Australian Dental Journal

Transcription

1 Australian Dental Journal The official journal of the Australian Dental Association Australian Dental Journal 2015; 60:(1 Suppl): doi: /adj Improving the oral health of frail and functionally dependent elderly A Lewis,* J Wallace, A Deutsch, P King *SA Dental Service and School of Nursing, The University of Adelaide, South Australia, Australia. School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Ourimbah, New South Wales, Australia. Private Practice, Bondi Junction, Sydney, New South Wales, Australia. Hunter New England Health and School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Ourimbah, New South Wales, Australia. ABSTRACT The Australian Government endorsed a national evidence based oral health model when it introduced the first Nursing Home Oral and Dental Health Plan in Called Better Oral Health in Residential Care, it promotes a multidisciplinary approach with doctors, nurses, care workers and dental professionals sharing responsibility for the four key processes of oral health screening, oral health care planning, daily oral hygiene and access to dental treatment. Frail and dependent residents are most conveniently treated on-site, hence an aged care/dental partnership is encouraged to facilitate the use of portable dental equipment in the delivery of dental care. Currently, few dentists provide services to residential aged care facilities (RACFs), with loss of clinical time in practice, difficulty in providing clinical care in a non-dental environment and lack of referral pathways from the RACFs to the dentists contributing to the problem. The need to establish a model of care involving dental hygienists/oral health therapists in RACFs has merit. Minimal intervention treatment using glass ionomer cement (GIC) and silver fluoride is ideal in aged care. However, GIC has limitation in dry mouths with low ph caused by polypharmacy or disease. Palliative and definitive treatment techniques need to be individualized with consideration of a patient s ability to maintain their own mouths as well as their mental and physical competence. The range of products available to address the oral diseases common to the frail elderly is growing. The oral health care provider is required to establish a preventive regime that is tailored to the patient s needs, is realistic and under revision as the patient s needs change. Keywords: Frail elderly, functionally dependent elderly, preventive strategies, residential aged care, restorative approaches. Abbreviations and acronyms: AgF/SnF 2 = stannous fluoride; ART = atraumatic restorative treatment; EBPAC = Encouraging Better Practice in Aged Care; EN = enrolled nurse; GIC = glass ionomer cement; OHAT = Oral Health Assessment Tool; RACF = residential aged care facility; RN = registered nurse; SDF = silver diamine fluoride; SGH = salivary gland hypofunction. NATIONAL BEST PRACTICE APPROACH Aged care sector The ageing of the Australian population is widely documented. With regards to aged care provision, the Australian Government currently subsidizes approximately 2800 residential aged care facilities which provide care and services to over residents annually. In addition, it provides community aged care support through its Home Care Program and the National Respite for Carers Program. These programmes deliver care to about care recipients and their carers annually. 1 A dramatic increase in need for aged care services is predicted to be about 250% over the next 40 years, with about 10.3% or 3.5 million older Australians using aged care services by Furthermore, it has been predicted the expected increase in the incidence of dementia and other agerelated chronic illnesses will result in a growing demand for more complex aged care services. Similarly, it has been anticipated there will be a decrease in the number of family members and friends who are able to act as informal carers. Subsequently, increasing numbers of older people will become more reliant on the formal aged care system. 2,3 Aged care reforms Therefore, it is not surprising the Australian Government introduced a major aged care reform package in 2015 Australian Dental Association 95

2 A Lewis et al. April These reforms place strong emphasis on supporting healthy ageing. They call for a strengthening of the aged care workforce as well as the provision of better health (inclusive of oral health) connections for older people. Moreover, this national policy directive requires the implementation of multipronged strategies and multidisciplinary approaches to address the changing needs of older people, especially as they transition from independence to informal assistance to formal assistance and finally to residential care. Aligned with these aged care reforms are corresponding dental initiatives which seek to address the oral health needs of older people. Over recent years, many of Australia s National Oral Health Plan (Healthy Mouths Health Lives) recommendations for multidisciplinary approaches have commenced. It is essential there be opportunity to continue to strengthen and build upon these with the subsequent 10-year national oral health plan. Coupled with this is the release of the Australian Government Dental Package in August This reform is directed at increasing access to more timely government-subsidized dental care for vulnerable populations group. Ageing population and oral health challenges Older people are representative of a vulnerable population group who suffer greatly from oral diseases. 4 Given the co-morbidities associated with the chronic disease profiles of older people, poor oral health further compromises healthy ageing. The literature consistently describes oral health as being a significant determining factor for an individual s quality of life. Pain, infection and tooth loss are identified as the most common consequences of poor oral health. Tooth loss is directly associated with a deteriorating dietary intake and compromised nutrition. Furthermore, it is well acknowledged poor oral health affects a person s appearance, self-esteem and self-confidence as well as their ability to talk and communicate effectively, thus impacting on social well-being and interpersonal relationships The growing body of scientific evidence also substantiates good oral health is integral and essential to a person s general health. 5 7,11,13,15 22 Oral health and disease are closely linked to general health and disease. Research has found tooth decay, oral cancer and periodontal disease share links with chronic conditions such as cardiovascular, cerebrovascular and respiratory diseases. Periodontal disease has a known bi-directional relationship with diabetes. The impact of this bi-directional relationship is significant as the prevalence of diabetes in older Australians is currently estimated to be 16.8% with a further 16.8% at high risk of diabetes. 23 Subsequently, oral diseases represent a growing public health issue. 4,13,24,25 Research has shown increasing rates of tooth decay, oral cancers and periodontal disease significantly contribute to the burden of oral disease. Studies have rated oral health conditions as high in terms of potentially avoidable admissions of which older people are over-represented. 4,14,26 In relation to the economic impact of oral health outcomes of older people, a 2007 analysis estimated the indirect cost as a consequence of periodontal disease to the Australian health system to be $412 million per annum. The same economic analysis estimated the total cost of poor oral health for older Australians was more than $750 million per annum. 27 Oral hygiene as an aspect of everyday care seems to be taken for granted. However, as people age, like many other self-care activities, good standards of oral hygiene become more difficult to achieve. Older Australians in particular are at increased risk of oral diseases and conditions due to their higher levels of functional dependence, physical frailty, medical comorbidity, polypharmacy, cognitive impairment and dependence upon carers. 7,11,28 Older people with dementia are further compromised by care resistant behaviours and their inability to reliably report their experience of oral health problems and dental pain. 5,11,25,29 31 For these reasons, addressing oral health needs for older people needs to reflect the aged care continuum and be appropriately tailored to life stages. In the past, growing old was associated with edentulism. 32 Therefore, dental needs were largely confined to the care of dentures and oral health tended to be low on the list of priority for the care of older people. However, due to the strong social trend of retaining natural teeth well into old age, the percentage of people who wear full dentures in the age group 75+ years has significantly dropped from 78.6% in 1979 to 35.7% in Undoubtedly, this rapid decrease in rate is expected to continue. 4 In terms of oral health related quality of life, the benefits of tooth retention has indeed been a positive one. However, the paradox is that older people s mouths will become more and more complex with increased numbers of heavily restored natural teeth aided by restorative dentistry such as crown and bridgework, partial dentures and implants. Therefore, this means maintaining the oral health of older people will shift from a low priority to a high priority due to the higher demand for dental care coupled with the increased complexity of oral hygiene assistance delivered by aged care workers. 13,32 Furthermore, it is well documented that poor patterns of dental care undermine the foundations of good oral health and hence compromise healthy ageing. Surveys have found people over 75 years of age visit a dentist less frequently than other age groups Australian Dental Association

3 Improving the oral health of the elderly Reasons for this can be attributed to physical and cognitive impairment, as well as difficulties with transport, past negative experiences, anxiety and dissatisfaction with dental services. 33,34 A significant long-term barrier has been the affordability of dental care. 13 Disturbingly, there is also a perceived view from older people and their families as well as health workers, that oral diseases are naturally associated with growing old. In other words, the relationship between oral health and general health seems to be either misunderstood or overlooked by older people and their families and by the aged care workforce. The cumulative effect of this often means older people only see the dentist when they have a painful and urgent problem. Therefore, it is not surprising studies have shown an older person s oral health deteriorates most rapidly in the year or so prior to entering residential care and then rapidly worsens following admission. 11,15 Oral health knowledge gap in aged care Dental research indicates many oral diseases associated with an ageing population can be easily prevented by good daily oral hygiene practices in conjunction with timely access to dental care. While it is acknowledged many older people may not visit dental professionals on a regular basis, they do, however, develop ongoing relationships with aged care workers who are responsible for monitoring and providing fundamental personal care as well as assisting older people with activities such as cleaning, shopping, meal preparation and transport. While doctors and allied health professionals contribute to aged care service provision, the direct care aspect of the aged care workforce generally refers to three main occupational groups: registered nurses (RNs); enrolled nurses (ENs); and care workers. The latest national Aged Care Workforce Survey (2012) reported the residential aged care workforce (per head count) was made up of 0.2% nurse practitioners, 14.9% RNs, 11.5% ENs and 68.2% care workers. In comparison the community aged care workforce was made up of 0.2% nurse practitioners, 8.2% RNs, 3.9% ENs and 81.4% care workers. 35 With the increased complexity of aged care service provision, it is of concern the responsibility for direct care falls largely to care workers who hold minimal level health care qualifications, knowledge and skills. This is further complicated by high staff attrition rates and the need for aged care organizations to repeatedly induct new staff. 36 National and international literature consistently describe the aged care workforce as lacking appropriate oral health knowledge and skills to be able to provide appropriate oral health for older people. 5,9,11,18,28,30,37 44 BETTER ORAL HEALTH IN RESIDENTIAL CARE In 2007, a two-year oral health project called Better Oral Health in Residential Care was funded by the Australian Government under the Encouraging Better Practice in Aged Care (EBPAC) initiative. This project developed a model of oral health care based on the systematic review findings of Chalmers and Pearson. 11 These findings were disseminated as a suite of oral health evidence based practice education and training resource portfolios designed to build the oral health capacity of the aged care workforce. While the project developed an oral health education and training package for care workers, this was not its primary intervention. Rather, it sought to encourage the integration of oral care processes into existing general care frameworks. Historically, there has been a tendency for health workers to regard oral health as the dental sector s responsibility. Changing this perception and spreading ownership through a team approach was a fundamental component of the Better Oral Health in Residential Care Model. Therefore, the model strongly advocated for a sharing of roles amongst GPs, nurses, care workers and dental professionals to implement four key oral health processes. 45 These include oral health assessment, oral health care planning, daily oral hygiene support and dental assessment and treatment. Oral health assessment This assessment does not replace a comprehensive examination undertaken by a dental professional but is used for the purposes of oral health screening to help monitor an older person s oral health, inform oral health planning, to evaluate oral hygiene and to trigger a dental referral. GPs and RNs use the Oral Health Assessment Tool (OHAT) on admission to residential aged care, on a regular basis and when the need arises. Oral health care planning Care planning is a role primarily undertaken by RNs with GPs and dental professional input as required. It is based on a simple protective oral care regime which is informed by the outcome of the oral health assessment. Daily oral hygiene support Assisting with daily oral hygiene is based on directions identified in the resident s care plan. This role is largely undertaken by care workers Australian Dental Association 97

4 A Lewis et al. Fig. 1 Flowchart showing the Better Oral Health in Residential Care Model. Dental assessment and treatment This is undertaken by dental professionals. Because many frail and dependent residents are best treated on-site at the residential aged care facility (RACF), a dental referral protocol was developed to provide information on how aged care staff can support a visiting dentist. This included a breakdown of responsibilities amongst the aged care facility, the dental professional and the resident and their family. Guides provided information on how to set up a dental room as well as other requirements such as consent for dental examination and treatment, medical history and current medications. In 2010, the Australian Government endorsed the Better Oral Health in Residential Care Model when it was introduced as part of Australia s first Nursing Home Oral and Dental Health Plan (Fig. 1). This involved the national roll-out of the Better Oral Health in Residential Care train the trainer programme. During this time, 89% of Australian residential aged care service providers were involved in the training and 4885 nurses were trained as trainers. This building of aged care oral health capacity was further enhanced by the complementary development of oral health competencies produced by the Community Services and Health Industry Skills Council and endorsed by the National Quality Council in March At a systems level, the implementation of this evidence based model promoted a nationally consistent approach for better oral health care practice. Strategically, this connected with the National Oral Health Plan (Healthy Mouths, Health Lives) and the Australian Government s Accreditation Standards and Guidelines for Residential Aged Care Services (Standard 2.15: oral and dental care). At an organizational level, the connecting of the four oral health processes to residential care policies and procedures provided a mechanism to improve oral health care delivery and hence support the RACFs accreditation obligations. Better Oral Health Connections The interplay of contextual issues involved in improving oral health care in the residential aged care setting are highly complex. There are many interdependent factors across organizational, professional and sectorial boundaries. Therefore, many of the causes and solutions are subject to understandings held by multiple stakeholders. The residential aged care sector is faced with competing demands and constraints in addressing the full range of care needs for older people. The oral health needs of older people represent one aspect of this and remain an ongoing challenge. There are particular barriers around the provision of quality dental care in residential aged care settings. RACFs generally do not have dental rooms or dental chairs or equipment that supports the provision of dental care. However, it has been demonstrated that the provision of portable dental equipment and/or other mobile service delivery options can largely alleviate this barrier and support the provision of basic but high quality clinical care in the residential aged care setting. In policy terms, improving oral health in residential care is referred to as a wicked problem. Essentially, a wicked problem is one that cannot be managed by a single entity acting alone In other words it is neither an aged care problem nor a dental problem; it is a shared problem that calls for collaboration. Collaboration offers the benefits of combined knowledge, expertise and resources. It also offers the prospect of solutions based on participation, ownership and stakeholder involvement. Ideally, the outcome of collaboration can lead to interventions that are superior in quality and innovation. However, collaboration takes commitment, skilful management and facilitation to make the most of the combined knowledge, expertise and resources of each sector. 48,49 In other words it requires ongoing leadership. While the national roll-out of oral health training was a positive start, the need for ongoing support to build and sustain the oral health knowledge and skills of the aged care workforce cannot be underestimated. Moreover, feedback from RACFs indicated that of the four oral health key processes, timely access to dental care on-site was the most difficult to achieve. In this circumstance, it is the dental sector that is best placed to take on the role of leader and facilitator of improving oral health for older people Australian Dental Association

5 Improving the oral health of the elderly Barriers to oral health professionals providing care: how to overcome these barriers and the role of the oral health therapist In 2003 Chalmers 50 reported that residents within RACFs face significant barriers to good oral hygiene care, including a lack of appropriate oral health knowledge and skills in association with a shortage of available dental and nursing staff. She argued that dental education could provide a better understanding of geriatric dental issues, including a specific clinical exposure to the provision of dental services to the homebound and institutionalized. Chalmers stated that dental hygienists should be able to provide a significant amount of this care. 51 A later study in 2008 by Hopcraft and colleagues reported high oral disease rates in residents were directly linked to the inability to access dental services, principally preventive dental care. 52 In 2007, a study conducted in Victoria analysed the employment and scope of practice of dental hygienists working in RACFs. 53 The study identified that 54% of dental hygienists believed they made dental care more affordable and 88% believed they improved access to dental care for residents. The role of dental hygienists, dental therapists and oral health therapists in Australia has slowly expanded over the last few years with national registration initiating a review into their scope of practice and training. 55 In many countries, dental hygienists practice independently without direct supervision from a dentist. In Germany, Latvia and Canada and several states in the USA, independent practice is common in restricted locations such as nursing homes and public health facilities. 56 Dental hygienists and oral health therapists have the knowledge, skills and training necessary to positively contribute to better oral health for older people living in RACFs; currently these attributes are not being fully utilized in Australian RACFs. The need to establish a model of care involving dental hygienists/oral health therapists in RACFs has merit; they have the qualifications and training to provide preventive oral hygiene care, diagnose and formulate treatment plans and refer to dentists for necessary clinical dental treatment In 2010, the University of Newcastle implemented an innovative student placement programme for final year dental hygiene students. Since then as part of their Bachelor of Oral Health degree, students have attended placement in 17 RACFs on the New South Wales Central Coast for a period of 12 weeks during semester one of their final year. The experiential student placement programme provides students with an opportunity to increase their knowledge and ability to provide oral hygiene care for older people. This programme has undergone a number of evaluations including a study completed in 2012, 57 which reported that following placement students showed a significant improvement in the area of assessing the oral health needs of residents with dementia and placement had a positive effect on reducing student apprehension in providing oral hygiene care to residents. Students also reported feeling significantly less nervous following their placement. A further study of the same placement programme published in 2013 reported a reduction in student anxiety in the RACF environment, improvement in providing oral hygiene care to residents with dementia and Alzheimers disease, and a clearer understanding of the oral health and medical needs of older people after completion of the placement programme. 58 Students reported the need to develop a rapport with residents prior to assessing their oral hygiene needs 58 and the need to develop specific skills in managing residents with cognitive impairment. This model of care is currently being tested by the University of Newcastle with a pilot research project Senior Smiles funded by Medicare Local in five RACFs on the New South Wales Central Coast. A qualified dental hygienist is currently conducting oral health risk assessments, developing oral health care plans and has established referral pathways for residents who require further dental care. The research project also provides oral health education to RACF staff to assist them in their care of residents. It is hoped that as a result of the research being conducted by the University of Newcastle, preventive focused oral hygiene care for older people in RACFs will be supported by the employment of dental hygienists/oral health therapists. CLINICAL APPROACHES The elderly can be placed into cohorts of different risk categories according to their dental competence, ability to cooperate and mobility to seek treatment. Dental competence in this article is defined as a patient s ability, either physically and/or mentally, to maintain their own oral health. With increasing infirmity the elderly may progress in stages from being cooperative and easily treated in general practice to non-cooperative and very difficult to treat in an aged care facility. 59 Each stage requires a different approach to treatment, risk assessment, preventive strategies and patient consent (Fig. 2). The balance between oral health and disease is affected by many competing factors (biofilms, saliva quality, oral hygiene, diet and fluoride exposure). The relative importance of these factors alters throughout life. Inadequate hydration, poor manual dexterity, lack of cooperation and the inability to maintain one s 2015 Australian Dental Association 99

6 A Lewis et al. to be considered before the patient becomes too frail. Reducing a dentate patient to 20 functioning teeth, ideally a second premolar to second premolar occlusion, may have to be considered where there is limited cooperation to allow oral hygiene maintenance by patients or carers and placement of restorations by dentists. Exceptions may be made in order to retain functioning pairs of opposing teeth or key teeth to support a denture. Fig. 2 Risk factors involved in the treatment of elderly patients. (Reproduced with permission and courtesy of Dental Outlook. 73 ) own oral care may be a major problem for the elderly but rarely a problem in the young. With increasing age, the increased incidence of polypharmacy induced salivary gland hypofunction (SGH) further adversely impacts on oral health (Fig. 3). In the elderly, any one of these risk factors can be so profoundly abnormal that it can overwhelm all others. Concentrating on only one treatment option, such as remineralizing teeth, without addressing other risk factors may prove unsuccessful. Creating a premolar occlusion The difficult decision to prophylactically remove molar teeth in very high-risk caries patients may have Treatment strategies The material of choice, particularly for root surface lesions, is a high-viscosity glass ionomer cement (GIC) in conjunction with atraumatic restorative treatment (ART). ART is a minimally invasive approach particularly suited to aged care. 63 GIC leaches fluoride and retards recurrent caries despite increased failures in marginal adaptation and loss of restorations in SGH patients. 64 Recurring GIC dissolution occurs due to erosion from prolonged acidic challenges and dehydration. 65 Polypharmacy is a major cause of SGH with 49.4% of years olds and 66.0% of over 70 year olds taking four or more drugs. 66 SGH causes reduced saliva flows with poor buffering capacity, lower saliva ph and a more pathogenic biofilm. 67 Both SGH and xerostomia (the subjective feeling of dry mouth) increases with age and is higher again with the institutionalized elderly (Fig. 4). 61,68 Food management in aged care facilities is defined by the author as the non-nutritious use of food to manage behaviours and the taking of medicines. Its effect on oral health is not well understood in the Fig. 3 Radiographs showing the degree of destruction that can occur rapidly in an elderly patient. (Reproduced with permission and courtesy of Dental Outlook. 73 ) Australian Dental Association

7 Improving the oral health of the elderly Fig. 4 Photograph showing dissolution of glass ionomer cement restorations in an elderly patient with excellent oral hygiene years after placement. (Reproduced with permission and courtesy of Dental Outlook. 73 ) aged care industry. The increased frequency of sweet foods at home and food management in aged care facilities, together with poor oral hygiene, inadequate hydration and SGH results in a dry mouth that may remain acidified for extended periods of time causing increased GIC dissolution and decay. Fig. 5 Photograph showing a transitory chemical burn to the gingival margin following use of an ammoniated silver fluoride preparation. (Reproduced with permission and courtesy of Dental Outlook. 73 ) Use of silver fluorides: silver diamine fluoride and aqueous silver fluoride The treatment of fearful frail elders with minimal cooperation can be a challenge. In these difficult situations, the author has found that silver fluoride techniques previously used with children to be a valuable atraumatic, non-threatening intervention for preventing, arresting or slowing caries progression. Thirtyeight per cent ammoniated silver diamine fluoride (SDF) has been used to treat open carious lesions in primary teeth and first permanent molars in children. 69 SDF was effective in preventing root surface caries in institutionalized elders. 70 SDF is less suited for elderly patients with thinner biotypes as SDF can cause a chemical gingival burn. SDF immediately followed by multiple applications of potassium iodide is more suited for aesthetically visible smaller carious lesions with sound peripheral boarders (Fig. 5). Water based silver fluoride was originally used by Craig et al. 68 to treat open carious lesions in primary molars. A one-minute application of silver fluoride was followed by stannous fluoride which acted as a reducing agent. The appearance of a continuous black matt surface indicated caries arrestment and a colour change indicated new caries reactivation. 69 The author prefers the application of water based 40% silver fluoride for 1 3 minutes, followed by 10% stannous fluoride (AgF/SnF 2 ) instead of SDF for the majority of open carious lesions in the elderly. Depending on the clinical situation, the author has found treated lesions may be simply monitored, restored immediately or in many cases restoration should ideally be delayed by 2 3 weeks. Better results seem to be achieved if treated lesions are temporarily sealed using Orabase (ConvaTec). Treat and monitor technique AgF/SnF 2 may be applied to open carious lesions and left unrestored if adequate salivary function remains and provided the area is periodically monitored for colour change. Patients and carers should be warned prior to treatment that decay will remain black once treated with AgF/SnF 2. Other surfaces coming into contact with AgF/SnF 2 will have a temporary black surface coating that soon wears away or can be polished away. The treat and monitor technique is not suited for patients with SGH and poor oral hygiene as caries reactivation can occur relatively rapidly. Delayed restoration technique Apply AgF/SnF 2 as described previously and delay the placement of a restoration for 2 3 (up to 5) weeks. The delayed restoration technique is the author s preferred treatment option and has found the technique ideal to treat fearful patients with limited ability to cooperate due to dementia, the very frail, subgingival caries, multiple carious lesions ( rampant decay ) and particularly for any open ring bark caries. During the delay, softened caries usually comes away leaving 2015 Australian Dental Association 101

8 A Lewis et al. a hard matt black surface without the need for any rotary instrumentation. Minimal, or often no, hand excavation is required for open lesions. AgF/SnF 2 is reapplied if needed, the site washed, dentine conditioner applied and the tooth restored with a high viscosity GIC which masks the black treated surface. The delay also allows time for consultations with medical staff, patients and family about treatment, costs and for informed consent. Multiple teeth can be rapidly restored at subsequent visits without the need for tooth preparation or local anaesthetic. There is a very high acceptance of this technique with fearful dementia patients and the elderly in general (Fig. 6). (a) Subgingival caries Gingival tissues often grow into subgingival caries, become inflamed and bleed readily on manipulation making restoration difficult. Two to three weeks after the AgF/SnF 2 application, an improvement in gingival health is usually evident with the gingiva occasionally retracting out of the lesion. Gingival tissues can be pushed aside, usually without bleeding and restorations may be placed without the need for drilling below gingival margins, use of haemostatic agents, gingivectomy or use of local anaesthetic (Fig. 7). The decision when to restore is determined more by whether the patient is likely to return within the month than by the need to immediately restore the tooth. In cases where a patient is unlikely to be seen within four weeks, an immediate restoration is placed. Superficial caries is removed with hand instruments, AgF/SnF 2 applied, the site washed, dentine conditioner used and the tooth restored with high-viscosity GIC. Designing a preventive regime for protecting root surfaces Root surfaces are a prime site for carious lesions. There are numerous techniques proposed for preventing caries at these sites, including the use of fluoride varnishes, chlorhexidine preparations and remineralizing agents. However, there are few differences in effectiveness among the various interventions, which included: (1) regular use of a 5000 ppmf toothpaste; (2) monthly or (b) (c) (d) Fig. 6 Silver fluoride treatment of a fearful dementia patient with limited ability to cooperate. (a) Large open carious lesion extending subgingivally. (b) Only topical application of AgF/SnF 2 without hand or rotary preparation. (c) Delayed restorative technique: after 5 weeks a hard black matt surface is evident, treated softened carious surface has fallen away and gingival health has improved. (d) High viscosity GIC placed subgingivally masking treated black surface. Surface was cleaned with pumice interproximal brushes, etched and GIC was hand moulded without rotary finishing. (Reproduced with permission and courtesy of Dental Outlook. 73 ) Australian Dental Association

9 Improving the oral health of the elderly (a) (b) (c) (d) Fig. 7 Example where silver fluoride followed by stannous fluoride was used to treat lesions extending subgingivally in an upper second premolar. (a) Radiograph showing two distinct subgingival carious lesions on the distal surface. (b) Appearance following the AgF/SnF 2 treatment. (c) One year following restoration of the site with GIC. (d) The same restoration 2 years and 4 months later using no preparation and delayed restoration technique. (Reproduced with permission and courtesy of Dental Outlook. 73 ) three-monthly application of a ppm fluoride varnish; (3) three-monthly applications of a 4% chlorhexidine varnish; (4) three-monthly applications of a 5% NaF varnish; and (5) annual application of a 38% silver diamine fluoride. 71 While there is limited evidence for the use of calcium phosphate preparations as an adjunct to a fluoride containing toothpaste in the prevention of root caries, that which is available comes from high-risk populations with xerostomia. This group comprises a very large group of the frail elderly population, making calcium phosphate preparations another chemical to consider in a preventive regime for root surface lesions. 71 The availability of arginine in toothpastes and recent developments in readily available high ph toothpaste warrant close attention as research into their effectiveness unfolds. Similarly, Xylitol is yet another preventive option available that could be included in a preventive regime. With the large range of options available to prevent root surface caries, designing a preventive regime for any particular patient is complex. Dental practitioners need to identify simple regimes that patients can adhere to. The decision to choose a particular regime should be guided by the risk profile of the patient after a full assessment of the patient s diet, saliva, oral hygiene, caries experience and current preventive regime. In the elderly, any one of these risk factors can be so profoundly abnormal that it can overwhelm all others. In addition to efficacy of agents, issues of availability, affordability and complexity need to be considered when designing a preventive regime for a particular patient. The concept of root surface protection using a thin film of flowable glass ionomer cement such as Fuji VII is also an approach worthy of consideration. 72 This technique described by Ngo creates a physical barrier as well as a fluoride reservoir in these highly susceptible sites. There is an inevitable focus on root caries in older people; however, coronal lesions in the elderly are also common. These coronal lesions occur mainly as caries associated with restorations. They most commonly occur on the surface of a tooth adjacent to a restoration, at its gingival extent, and in association with overhanging margins. 71 This places an emphasis on the importance of excellence in operator technique in the placement of restorations Australian Dental Association 103

10 A Lewis et al. CONCLUSIONS The Australian Government has invested in improving the oral health of elderly people in RACFs by sponsoring the Better Oral Health in Residential Care Program in The need to develop models of care that improve access to dental treatment for the frail and functionally dependent elderly is important. Involvement of dental hygienists/oral health therapists in models of care has merit. Treatment of the frail elderly can be a challenge. The inability to maintain oral health, poor oral hygiene and polypharmacy causing SGH may result in an oral environment conducive to rapid tooth destruction. Preventive interventions need to be tailored to a patient s changing requirements. New restorative materials better able to withstand extreme oral conditions need to be devoloped. Silver fluoride techniques show promise as a new approach. ACKNOWLEDGEMENTS The authors gratefully acknowledge the valuable comments and assistance with this article by Dr Graham Craig, Professor Clive Wright (Centre for Education and Research in Ageing) and Dr Keith Baetz. DISCLOSURE The authors have no conflicts of interest to declare. REFERENCES 1. Australian Government. Department of Health and Ageing. Encouraging Better Practice in Aged Care (EBPAC) Initiative. Evidence Translation Projects Funding Guidelines and Invitation to Apply Funding Round 3, Access Economics. The future of aged care in Australia Australian Government. Department of Health and Ageing. Discussion Paper. Development of the aged care workforce compact Slade GD, Spencer AJ, Roberts-Thomson KF. Australia s dental generations: the National Survey of Adult Oral Health AIHW cat. no. DEN 165. Canberra: Australian Institure of Health and Welfare (Dental Statistics and Research Series No. 34), Unfer B, Braun KO, Ferreira AC, Ruat GR, Batista AK. 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