and research series no. 48. AIHW, Canberra. Chrisopoulos S, Teusner D (2008) Dental labour force projections 2005 to 2010: the impact of new regional dental schools. Australian Dental Journal 53, 292–296. doi:10.1111/j.1834-7819.2008.00065.x Coleman P, Watson N (2006) Oral care provided by certified nursing assistants in nursing homes. Journal of the American Geriatrics Society 54(1), 138–143. doi:10.1111/j.1532-5415.2005.00565.x Cornejo-Ovalle M, Costa-de-Lima K, Perez G, Borrell C, Casals-Peidro E (2013) Oral health care activities performed by caregivers for institutionalized elderly in Barcelona-Spain. Medicina Oral, Patologia Oral y Cirugia Bucal 18(4), e641–e649. doi:10.4317/medoral.18767 De Visschere L, de Baat C, Schols J, Deschepper E, Vanobbergen J (2011) Evaluation and implementation of an oral hygiene protocol in nursing homes: a 5-year longitudinal study. Community Dentistry and Oral Epidemiology 39, 416–425. doi:10.1111/j.1600-0528.2011.00610.x De Visschere L, De Baat C, De Meyer L, Van de Putten G, Peeters B, Soderfelt B, Vanobbergen J (2013) The integration of oral health care into dayto-day care in nursing homes: a qualitative study. Gerodontology doi:10.1111/ger.12062 Dental Board of Australia (2010) Scope of practice registration standard. Available at http://www.dentalboard.gov.au/Registration-Standards. aspx [Verified 28 July 2014] Ettinger RL (2010) Meeting oral health needs to promote the well-being of the geriatric population; educational research issues. Journal of Dental Education 74(1), 29–35. Fallon T, Buiksta E, Cameron M, Hegney D, Mackenzie D, March J, Moloney C, Pitt J (2006) Implementation of oral health recommendations into two residential aged care facilities in a regional Australian city. International Journal of Evidence-Based Healthcare 4, 162–179. Frenkel H, Harvey I, Needs K (2002) Oral health care education and its effect on caregivers’ knowledge and attitudes: a randomized control trial. Community Dentistry and Oral Epidemiology 30(2), 91–100. doi:10.1034/j.1600-0528.2002.300202.x Fricker A, Lewis A (2009) Better oral health in residential care – final report. Central Northern Adelaide Health Service, South Australian Dental Service, Adelaide. Gaskin S, Georgious A, Westbrook J (2012) Examining the role of information exchange in residential aged care work practices – a survey of residential age care facilities. BMC Geriatrics 12, 40. doi:10.1186/ 1471-2318-12-40 Gluhak C, Arnetzl G, Kirmeier R, Jakse N, Arnetzl G (2010) Oral status among seniors in nine nursing homes in Styria, Austria. Gerodontology 27, 47–52. doi:10.1111/j.1741-2358.2009.00281.x Grytten J, Golst D (2013) Perception on providing good access to dental services for elderly people: patient selection, dentists’ responsibility and budget management. Gerodontology 30, 98–104. doi:10.1111/j.17412358.2012.00646.x Hellyer PH (2011) The older dental patient – who cares? British Dental Journal 211(3), 109–111. doi:10.1038/sj.bdj.2011.618 Hopcraft MS, Morgan MV, Satur JG, Wright FA (2008) Dental service provision in Victorian residential aged care facilities. Australian Dental Journal 53, 239–245. doi:10.1111/j.1834-7819.2008.00055.x Hopcraft MS, Morgan MV, Satur JG, Wright FAC, Darby IB (2012) Oral hygiene and periodontal disease in Victorian nursing homes. Gerodontology 29, e220–e228. doi:10.1111/j.1741-2358.2010.00448.x

156



Kandelman D, Petersen P, Ueda H (2008) Oral health, general health and quality of life in older people. Special Care in Dentistry 28(6), 224–236. doi:10.1111/j.1754-4505.2008.00045.x MacEntee MI (2013) How should we educate dental geriatricians? Gerodontology 30, 89–90. doi:10.1111/ger.12057 MacEntee MI, Kazanijian A, Kozak JF, Hornby K, Thorne S, KettratadPruksapong M (2012) A scoping review and research synthesis on financing and regulating oral care in long-term facilities. Gerodontology 29, e41–e52. doi:10.1111/j.1741-2358.2011.00575.x Mattila KJ, Pussinen PJ, Paju S (2005) Dental infections and cardiovascular diseases: a review. Journal of Periodontology 76, 2085–2088. doi:10.1902/jop.2005.76.11-S.2085 Mays N, Pope C, Popay J (2005) Systematically reviewing qualitative and quantitative evidence to inform management and policy-making in the health field. Journal of Health Services Research & Policy 10, 6–20. doi:10.1258/1355819054308576 McHarg J, Kay E (2009) Designing a dental curriculum for the twenty-first century. British Dental Journal 207, 493–497. doi:10.1038/sj.bdj. 2009.1011 Miegel K, Wachtel T (2009) Improving the oral health of older people in long-term residential care: a review of the literature. International Journal of Older People Nursing 4(2), 97–113. doi:10.1111/j.17483743.2008.00150.x National Advisory Committee on Oral Health (2004) Healthy lives, healthy mouths: Australia’s Oral Health National Plan 2004–2013. Government of South Australia, Adelaide. Nicol R, Sweeney M, McHugh S, Bagg J (2005) Effectiveness of health care worker training on the oral health of elderly residents of nurse. Community Dentistry and Oral Epidemiology 33, 115–124. doi:10.1111/ j.1600-0528.2004.00212.x Nitschke I, Majdani M, Sobotta BAJ, Reiber T, Hopfenmüller W (2010) Dental care of frail older people and those caring for them. Journal of Clinical Nursing 19, 1882–1890. doi:10.1111/j.1365-2702.2009. 02996.x Paley GA, Slack-Smith LM, O’Grady MJ (2004) Aged care staff perceptions on oral care for residents: Western Australia. Gerodontology 21, 146–154. doi:10.1111/j.1741-2358.2004.00020.x Paley GA, Slack-Smith L, O’Grady M (2009) Oral health care issues in aged care facilities in Western Australia: resident and family caregiver views. Gerodontology 26, 97–104. doi:10.1111/j.1741-2358.2008. 00230.x Peltola P, Yehkalahti M, Somoila R (2007) Effects of 11-month interventions on oral cleanliness among the long-term hospitalized elderly. Gerodontology 24, 14–21. doi:10.1111/j.1741-2358.2007.00147.x Petersen PE (2009) Global policy for improvement of oral health in the 21st century – implications to oral health research of World Health Assembly 2007, World Health Organization. Community Dentistry and Oral Epidemiology 37, 1–8. doi:10.1111/j.1600-0528.2008.00448.x Petersen PE, Kandelman D, Arpin S, Ogawa H (2010) Global oral health of older people – call for public health action. Community Dental Health 27, 257–267. Preston AJ, Kearns A, Barber MW, Gosney MA (2006) The knowledge of healthcare professionals regarding elderly persons’ oral care. British Dental Journal 201, 293–295. doi:10.1038/sj.bdj.4813973 Reed R, Broder H, Jenkins G, Spivak E, Janal M (2006) Oral health promotion among older persons and their care providers in a nursing home facility. Gerodontology 23, 73–78. doi:10.1111/j.1741-2358.2006. 00119.x

Rivett D (2006) Compliance with best practice in oral health: implementing evidence in residential care. International Journal of Evidence-Based Healthcare 4, 62–67. Rychetnik L, Wise M (2004) Advocating evidence-based health promotion: reflections and a way forward. Health Promotion International 19, 247–257. doi:10.1093/heapro/dah212 Samson H, Berven L, Strand G (2009) Long-term effect of an oral healthcare programme on oral hygiene in a nursing home. European Journal of Oral Sciences 117, 575–579. doi:10.1111/j.1600-0722.2009.00673.x Sheiham A (2005) Oral health, general health and quality of life. Bulletin of the World Health Organization 83(9), 644. Slack-Smith L, Lange A, Paley G, O’Grady M, French D, Short L (2010) Oral health and access to dental care: a qualitative investigation among older people in the community. Gerodontology 27(2), 104–113. doi:10.1111/j.1741-2358.2009.00320.x Slade G, Spencer AJ, Roberts-Thomson K (2007) Australia’s dental generations: the National Survey of Adult Oral Health 2004–2006. Cat no. Den 165. Dental statistics and research series no. 34. Australia Institute of Health and Welfare, Canberra. Somkotra T (2013) Inequity in oral health-care utilisation exists among older Thais despite a universal coverage policy. Australasian Journal on Ageing 32, 110–114. doi:10.1111/j.1741-6612.2012.00617.x Tham R, Hardy S (2013) Oral healthcare issues in rural residential aged care services in Victoria, Australia. Gerodontology 30(2), 126–132. doi:10.1111/j.1741-2358.2012.00652.x Van Lancker C, Verhaeghe S, Van Hecke A, Vanderwee K, Goosens J, Beeckman D (2012) The association between malnutrition and oral health status in elderly in long-term care facilities: a systematic review. International Journal of Nursing Studies 49(12), 1568–1581. doi:10.1016/j.ijnurstu.2012.04.001 Vanobbergen JN, De Visschere LM (2005) Factors contributing to the variation in oral hygiene practices and facilities in long-term care institutions for the elderly. Community Dental Health 22, 260–265. Wårdh I, Jonsson M, Wikstrom M (2012) Attitudes to and knowledge about oral healthcare among nursing home personnel – an area in need of improvement. Gerodontology 29, e787–e792. doi:10.1111/j.1741-2358. 2011.00562.x Watt RG (2007) From victim blaming to upstream action: tackling the social determinants of oral health inequalities. Community Dentistry and Oral Epidemiology 35(1), 1–11. doi:10.1111/j.1600-0528.2007.00348.x Webb BC, Whittle T, Schwarz E (2013) Provision of dental care in aged care facilities, NSW, Australia – Part 1 as perceived by the Directors of Nursing (care providers). Gerodontology 30, 226–231. doi:10.1111/ j.1741-2358.2012.00670.x Weening-Verbree L, Huisman-de Waal G, van Dusseldorp L, van Achterberg T, Schoonhoven L (2013) Oral health care in older people in long term care facilities: a systematic review of implementation strategies. International Journal of Nursing Studies 50(4), 569–582. doi:10.1016/ j.ijnurstu.2012.12.004 Western Australian Department of Health (2012) Results of the models of care survey: a snapshot of how models of care have been implemented in Western Australia. Health Networks Branch, Perth. World Health Organization (2002) Global oral health data bank. World Health Organization, Geneva. Yoon MN, Steele CM (2012) Health care professionals’ perspectives on oral care for long-term care residents: nursing staff, speech-language pathologists and dental hygienists. Gerodontology 29, e525–e535. doi:10.1111/j.1741-2358.2011.00513.x

www.publish.csiro.au/journals/py

Health-promoting residential aged care: a pilot project in Austria.

Patterns of use of oral health care services and barriers to dental care among ambulatory older Chilean.

Primary-care providers' perceived barriers to integration of genetics services: a systematic review of the literature.

Medication charts in residential aged-care facilities.

Engaging with health-care policy.

Knowledge, experiences, and barriers to colorectal cancer screening: a survey of health care providers working in primary care settings.

"A constant struggle to receive mental health care": health care professionals' acquired experience of barriers to mental health care services in Rwanda.

Engaging men as coproducers in health care.

Barriers to Utilization of Antenatal Care Services in Eastern Nepal.

Non-dental primary care providers' views on challenges in providing oral health services and strategies to improve oral health in Australian rural and remote communities: a qualitative study.

Barriers to the use of face protection for standard precautions by health care providers.

Retention in Care Services Reported by HIV Care Providers in the United States, 2013 to 2014.

Mental Health Services in Rural China: A Qualitative Study of Primary Health Care Providers.

Helping newcomers overcome barriers to health care.

Primary care providers' beliefs about teen and parent barriers to depression care.

Health care providers in rural America.

Knowledge, attitude, willingness and readiness of primary health care providers to provide oral health services to children in Niagara, Ontario: a cross-sectional survey.

Transition from child to adult mental health services: needs, barriers, experiences and new models of care.

Barriers and Facilitators to Adoption of Genomic Services for Colorectal Care within the Veterans Health Administration.

Assessment of sexual health and sexual needs in residential aged care.

Barriers and facilitators of the use of mind-body therapies by healthcare providers and clinicians to care for themselves.

Professionals' perspectives towards health promotion in residential aged care: an explorative study in Austria.

Burnout in Army health care providers.

Public health care nurses' views of mothers' mental health in paediatric healthcare services: a qualitative study.