An Exploratory Investigation of the Oral Health of Hospitalised Older People

Abstract

The poor oral health of older people in Australia was well documented 20 years ago in the premier ageing oral health study, The Adelaide Study of Nursing Homes, published in 1999. Since then this study has been replicated across Australia with similar conclusions, the oral health status of older people living in residential care is poor. Access to fluoride and improvements in preventive dentistry have resulted in natural tooth retention and a decrease in the number of fully edentulous older people. Coupled with increased life expectancy and medical complexity there is recognition that this change in dentition status has the potential to impact systemic health. Poor oral health usually results from inadequate daily oral hygiene and leads to a heavy bacterial plaque load that increases the risk of periodontal infection, dental caries as well as aspiration pneumonia. Older people are often late dental attenders presenting only when symptomatic, and with significant barriers preventing them gaining access to dental care, both physical and financial. In this thesis I highlight the poor oral health status of older people from community and aged-care domiciles admitted to an acute care tertiary hospital, The Queen Elizabeth Hospital (TQEH), in Adelaide, South Australia and make recommendations to improve access to dental care through an acute hospital admission. The majority of participants in this study had a potential source of infection in their mouths. Dental decay, periodontal disease and oral mucosal conditions were common. Three-quarters of the participants were considered in need of a comprehensive dental consult. Dentate (with teeth) and edentulous (without teeth) participants were just as likely to have dental conditions that required referral to the dentist. Attempts were made to identify general and medical conditions associated with poor oral health that could assist physicians to ascertain who required referral to the dentist. Admission polypharmacy was common and patients who took more than five medications daily were more likely to require referral to the dentist, but apart from this, it was not possible to categorise patients requiring dental referral based on their admission and in-hospital health characteristics. This was a cross-sectional study which limited the implications that can be drawn from the results. A 6-year retrospective medical record audit revealed that it is not common for older patients admitted to TQEH to be referred to the on-site dental clinic. The results must be viewed in context, the focus of the hospital admission is to restore patient’s health so that they are well enough to be discharged home. However, given that many patients experienced an extended length of stay of over 20 days, there could be some consideration to consulting a dentist as part of total patient care. This study was subject to significant limitations particularly in terms of study design and participant recruitment that resulted in it being an exploratory, pilot style study. The difficulties in participant recruitment led to a survey of Australian orthopaedic surgeons to explore their opinion of the requirement for antibiotic prophylaxis (AP) prior to dental assessments for patients with prosthetic joint replacements. The majority believe AP is required indefinitely and don’t recommend dental assessment prior to elective joint replacements. The Australian Arthroplasty Society (ASA) in 2016, published new recommendations on the use of AP for dental treatment, thereby aligning with the Australian Therapeutic Guidelines and international recommendations. This thesis highlights that conducting dental research in a medical setting is difficult, but these results, including the limitations, can be used to develop robust, longitudinal studies that have the potential to significantly change oral health delivery models for older people.