Oral health in aged care: a broken system – opinion

Dental Health Week (2-8 August) puts a focus on oral care both for those at home and in residential aged care. For the ADA it’s a system that’s in need of urgent attention but for which it also has a solution.

Most Australians are left to fend for themselves when it comes to paying for their own dental care, making it one of the biggest health and financial challenges facing older people who invariably have the most dental health needs.

Some people qualify for government assisted help but often that eligibility is offset by having to endure many months, if not years, of patiently waiting their turn on unacceptably long public dental lists.

In the meantime their oral health deteriorates and their pain, discomfort and inability to have a properly functioning mouth, and the inherent loss of self-esteem that brings, all increase.

Those not qualifying for government assistance often have to pay large out of pocket amounts for treatment, even if they have extras cover with private health insurance (PHI), because of poor rebates paid out by insurers.

These dilemmas go a long way to explaining why so many older Australians go into residential aged care with very poor oral health.

For people either receiving care at home via a Level 4 Home Care Package or those in residential care, oral health is the poor relation when it comes to being a health priority.

Overstretched staff in aged care homes have insufficient time to deliver the oral care needed to ensure residents receive the regular brushing and flossing they need, while regular check-ups and treatments by visiting dentists also fall by the wayside.

Amongst the upsetting reports heard at the Royal Aged Care Commission were cases of patients with dementia or arthritic hands unable to brush their own teeth, so they remained uncleaned for several weeks, and of patients in significant oral pain.

The Australian Dental Association (ADA) has long had a remedy to fix this situation, the Australian Dental Health Plan (ADHP) which proposes three schemes aimed at children, adults and older Australians to address the dental needs of disadvantaged Australians.

One of these, the Child Dental Benefits Schedule, is currently offered to children, so it would be easy to introduce something similar under the same legislative framework.

This plan would address the needs of those in aged care, and the socially and economically disadvantaged senior population, helping them to get the very badly needed dental care to which they are entitled.

A key element of the plan, the Senior Dental Benefits Schedule (SDBS) would cater for the needs of older Australians either receiving Level 4 Home Care Packages or in residential care.

While federal health ministers make all the right noises, and while ADA representatives have met with Treasury to discuss the ADHP, with Treasury saying it would consider the plan, nothing along these lines has yet been implemented.

This is despite several ADA submissions in 2019 and 2020 to the Aged Care Royal Commission.

The ADA advocated in these submissions for the Certificate III qualification of aged care workers to include the delivery of quality oral care as one of its core competencies, and assurances that there are sufficient numbers of workers to carry out proper daily oral care.

We also want to see immediate funding for better education and training to improve the quality of care delivered, and for residential aged care to include allied health care including oral health practitioners.

There is also a need for an urgent review of the Aged Care Quality Standards, so these standards include ‘best practice’ oral care.

While the Aged Care Commissioners both agreed with many of the ADA recommendations, the Commonwealth Government didn’t go far enough when it responded in March this year to the Aged Care Commissioner’s report by outlining a five-year road map to fix the broken aged care system, starting with an extra $425m for the beleaguered sector. It’s not yet known how much of this will be spent on dental services.

While the government has accepted some of the Commissioners and our recommendations, including ringfencing funds to educate and train existing staff, it fails to stipulate training specifically in oral health care.

Also, most recommendations they’ve accepted are subject to further consultation with the states or further review, with outcomes that can’t be predicted.

With an election expected in the next 12 months, the ADA’s plan will be placed yet again before all political parties in the lead-up to it. The ALP promised to introduce funding dedicated to older Australians featuring the SDBS, when campaigning in the 2019 federal election.

The ADA will continue to advocate to get our message across and get governments to understand the enormous benefits the ADHP represents to improve the nation’s oral health in an affordable way.

The SDBS is critical to building better oral health among older Australians before and after they enter residential care. It’s particularly important for those older Australians receiving home care or going into aged care facilities that their oral health issues are assessed and treated, and that they receive ongoing care to ensure they can continue to eat, speak, socialise and be free from pain.

With the SDBS, ongoing assessments and access to oral health treatment will be improved for residents which will benefit their general health and nutritional status, while aged care providers, carers and families will have access to a range of available practitioners to provide these services.

Why is a dental scheme for seniors needed?

Consider these disturbing statistics from the the National Oral Health Survey (2017 to 2018), which show just what a bad state seniors’ oral health, and their capacity to pay for dental care, is actually in:

• 23% of people aged 55 to 74 and 10% of those 75 and over reported that dental costs had prevented recommended treatment
• a quarter of people aged 55 to 74 and one in five people over 75 said they’d have a lot of difficulty paying a $200 dental bill
• 28% of 55 to 74-year-olds surveyed and 26% of over 75s avoid foods due to dental problems, and
• around 25% of those eligible for public dental don’t have the teeth needed for their mouth to function properly (21 teeth are the threshold dentists use for the minimum number of teeth needed for the mouth to function efficiently).

But PHI isn’t funding all of the shortfall: a 2019 Your Life Choices poll of 225,000 Australians aged 65+ found many could no longer afford PHI.

Almost half didn’t have it, while only 47% with private cover had general treatment or extras cover that includes dental treatment, and only 10% of those with PHI had the top level of dental cover.

It's a dire situation getting worse daily. The ADA’s plan would help resolve many of these issues by making dentistry affordable to many older Australians.

The other linchpins of the Australian Dental Health Plan

Aside from seniors, a sizeable number of Australians from low socioeconomic backgrounds, Aboriginal and Torres Strait Islander populations, those in rural areas and special needs groups also have unmet dental requirements.

So as well as the SDBS, the ADHP proposes two other targeted dental schemes: a modified version of the existing CDBS for kids 17 and under, and a new income-tested scheme for adults aged 18 to 64, the Adult Dental Benefits Schedule (ADBS).

The SDBS and ADBS schedules would cover all adults and seniors in receipt of Commonwealth income support payments, and some on low incomes who just miss out on eligibility for payment of Commonwealth pensions/allowances, while the CDBS covers all kids aged 17 and under regardless of parental income.

How would the plan be paid for?

The plan would be funded a number of ways including phasing out the PHI rebate – that’s the income-tested amount the government contributes towards the cost of private hospital health insurance premiums, for general treatment policies.

The projected cost of the premium rebate for hospital and general treatment policies in 2019/20 is $6.3 billion, and around $800 million of this amount will subsidise benefits for dental costs paid out by health funds. A component of this subsidy could fund the ADHP.

It could also be paid for by introducing a tax on the consumption of sugary drinks, which the AMA also recently advocated for, or more taxes on tobacco products.

A third way would be to increase by 0.5% the Compulsory Medicare Levy: the current 2% levy raised $15.8 billion in 2017/18, so a 0.5% increase would initially raise an additional $3.9 billion annually.

Without the funding mechanism to ensure that older Australians both at home and in aged care can access screening and treatment through both public and private dental practitioners, the oral health of our most vulnerable population will continue to be neglected.

Dr Mark Hutton is the president of the Australian Dental Association.

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