Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2015; 60:(1 Suppl): 114–124 doi: 10.1111/adj.12290

Social implications and workforce issues in the oral health of an ageing population FAC Wright* *Centre for Education and Research on Ageing, The University of Sydney, Concord Clinical School and Faculty of Dentistry, Department of Aged Care and Rehabilitation, Concord Repatriation General Hospital, Sydney Local Health District, New South Wales, Australia.

ABSTRACT A functional and socially acceptable level of oral health is an integral part of healthy ageing! More teeth, more sophisticated dental technology and increasing co-morbidities of an ageing Australian society will have significant impacts on oral health professionals and their capacities to work within expanded teams of health, education and social organizations. Society is adapting its perspective on the social role of older citizens; replacing its perception of the elderly as an economic social burden, to one of senior citizens as being a respected and active source of social and economic benefit. Maintaining general and oral health for older Australians will bring into sharp focus the need for recognizing and managing not only the biological markers associated with ageing and frailty, but also the potential mediators on health outcomes associated with changing health and social behaviours. Increasing social capital of older Australians through national policy initiatives such as the Living Longer Living Better reforms, and greater involvement of allied health and carers’ organizations in oral health education and health promotion will set a new scene for the roles of dental professionals. Issues of equity will drive the service delivery agenda, and a socio-cultural shift to ‘consumer-directed’ health outcomes will shape the range of services, quality of care and support required by an older Australian population. Formal education and training modules for aged care workers, allied health practitioners and geriatricians will develop. The challenge for the dental profession is the coordination and integration of these changes into new models of dental and general health care. Keywords: Ageing and oral health, equity within an ageing society, social determinants of oral health, social policies. Abbreviations and acronyms: ACAT = Aged Care Assessment Team; AHRC = Australian Human Rights Commission; AIHW = Australian Institute of Health and Welfare; BOHRC = Better Oral Health in Residential Care; CDBS = Child Dental Benefits Scheme; CDC = Consumer Directed Care; COTA = Council on the Ageing; EPC = Enhanced Primary Care; HCP = Home Care Packages; IGR = Intergenerational Report; OHIP = Oral Health Impact Profile.

INTRODUCTION The changing population demographics place the increased number and proportion of older people in our community as the single most important health and social issue impacting on potential public costs and service infrastructure.1,2 Australia is not unique in this reshaping of the basic age structure of its populations. Both developed and developing nations are recognizing and reacting to these changes.3 The proportion of the Australian population in 2007 over 65 years of age was approximately 13% – and this is expected to rise to between 23% and 25% by 2056 – and to between 25% to 28% by 2101.4 The key driver to Australia’s rapidly ageing society is the increase in life expectancy due to decreasing agespecific mortality rates.5 Life expectancy of Australian males is expected to rise from 80.3 years in 2012 to 114

89.1 years by 2060; and for females, from 84.6 years to 91.4 years over the same period. While significant advances in public health (food security, water quality, sanitation, housing, immunization and antibiotic uses) have contributed to the global declines in age-specific mortality rates, continuous advances in medical technologies and interventions with new medication for blood pressure reduction, surgical techniques and therapeutics have enhanced life expectancies. Medical interventions which delay ageing, especially through cellular mechanisms to mediate caloric restrictions, will further contribute to the changing demographics in future years. Pharmacological agents which replicate the benefits of caloric restriction show considerable promise as drug interventions which may slow the ageing process, lengthen life and improve productivity of older citizens.6 © 2015 Australian Dental Association

Social implications of ageing on oral health This diversity of older folk – rich and poor, Indigenous and migrant, with and without cumulative chronic disease or disorder – brings with it a changing demography and social implications unheralded in our history. Almost two million Australians will be 85 years of age or older by 20507 and most of them will have some natural teeth. Possession of natural teeth within older populations is likewise expected to escalate;8,9 as will the need to maintain the technically more complex, reconstructed, maintenance-demanding and biologically older mouth. Australian projections to 2020 for percentage increases in complex care have been estimated as: crown and bridge services 69.6% increase, endodontic services 51.9% and prosthodontic services an increase of 51.6%.10 Dental caries is a decreasing phenomenon in children and adolescents, but it and other oral diseases are becoming an increasing biological hazard and social issue in older Australian populations.11–13 Chalmers14 has summarized the relationship between oral diseases in older Australians, the complex personal, medical and environmental influences on the onset and progression of oral diseases and their social impact on the individual. General health, maintenance of oral health and social support were the key influences on disease onset and progression. Social impact on the individual was linked to quality of life issues such as the overall feeling of the comfort of one’s mouth, freedom from pain, capacity to eat and chew one’s favoured food and personal appearance. The social impact of poor oral health for older Australians could accentuate impairment, limitation, disability or handicap. The social impact of poor oral health for older Australians is also intimately linked into the larger picture of the social determinants of health,15,16 the family, community and socio-economic environment which will shape opportunities for the new cohorts of dentate elderly or establish barriers which increase inequities. Substantive barriers may be created through inadvertent consequences of government policies, through professional isolation of dental care from the mainstream Australian health and welfare system, or through the growth of high technology – high maintenance dependent dental treatments. Social and economic challenges The changing age profile of the Australian community has not been without fears of impending costs as a result of the perception of a greater demand for aged pensions and health and aged care spending. The Australian Government’s Intergenerational Report (IGR) of 2004 projected that:1 © 2015 Australian Dental Association

. . . spending by Government will exceed the amount it raises in taxes by around 5 per cent of Gross Domestic Product (GDP) by 2041–42. In 2004 GST raised $32.4 billion (4% of GDP) and personal income tax a further $94.7 billion (12% of GDP). A tax increase of 5 per cent of GDP (in 2004 dollars) would require an increase in personal income tax collections of over 40%. (p. 25) The increased costs in medical and especially pharmaceutical benefits, together with the expectation of access to new and more expensive diagnostic procedures were predicted to jump in the Commonwealth health spend in 2001–2002 from 4.0% to 8.1% of GDP in 2041–2042. Pharmaceutical benefits were predicted to move from less than 1% of GDP to more than 3% of GDP in the same period. Economic conservatives interpreting these data become concerned, especially in nations where there is a declining younger workforce and a growing beneficiary population. Dependency ratios (the proportion of non-working to working proportions of a population), especially the contribution the increasing number of those over 65 years make to a nation’s total dependency ratio, have been highlighted internationally17 and in the Australian 2014–2015 budget discussions.18 With ageing also comes an increased accumulation of chronic disorders and of accompanying prescription and non-prescription medications. In the Australian Institute of Health and Welfare’s (AIHW) analysis of the 2004–2005 Australian National Health Survey,19 32% of 45–64 year olds and 65+ year olds had one chronic disorder; however 50% of 65+ year olds had two or more chronic conditions compared with 21% of those aged 45–64 years of age, and less than 5%, of those under 45 years of age. Almost one-quarter of people (24%) who were taking prescription medicines were taking five or more medicines. A study by Adair et al.20 showed that the number of medicines used increased with age, with 39% of the 75+ age group taking five or more prescription medicines, compared with 14% of the 50–54 year old age group. Again, the IGR1 and more recently Australian 2014–2015 Federal Budget discussions have reflected on the sustainability of the predicted growth in pharmaceutical benefits and health costs with alarm! Health expenditure is also a significant component of end-of-life care, with most death related costs incurred in the last year of life.21 Hospital costs appear to make up the most significant contribution to decedent cost. The Wall Street Journal22 in its candid report on the high costs of US health care in retirement speculated that ‘[A] couple retiring in 2013 with a median medication expenses would need US$151 000 for a 50% chance of having enough 115

FAC Wright money to cover health costs in later life . . . [and a] couple at the 90th percentile of drug spending would need US$220 000’. These economic and fiscal components of analysis of an ageing population leads to considerable social concern within the Australian political and social structures as reforms are mooted or introduced.23,24 Therefore, the increasing cost of dental (and health) care, the lack of universal dental health insurance arrangements for seniors within Medicare and the increased difficulty in maintaining a highly restored dentition pose significant questions with respect to how to best link oral health needs, access to dental care and cost of dental services into the Australian aged care system. The social implications of these confronting issues for an ageing Australian population cannot be underestimated. Governments and the Australian media play a central role in shaping community responses. The dental professions, while acknowledging the growing issues of dental care for older Australians, have not yet developed a consensus approach with regards to their roles and scopes of practice within the Australian health and aged care system. Sociological perspectives and community attitudes From a sociological perspective, older people have traditionally held a special social role within a community or societal context. One of the first sociological analyses of healthy ageing, by Cumming and Henry,25 described ageing within a ‘disengagement’ social theory. That is, the social acceptance of an individual’s usual adult social roles (work, active community and family leadership) decreasing, as younger people take over these roles and the older person prepares for death. Such a process may start with the compulsory retirement from work at age 65. As the older individual moves into this role, society moves toward segregating the older person from their usual duties and roles by increasing residential opportunities in retirement and supported home care; by designing educational programmes specifically for older people (the University of the Third Age – U3A) and developing recreational activities through senior citizens’ and community based aged care centres. The translations of this into medical and dental environments has seen the focus on the biological deterioration of the body, the increasing frailty and wear of the body tissues and the replacement of impaired body parts, be they knees, hips or teeth. An alternative sociological perspective to the ‘disengagement theory’ sees older members of communities staying active, staying employed and celebrating their independence. Successful ageing (activity theory)26 holds that those elderly people who maintain active 116

and socially involved lives, will be best adjusted, have better health outcomes and higher quality of life satisfaction. Improving the health of older people and the management of many chronic illnesses and disorders through better medical technologies permits many of those in their 70s and 80s the ability to perform the various social roles they did when they were in their 40s or early 50s. For example, the development of the Internet has permitted many older people to find new ways of social engagement and keeping in touch with family and friends while maintaining independence.27 However, social changes brought about by these active older groups differ from the same activities often delivered by younger adults. Older active people tend to be unpaid, volunteers (in hospitals, teaching, charity organizations), and work in part-time capacities as compared with younger paid workers in comparable industries.28 Here lies a further social implication for governments and professions. Active, older Australians increasingly contribute to the nation’s wealth but like the activities of women in previous eras, their value to economic productivity has been largely ignored by economists.29 Neither of these two sociological theories alone has either a strong empirical base nor substantially explains the current social norms toward the elderly in Australian society. But they both clearly illustrate that the expectations held by a society for older people are socially determined, and consequently vary cross-culturally and cross-generationally. The expectations for what were the social norms for our grandparents are vastly different from our grandchildren’s normative expectations. Australian society, and especially an ageing Australian society, is increasingly recognizing the cross-cultural issues uniquely impacting on changing social roles and caring expectations. In 2011, over a quarter (26%) of Australia’s population was born overseas, and a further one-fifth had at least one overseas born parent.4 This dynamic mix and change is reflected in both government policies and social surveys. However, the popular belief of the moment – that the elderly will be an increased social and economic burden – is not well established and it may well be shown that the opposite is the case! Further, advances in medical science may lead to a new social concept – that of ‘longevity dividend’.30 Olshansky and colleagues propose that advances in science and medical research have now created new opportunities for older people to live substantially healthier, happier and longer lives than their predecessors. Further, by slowing down the ageing process, and extending the duration of a healthy life, people could remain in the workforce longer, amass more savings and thereby contribute to national economic growth and sustainability – the longevity dividend. This view is shared by a number of analysts and © 2015 Australian Dental Association

Social implications of ageing on oral health underscores the social journey into an unknown but potentially very exciting future.31 An ageing Australian society is not all ‘doom and gloom’ if managed well; it may in fact herald in a new age of growth and prosperity.17 Contemporary attitudes shaping social outcomes for older Australians Social norms and values create the reality of the world in which we live. In 2013 the Australian Human Rights Commission (AHRC) published the first stage of an Australian Government funded project on Age Positive: Promoting Positive and Diverse Portrayals of Older Australians.32 This report was the result of research on age discrimination, age stereotyping and ageism in contemporary Australian society. The findings of the research described the predominant attitudes of a cross-section of Australian society to the concept of ageing. The key findings were a salutary contribution to our understanding of how health and oral health matters of older Australians may be shaped in the 21st century. The research described how younger and older Australians defined ageing differently. Younger Australians (those under 30 years) held more negative attitudes toward ageing, associating ageing with a loss of health, mental capacity and income. However, most people over the age of 65 years did not feel that the term ‘old age’ applied to them – and the horizon of what they perceived as ‘old age’ shifted as they themselves became older. For both young and old however, most Australians felt that age discrimination was common. Over 70% of subjects in the AHRC study reported ‘age discrimination’ as common – with almost a quarter (24%) believing it ‘very common’. These different attitudes will shape how governments respond to emerging needs and community perceptions – they will influence the debates over universality versus targeted access to health and dental health services, on equity issues with respect to waiting times and priorities for access to health and oral health care. Social attitudes and values on ageing and oral health can be enablers or barriers to how we see service provision and provide oral health care. The influence of the media in creating and sustaining stereotypes on older Australians is of significance to our better understanding of how social norms and community attitudes are formed and shaped. The AHRC findings were that a significant influence on the ‘negative perceptions of older Australians’ is generated through the media, where older people are often portrayed as frail, weak, victims or in poor health. Respondents of the AHRC survey believed that a more neutral or positive representation of older Australians in the media was required to breakdown © 2015 Australian Dental Association

the negative stereotyping. In health and oral health this may mean that we need to focus more on the totality of an older Australian population and their health needs rather than fragmenting the older sector into specific classes of disability or dysfunction. The irony may be that as ‘successful ageing’ – an ability to live within the community, to function with the appearance of relative ease, to manage one’s chronic conditions and disabilities with minimal external interventions – becomes more pervasive across Australian society, subclasses of vulnerability and disability may develop and become the focus of health and oral health activity. This may perversely lead to an inequity outcome whereby care for those with high dependency needs improves, while those self-managing their age related conditions are left to care for themselves. Dental care operates in two quite different economic markets. The ‘public market’ – publically funded dental care for means-tested or socially defined groups (see, for example, the Child Dental Benefits Scheme) and the ‘private market’ – privately funded either directly through personal payments or via private insurance arrangements. In Australia the private dental market for dental care provision is around six times larger than the public market. In addition, the public market is non-competitive with the private market in adult dental care as it has policy barriers through eligibility and service limitation policies which exclude access, usually on socio-economic grounds. Should the political environment within the aged and health care systems (higher age for pension eligibility, lower pension rates, fees for health care, etc.) create additional financial burdens on older Australians, then their access to oral health care within the private market will decrease as would their access to the public provision of dental care. The social impact of changes within the general aged care and health system may have important negative consequences for the oral health care of older Australians. Equality and equity are not the same. The balance and mix between these two constructs is under constant change. It is important that the social impact of access to dental care, not only for highly dependent older Australians, but also those independent seniors on limited and fixed incomes become a priority action activity. There are new models of financing maintenance of oral health care in residential aged care facilities, increasing use of portable dental equipment and core dental services developing for domiciliary care and greater involvement of carers, allied health practitioners and dental professionals in oral health promotion for older Australians. It will be the widespread introduction of these different models of care, together with a consensus on roles and responsibilities of the various parties which will move to redress the inequities and inequalities within the Australian oral health care system. 117

FAC Wright Reshaping of the roles of older people – longer working lives, lower pension payments, greater personal accountability for maintaining one’s own care – and redefining the obligations of a civil society, to respect past and present contributions, to ensure safety, dignity and quality of life and to enhance independence and choice for elders will inevitably have policy and public expenditure flow-on. Adapting policies to encompass both equity and equality outcomes across Australia’s multicultural society in an ageing population environment is not an exact science. For example, the total dependency ratio in Australian society is increasing; however, the ratio itself can be divided in terms of child-dependency and old-age dependency. In the Australian context the distinction is important when full consideration is given to policy issues and changes in funding. In the mid1990s Australia’s child dependency ratio (children aged 0–14 years divided by persons 15–64 years) was relatively high at a value of 0.32, ranking fifth behind Israel, Ireland, New Zealand and the United States.33 In contrast, Australia’s aged dependency ratio was low, at a value of 0.17, compared with Sweden, Norway, the United Kingdom and Greece all having substantial higher values. While Australia’s ageddependency ratio is increasing, the child-dependency ratio is decreasing.34 In oral health care, expenditure through the Child Dental Benefit Scheme (CDBS) is increasing, while expenditure in age care dental benefits remains ethereal. Currently, there is no equivalent of the CDBS for older people. Therefore, should policies and public expenditure recognize this shift and reduce benefits within the child sector and increase benefits within the aged sector? Aged care reforms in Australia The Productivity Commission Inquiry into Caring for Older Australians7 (the Inquiry) made numerous recommendations for reforming the Australian aged care system which led to a major package of reforms being presented to the Australian Parliament in 2013. The Aged Care (Living Longer Living Better) Act, given assent in June 2013, provided impetus for the bipartisan support of a 10-year aged care reform plan, and $3.7 billion allocated to the implementation of the reforms over its first five years. Policy development in aged care also relies on objective estimates of what older Australians express their needs and wants to be.35 The survey by Dow et al.35 was a qualitative study drawn from submissions to the Inquiry and interviews conducted with the Council on the Ageing (COTA) between August 2011 and February 2012. Analyses of submissions to the Commission were reviewed under five sections: services that should be provided by government; 118

quality of services; accessibility of services; costs of services and who should pay; and information and education for consumers and carers. Fifteen themes were summarized from the COTA conversations, which were largely consistent with consumer responses to the Inquiry. Older Australians want to be included as full citizens in community life and have their contributions acknowledged, including as contributors to the care system as carers. They want knowledge and services that support them to maintain their independence as long as possible. They want clear information and a sensible system of care services that is able to respond to their needs. They want funding arrangements, including their contributions, to be fair and transparent and they want care that caters for the diversity of Australia’s older people. Most of all they want reform, they want it soon and they want it to have bipartisan support. (p. 239)35 Choice, easy access to an understandable aged care system and the government to address service gaps were areas which meshed well with both the direction of the Living Longer Living Better approach, and the inclusion of dental services within the reform matrix. Dental services were specifically identified within the ‘gaps’ of services for older Australians ‘especially in residential care’.35 Therefore, the Australian Government’s Living Longer Living Better36 reforms provide both a policy and a legislative framework for substantial reforms to aged care in tomorrow’s Australia. The reform package largely survived the change in government in 2013 and refocused effort onto the key elements of accessing appropriate aged care services (the Gateway program), Consumer Directed Care (CDC) across all new home care packages, as well as residential aged care, and assistance to help older people to remain in their own home. Living Longer Living Better expands home care activities to assist people to remain living at home for as long as possible and find their way through a complex federal, state, private and public mix of aged care services available. A provider of home care services may be funded by the Australian Government to provide a range of services under one of four defined Home Care Packages (HCP) which may include: personal care (help with showering, dressing, meal preparation, etc.); support services (such as house cleaning, gardening, transport, etc.) and clinical care (such as nursing, podiatry and physiotherapy).36 Eligibility for a HCP, and the type of package, is determined by an Aged Care Assessment Team (ACAT) which may comprise a doctor, nurse, social worker or other health care provider who visits the © 2015 Australian Dental Association

Social implications of ageing on oral health recipient in either their own home or hospital. A second important component to Living Longer Living Better is that all home care packages must be delivered on the basis of CDC. This is a contractual agreement between the recipient of the HCP and the provider of the home care services once the ACAT assessment has determined the specific level of government subsidized package. The CDC arrangements allow the recipient (their family or representative) to control the types of care they access and who provides the agreed plan of care. At this time, oral health care has a token inclusion within these reforms. It is, for example, included within the Gateway process to self-care essentials which are listed on the Gateway site. It is not included in any discussion on support services within Living Longer Living Better. Again this is a reflection of the marginalization of oral health care and dental services and their isolation from mainstream involvement and consideration. Given the social impact of oral health care on the aged care and health system, it underscores the need for far greater and effective advocacy of these issues by the dental professions in Australia and the mechanisms which can be developed to link with community health and community aged care groups. Residential aged care facilities have also received additional funding under the Living Longer Living Better reforms, including the trialling of CDC within facilities. The My Aged Care (the Aged Care Gateway)37 initiative provides a website and national contact centre for older people, their families and carers to access information about the aged care system and available services. Oral health and aged care To date there has been little attempt by the architects of aged care health and social policy to incorporate oral health into the national reform process. While oral health issues may be at the margin of public cost-based expenditure savings38 for older people on pensions, low and fixed incomes – dental services are highly privatized, with about 75% of all dental expenditure funded by individuals. This becomes a major access barrier.39 Ettinger and Beck40 recognized the different needs of older people and related oral health care provision to three classes: functionally independent older people; the frail older adult; and the functionally dependant older adult. They argued that oral health care management and treatment therefore should be structured on the basis of patient needs and expectations; the complexity of the treatment needed; the impact of underlying medical co-morbidities; capacity for maintaining oral health care; and the financial and social © 2015 Australian Dental Association

costs for the patient. This classification has great practical value in distinguishing between general treatment and preventive regimes for individual care, but it also lends itself to policy and programme complexities. Classifications are guidelines to allow clinicians to identify a collection of therapies and activities most suited to good practice and the best health outcomes. However, when such classifications are translated into policy and administrative documents, they often become rigid and confined to the interpretation of an individual’s need, and as such, discriminatory. Translation of sound clinical guidelines into regulatory eligibility and funding definitional groups is fraught with problems and requires a balance of exemptions, conditions and monitoring linkages to ensure that perverse decisions or outcomes do not occur. These are important issues to consider when welfare eligibility criteria tighten, and fixed and low-income older people must compete within a private dental market for access to care. Assuring quality and appropriate oral health care becomes a social justice priority. Policies which implicitly (through cost) or explicitly (through eligibility criteria and waiting lists) ration access to dental services, need to carefully consider barriers for older Australians that may inadvertently increase inequalities and inequities. Slade and Spencer41 provided the first empirical study of the social impact of oral conditions on older Australians. Their study of community-dwelling people aged over 60 years from Adelaide and Mount Gambier in South Australia used a 49-item questionnaire – the original Oral Health Impact Profile (OHIP) – to estimate the social impact of oral conditions on subjects’ lives. Overall, 50% reported ‘occasionally, fairly often or very often’ four or more impacts on their lives, over the previous 12 months, associated with their dental condition. Edentulous subjects had a greater frequency of reported social impacts than subjects with some natural teeth; largely related to greater chewing and eating activities, but also higher rates of psychosocial impact (self-consciousness, avoidance of going out because of the oral condition). Age and gender differences in this group did not appear to affect impacts; however, for dentate subjects, the lowest number of impacts (mean = 5.8) were reported in those subjects who had visited a dentist, usually for a check-up, within the previous 12 months. Those with the highest mean number of impacts either attended a dentist because of a problem (mean = 9.7) or had not had a dental check-up within the previous 12 months (mean = 9.7). For 5–10% of community-dwelling older South Australians, there are substantial direct social impacts of their dental condition on their everyday lives. Managing problems with dentures, access to dental care and seeking regular dental care appear significant 119

FAC Wright issues to improving the quality of life for older Australians. The social impact of oral health conditions was also assessed in relationship to community-dwelling people aged 75+ years (and for Aboriginal and Torres Strait Islander people, those aged 55+ years) who accessed the Medicare Enhanced Primary Care (EPC) health assessment program in Adelaide.42 There were five oral health related screen questions reportable during EPC assessments: Have you lost any fillings or do you need a dental visit? Have you had pain in your mouth while chewing? Have you had to interrupt meals because of problems with your teeth, mouth or dentures? Have you had difficulty relaxing because of problems with your teeth, mouth or dentures? Have you avoided laughing or smiling because of problems with your teeth, mouth or dentures? More than a third (36%) of those screened had either lost a filling or believed they needed dental care. Responses were grouped into three priority categories: ‘high priority’, those who responded that they had lost a filling or needed treatment plus reported one or more impacts canvassed in the other screening questions – 19% fell into this group; ‘medium priority’, those who had lost a filling or believed they required dental care or reported one or more of the other screen impacts – 20% were classified in this level of priority; and 61% fell into the ‘low priority’ group – those without a positive response to the five screening questions. The medical personnel administering the screening questions judged that 41% of patients (those who had responded to one or more of the screening questions) would benefit from a dental visit. There was also a high degree of agreement between the three priority categories and the health assessors’ perceptions of those who would benefit from a dental visit. The simple inclusion of questions on the social impact of oral conditions into the general health assessment of older Australians illustrates the recognition of the relationship between oral health and general health and improving the quality of life of older Australians. Rogers43 recognized the distinction between oral health interventions for ‘older people living within the community’ and those living in residential care in his review of evidence-based best oral health promotion practices. Including oral health checks within general health checks was cited as a ‘best practice’ opportunity from the Better Oral Health European Platform44,45 in relationship to a randomized clinical trial in the United Kingdom. The integration of oral health assessment as part of the health assessment for people aged 75 years and older would be an important first access step in recognition of the relationship between the health and oral health care systems for independent community-dwelling older Australians.46 Therefore, the impact of oral 120

health conditions should be an integral component of all policies and programmes in aged and health care for independent, community-dwelling older people. This is further illustrated by the cohort related attitudes and beliefs of older Australians in a Perth study on oral health and access to dental care.47 The professional literature is resplendent with examples of neglect of the oral health of older people within nursing homes or with neurological problems such as dementia and Alzheimer’s.48–53 Yet we see little more than token development of sustainable oral health initiatives to meet the challenges in Australian dental practice. The Australian Government’s Better Oral Health in Residential Care (BOHRC) programme54 is one of the few initiatives taking a national approach to improving the oral health of older Australians in residential care. This programme was based on the experience of the public–private dental service model established in South Australia and then trialled within residential aged care facilities in three states. Officially launched in 2009, the programme is directed toward education and training of staff in residential care facilities through a series of well-developed teaching modules available online. The programme had a short promotional life, and has required individual states and agencies to take up and sustain it since its introduction. The programme is cited as ‘best-practice’ by Rogers43 and is a similar model to a Canadian and other international bestpractice models.55 Again, support, integration and a better promotional approach to the national implementation of this model in residential age care would significantly move policy and access to dental care issues forward in Australia. The greater number of implants, crowns, bridges and endodontic work received by middle-aged Australian adults is accumulating at an exponential rate as market drivers and clinicians rehabilitate the mouths of those who regularly attend for dental care. More dental care does not necessarily lead to better oral health – as challenges to these treatments and high technical-based dental services increasingly require sophisticated maintenance and care. Pharmacological and technological solutions to oral health maintenance have not kept pace with treatment drivers. Nor have government initiatives, despite the rhetoric and seed-funding, led to an integrated approach to prevention and programmatic oral health care. This inertia is partially related to professional tensions in private versus public leadership, partly related to the dental industry (both health insurance and supply companies) marketing philosophy focus on treatment services, and partly related to dental professions rewarded (internally and externally) on treatment-service outcomes. However, over time new pharmacological and therapeutic techniques will be © 2015 Australian Dental Association

Social implications of ageing on oral health tested and developed commercially to provide an increasing range of appropriate interventions.56,57 Harford38 contends that because of dentistry’s marginal status of impacting on the general economics of the nation, relatively little research has been conducted in this arena, although she sees the improving oral health of older Australians may be complicated by increasing rates of chronic disease and co-morbidity. There is little doubt that leadership within the dental professions and at government level is needed to address the issues of oral health disparities – this appears to be a major factor in the lack of action in the area of oral health and aged care worldwide.58,59 Reforming oral health policies in Australia is not an easy, nor a short-term process. The Australian Dental Association Inc. has long contended that dental health care should not be part of a national health service in Australia.60 Yet Commonwealth governments have historically responded to consumer concerns about access to dental care with clear policies and funding. The School Dental Therapy Program; the Commonwealth Dental Health Program; the Medicare Teen Dental Program; the Medicare Chronic Disease Dental Scheme; the National Partnership Agreements in public dental health and the current CDBS are all examples of national oral health policy initiatives by both Conservative and Labor governments. Indeed, the current national Coalition Health Policy aspires to the inclusion of dental care within a national health insurance system when the economics are sustainable.61 Greater consumer advocacy from the ‘baby boomer’ generation, and more innovative models of financing dental care, such as the patient list and budget management system proposed by Grytten and Holst,62 may well see a new wave of interest in this area. Workforce issues Recent national and state health policy documents have recognized the need to consider and reshape the Australian oral health workforce.63–65 In each of these works, the characteristics of the oral health workforce, the scope of practice of the providers and the supply and demand for different levels of service provision have included cogent considerations of the needs of older Australians. Currently, Health Workforce Australia has a national lead in examining projected supply and demands for the registered workforce. But oral health for older Australians is more than simply the number and scope of practice of a dental team of specialists, dentists, oral health therapists, dental hygienists, dental prosthetists and dental assistants. Oral health for older Australians is all of these suppliers of dental services plus carers, nurses, doctors, pharmacists, speech pathologists, allied health and aged care workers. © 2015 Australian Dental Association

Education and training of the oral health workforce needs a different paradigm than simply to service health education aspects of dentistry. It requires an expanded and comprehensive appreciation of the role of all dental personnel within the broader framework of aged care; and that means that clinical dominance in oral health care problem-solving needs to give way to collective health decisions – consumer directed – and based firmly on quality of life outcomes. Although several authors14,40,51,53,60 have also emphasized the importance of the dental team, the different disciplines making up the team continue to be educated and trained separately. Broadly based networks or platforms which provide multidisciplinary communication between professionals and community groups should be encouraged to provide ongoing dialogue and education on oral health matters. These networks should include managers and owners of aged care facilities, and aged care providers. There are a number of organizations such as the Australian Association of Gerontology, COTA and the Combined Pensioners and Superannuants which provide opportunity for promoting oral health for older Australians, but only have limited input from dental professionals. The prevention and management of chronic oral diseases in older Australians is a shared responsibility between the individual, depending on their functional capacities, family, community and state. The ‘sharedcare’ paradigm requires the establishment of real partnerships between professionals and lay people who share a common goal. The focus is on joint effort and responsibilities, with all partners being of equal status. The model has special applicability in health care64,65 and is clearly the focus of the BOHRC programme.54 Therefore, in terms of both individual oral health care, and oral health care organized through community efforts, the roles and responsibilities of each party, together with the underpinning focus on the recipient of the care should be flexible, appropriate for the situation and sustained by evidence-based practices and products. The role each person has must be accompanied by an appropriate level of education, training and support to safely and effectively carry out their role. There will be an increasing need for dentists who specialize in geriatric dentistry and greater curriculum developments in geriatric dentistry in undergraduate programmes.68 However, this will require appropriate education and training programmes and discussion about whether the dental care of older people should continue to be regarded as a branch of special needs dentistry or should have more explicit recognition as a discrete discipline – perhaps even a registered dental speciality. There should also be greater opportunity for general dentists to follow their patients across the lifespan, and be responsible for previous dental care 121

FAC Wright supplied, if and when their patients’ capacity to care for themselves deteriorates. This will require a greater ethical responsibility from general dentists and a different mix of behavioural and social skills in dealing with domiciliary and residential patients with frailty. Monitoring of the oral health of those dependent on daily maintenance by others, support with individualized products and techniques and the general management and coordination of oral health care management plans in both residential and community aged care should largely become a responsibility of dental hygienists and oral health therapists. The role of dental hygienists and oral health therapists should also involve ongoing health promotion championing and material support to individuals, agencies, and community organizations within the aged care system. An ongoing presence of dental hygienists and oral health therapists within aged care facilities can influence the ‘oral health culture’ within an agency, improving perceptions of the need for daily maintenance of oral health and regular dental care. Domiciliary and mobile oral health services should increase with greater appreciation of the structural barriers faced by the frail elderly,69 and consequently the roles of carers, nurses, transportation workers and assistants will need to be coordinated for those with complex medical and co-morbidity conditions. This leads to the closer provision of dental care within mainstream health services; with opportunity for transportation, caring assistance and for access to clinical support to be provided within a one-stop clinical environment. All dental personnel will need to understand and work in close association with the full spectrum of aged care and medical personnel. Our traditional models of clinical training – both in oral health and general health disciplines – will need to be adapted to provide greater integration with community and health programmes across the aged care sector. The expanded involvement of allied health, carers, and residential care administrators in the delivery of oral health maintenance as a basic daily activity will also require a shift in perceptions and actions. Opportunities for such workers to gain qualifications in oral health are offered through the Community Services and Health Industry Skills Council initiative Development of Oral Health Competencies for the Community Services and Health Workforce.67 Government regulations should develop to support additional resources which will be required to ensure oral health activities and products are easily accessible and used effectively by both frail individuals and those assisting them with oral care. Ongoing information on the variety of products and therapies which are appropriate must be developed, trialled and embedded in sustainable daily practices. All of this will require greater 122

professional leadership, a sustained commitment over time and constant evaluation and renewal. SUMMARY The next two decades in Australia will see major population changes and continued improvement in oral health across all life phases. Older Australians will have more natural teeth and more sophisticated dental technologies restoring their dentitions than previous generations. Advances in public health and medical technology suggests that an older more active population will be more independent in their demands and lifestyles, and supported by sustainable government and self-managed financial structures. However, the inevitability of the biology of ageing will mean that many of the visible signs of an older body may be masked by therapies and technologies requiring greater maintenance, and greater skills and care in their management. The management of chronic oral diseases remains a lifelong commitment, and is complicated by co-morbidities, social attitudes and policy changes impacting on individual and community support systems. Equality in access of older Australians to appropriate oral health care must remain the sentinel professional goal; and equity to ensure this, will require dental professionals to embrace new and more dynamic models of care. Policy reforms within the aged care and health systems must critically evaluate the potential inadvertent social impacts which may increase rather than decrease social inequities with respect to access to oral health care, and the type of dental care delivered. ACKNOWLEDGEMENTS The author gratefully acknowledges the valuable comments and assistance with this paper by Dr Bill Cowie (Centre for Oral Health Strategy NSW), Dr Alan Deutsch (Montefiore Nursing Home, Randwick), Dr Peter Foltyn (St Vincent’s Hospital, Sydney) and Professor Linda Slack-Smith (University of Western Australia). DISCLOSURE The author has no conflicts of interest to declare. REFERENCES 1. Commonwealth of Australia. Australia’s Demographic Challenges. Australian Government: Canberra, 2004:23–28. 2. Commonwealth of Australia. Australia to 2050: future challenges. Barton: Commonwealth of Australia, 2010. 3. United Nations, Department of Economic and Social Affairs. World Population Prospects: 2012 Revision, June 2013. URL: ‘http://esa.un.org/unpd/wpp/index.htm’. Accessed April 2014. © 2015 Australian Dental Association

Social implications of ageing on oral health 4. Australian Bureau of Statistics. 3222.0 – Population Projections, Australia, 2012 (base) to 2101. URL: ‘http://www.abs.gov.au/ Ausstats/[email protected]/mf/3222.0’. Accessed December 2013.

28. Warburton J, Cordingly S. The contemporary challenges of volunteering in an ageing Australia. Aust J Volunteering 2004;9:67–74.

5. Productivity Commission. An Ageing Australia: Preparing for the Future. Canberra: Commission Research Paper, 2013:43– 45.

29. Waring M. If women counted: a new feminist economics. New York: Harper & Row, 1988.

6. Baur J, Ungvari Z, Minor RK, Le Couteur D, de Cabo R. Are sirtuins viable targets for improving health span and lifespan? Nat Rev Drug Discov 2012;11:443–461.

30. Olshansky SJ, Perry D, Miller RA, Butler RN. In pursuit of the longevity dividend. The Scientist 2006;20:28–36.

7. Productivity Commission. Caring for Older Australians, Final Inquiry Report. Canberra: Australian Government, 2011.

31. Tatchell M. Ageing and health costs: managing the future. In: Committee for Economic Development of Australia. Australia’s Ageing Population; Fiscal, Labour Market and Social Implications. Melbourne: CEDA, 2003:38–49.

8. Petersen PE, Kandleman D, Arpin S, Ogawa H. Global oral health of older people – call for public health action. Community Dent Health 2010;27(Suppl 2):257–268.

32. Australian Human Rights Commission. Fact or fiction? Stereotypes of older Australians. Research Report 2013. Sydney: Urbis, 2013.

9. Slade GD, Spencer AJ, Roberts-Thomson KF, eds. Australia’s dental generations: the National Survey of Adult Oral Health 2004–2006. Canberra: AIHW (Dental Statistics and Research Series No. 34), 2007.

33. Australian Institute of Health and Welfare. International health – how Australia compares. Dependency ratios. URL: ‘http://www.aihw.gov.au/WorkArea/Downloads’. Accessed April 2014.

10. Australian Institute of Health and Welfare. Projected demand for dental care to 2020. Adelaide: AIHW (Dental Statistics and Research Report No. 42), 2008.

34. Australian Bureau of Statistics. 3105.065.001 – Australian Historical Population Statistics, 2008. URL: ‘http://www.abs.gov. au/AUSSTATS/abs@nsf?Latestproducts/3105.0.65.001’. Accessed 8 April 2014.

11. NSW Ministry of Health. Oral Health 2020: A Strategic Framework for Dental Health in NSW. Sydney: Centre for Oral Health Strategy, 2013:3, 11. 12. Ettinger RL. Dental implants in the frail elderly: a benefit or liability. Spec Care Dent 2012;32:39–41. 13. Van der Maarel-Wierink CD, Vanobbergen JN, Bronkhorst EM, Schols JM, Be Baat C. Oral health care and aspiration pneumonia in frail older people: a systematic literature review. Gerodontology 2013;30:3–9. 14. Chalmers JM. Oral health promotion for our ageing Australian population. Aust Dent J 2003;48:2–9. 15. Rogers JG. Evidence-based oral health promotion resource. Melbourne: Victorian Department of Health Branch, 2011: 11. 16. Watt RG. Social determinants of oral health inequalities: implications for action. Community Dent Oral Epidemiol 2012;40:44–48.

35. Dow B, Sparrow P, Moore K, Garry E, Yates I. Policy and practices updates: what do older Australians want? Aust J Ageing 2013;32:236–240. 36. Australian Government. Living Longer Living Better – Aged Care Reform Package. URL: ‘http://livinglongerlivingbetter. gov.au’. Accessed March 2014. 37. Australian Government. My Aged Care (the Aged Care Gateway). URL: ‘http://www.myagedcare.gov.au’. Accessed March 2014. 38. Harford J. Population ageing and dental health. Community Dent Oral Epidemiol 2009;37:97–103. 39. Australian Institute of Health and Welfare. Aged and the costs of dental care. Adelaide: AIHW (Dental Statistics and Research Report No. 48), 2010. 40. Ettinger RL, Beck JD. Geriatric dental curriculum and the needs of the elderly. Spec Care Dent 1984;4:207–213.

17. Pew Research Center. Attitudes about aging: a global perspective, 2014. URL: ‘http://www.pewresearch.org’. Accessed March 2014.

41. Slade GD, Spencer AJ. Social impact of oral conditions among older adults. Aust Dent J 1994;39:358–364.

18. Knott M, Harrison D, Hunter F. $6 bulk-billing fee hits poor, spares rich. The Sun-Herald. 27 April 2014, p. 11.

42. Slade GD. Oral health for older people. Evaluation of the South Australian Dental Service Project. Canberra: AIHW (Population Oral Health Series No. 6), 2007.

19. Australian Institute of Health and Welfare. Chronic Disease. 2004–2005 National Health Survey. URL: ‘http://www.aihw. gov.au/chronic-diseases’. Accessed December 2013. 20. Adair T, Ortega L, Temple J. Senior Australians and prescription medicines: usage, sources of information and affordability. Canberra: National Seniors Productive Ageing Centre, 2012. 21. Productivity Commission. Economic implications of an ageing Australia. Technical Paper 13 – Costs of death and health expenditure. Canberra: Australian Government, 2003:2–6. 22. The Wall Street Journal. 12 January 2014. Online news downloaded 14 February 2014. 23. The Voice of Pensioners and Superannuants of NSW. Work ‘til you drop. December 2013 – January 2014. 24. The Senior NSW/ACT. Aged care work for the dole proposal. March 2014.

43. Rogers JG. Evidence-based oral health promotion resource. Melbourne: Victorian Department of Health Branch, 2011:52– 57. 44. Patel R. The state of oral health in Europe: Report Commissioned by the Platform for Better Oral Health in Europe. Better Oral Health European Platform 2012, p. 41. 45. Lowe C, Blinkhorn AS, Worthington HV, Craven R. Testing the effect of including oral health in general health checks for elderly patients in medical practice – a randomized controlled trial. Community Dent Oral Epidemiol 2007;35:12– 17. 46. Australian Government. MDS Primary Care. URL: ‘http:// www.health.gov.au/internet/main/pubishing.nsf/Content/mdsprimarycare_mbsitem_75andolder’. Accessed 14 April 2014.

25. Cumming E, Henry WE. Growing old. New York: Basic, 1961: 227.

47. Slack-Smith L, Lange A, Paley G, O’Grady M, French D, Short L. Oral health and access to dental care: a qualitative investigation among older people in the community. Gerodontology 2010;27:104–113.

26. Havighurst RJ. Successful aging. The Gerontologist 1961;1:8– 13.

48. Ettinger RL, Beck JD. The new elderly: what can the dental profession expect? Spec Care Dent 1982;2:62–69.

27. Bengtson VL, Putney N. Handbook of theories of aging. New York: Springer Publishing Company, 2009:32.

49. Ettinger RL, Mulligan R. The future of dental care for the elderly population. J Calif Dent Assoc 1999;27:687–692.

© 2015 Australian Dental Association

123

FAC Wright 50. Chalmers JM, Carter KD, Spencer AJ. Caries experience and increments in community-living older adults with and without dementia. Gerodontology 2002;19:80–94.

63. Report of the National Advisory Council on Dental Health. Canberra: Department of Health and Ageing. 23 February 2012.

51. Chalmers JM, Spencer AJ, Carter KD, King PL, Wright C. Caring for oral health in Australian residential care. Dental Statistics and Research Series No. 48. Cat no. DEN 193. Canberra: AIHW, 2009.

64. NSW Ministry of Health. Oral Health 2020: A Strategic Framework for Dental Health in NSW. Sydney: Centre for Oral Health Strategy, 2013.

52. Bartold PM. Nursing home care: we only have ourselves to blame. Aust Dent J 2011;54:1. 53. Hopcraft MS, Morgan MV, Satur J, Wright FAC. Dental service provision in Victorian residential aged care facilities. Aust Dent J 2008;52:239–245. 54. Australian Government. Better Oral Health in Residential Care. URL: ‘https://www.health.gov.au/internet/main/publishing. nsf/Content/ageing-better-oral-health.htm’. Accessed November 2013. 55. Van der Horst M, Scott D. Best practice approaches to oral health care in LTC Homes: Resources Kit, Best Practice in Long Term Care Initiative – Canada, 2008. URL: ‘http:// www.rcpc.ca’. Accessed February 2012. 56. Gluzman R, Katz RV, Frey BJ, McGowan R. Prevention of root caries: a literature review of primary and secondary prevention. Spec Care Dent 2013;33:133–139. 57. Amer RS, Kolker JL. Restoration of root surface caries in vulnerable elderly patients: a review of the literature. Spec Care Dent 2013;33:141–149. 58. Patrick DL, Lee RSV, Nucci M, Grembowski D, Jolles CZ, Milgrom P. Reducing oral health disparities: a focus on social and cultural determinants. BMC Oral Health 2006;6 (Suppl 1) S4:1–17. 59. Lee JY, Divaris K. The ethical imperative of addressing oral health disparities: a unifying framework. J Dent Res 2014;93:224–230. 60. Wright FAC, List PF. Reforming the mission of public dental services. Community Dent Oral Epidemiol 2012;40(Suppl 2):102–109. 61. National Liberal Party Pre-Election Policy. Our Plan Real Solutions for all Australians. September 2013. 62. Grytten J, Holst D. Perspectives on providing good access to dental services for elderly people: patient selection, dentists’ responsibilities and budget management. Gerodontology 2013;30:98–104.

124

65. Health Workforce Australia, Health Workforce 2025 – Oral Health. URL: ‘http//www.hwa.gov.au/our-work/healthworkforce-planning/health-workforce-2025’. Accessed April 2014. 66. Paquette-Warren J, Vingilis E, Greenslade J, Newman S. What do practitioners think? A qualitative study of a shared care mental health and nutrition primary care program. Int J Integrated Care 2006;6:1–9. 67. Maher L, Phelan C, Lawrence G, Dawson A, Torvaldsen S, Wright C. The early childhood oral health program: promoting prevention and timely intervention of early childhood caries in NSW through shared care. Health Promotion J Aust 2012;23:172–176. 68. Ettinger RL. A 30-year review of a geriatric dentistry teaching program. Gerodontology 2012;29:1252–1260. 69. Cox F. Evidence summary: why is access to dental care for frail elderly people worse than for other groups? Br Dent J 2010;208:119–122. 70. Industry Skills Council. Oral health workforce project. Developing oral health care competencies for the community services and health industries. Scoping Report. Community Services and Health Industry Skills Council. February 2010.

Address for correspondence: Professor Clive Wright Associate Director (Oral Health) Centre for Education and Research on Ageing Building 18 Department of Aged Care and Rehabilitation Concord Repatriation General Hospital Concord NSW 2139 Email: [email protected]

© 2015 Australian Dental Association