Faced with an ageing population, Dr Janet Wallace is finding new ways of offering oral health care to the elderly, writes Samantha Trenoweth.
Dr Janet Wallace wants to revolutionise the way we provide oral health care to older Australians. “There is a dire need for oral health services in residential aged care facilities, particularly preventative oral health services,” she explains.
Dr Wallace, a registered oral health therapist with qualifications in dental therapy, dental hygiene, business management, tertiary teaching and a PhD in oral health, acknowledges that many have tried and failed to deliver better oral health to Australia’s increasing population of elders. However, with the help of her students and colleagues at the University of Newcastle, she believes she has devised a system that’s inexpensive, efficient and, most crucially, works.
Dr Wallace wasn’t always a revolutionary. Born in Brighton, United Kingdom, she was the eldest of four children. She moved to Sydney with her parents at age 11 and was, she concedes, perhaps a little bossy—“a kid who liked to take control”—but never one to overthrow a system.
“I’ve always liked to find a solution to things though,” she admits. “I don’t like it when people say that something isn’t possible. I tell my students and my family [of two children and three grandchildren] that there’s only one thing in life you can’t fix and that’s death. To every other problem, there is a solution.”
It was while she was working in a conjoint position at University of Newcastle, in 2008-’09, that Dr Wallace first understood the immensity of the oral and dental health problem facing older Australians—particularly those in residential care—and she resolved to fix it.
She was setting up a student placement program in aged care facilities on the New South Wales Central Coast and, she says, “because of the feedback the students provided and because of what I saw myself in the facilities, I realised there was an enormous need for preventative oral health care with links and referral pathways to dentists, and I became passionate about trying to provide this”.
“Good oral care reduces the risk of aspirational pneumonia, it can reduce admissions to hospital, it makes residents more comfortable, it enables them to eat a wider variety of foods and enjoy their food more,” she explains. “It’s about quality of life. It has the potential to create a lot of positive outcomes.”
However, in spite of good intentions, there was not a lot of good oral care in evidence in the facilities she visited. The staff needed help and the student placement program was a start in assisting them. It rolled out to around 17 local facilities with the aim of “addressing some of the significant issues that we knew existed in residential aged care and also giving the students an experiential learning opportunity to increase their knowledge and skills”.
Determined to investigate the problem further, Dr Wallace undertook PhD studies that investigated and evaluated the student placement program over five years. She identified the challenges that the program faced and came up with some innovative solutions. “An aged care facility is a challenging environment to be a student in,” she points out. “Imagine being a very young person, who possibly doesn’t have any elderly relatives in their immediate family, walking into a facility where people have dementia and Alzheimer’s, where people are sick and dying. It can be very confronting and some students had huge issues, initially, with nervousness and feeling overwhelmed by it.”
Dr Wallace realised that if the placement program was to succeed, students needed to be better prepared not just for the technical aspects of work in these facilities, but for the emotional impact as well. In response, she developed a day-in-the-life training DVD to help them.
The DVD made a world of difference. Students who watched the DVD settled into the placement in half the time, felt comfortable with the work and valued the experience more than those who didn’t. “These placements are still part of our Bachelor of Oral Health Therapy degree here at Newcastle,” she says, “and now all students watch the DVD.”
A number of her students have also gone on to work in aged care facilities after graduation. “Working in aged care is not for everyone,” Dr Wallace admits, “but if you’ve been on a student placement and you’ve had some first-hand experience, then I think you’re more likely to pursue that after you graduate.”
And that is crucial to Dr Wallace’s revolution because she ultimately wants to see an oral health therapist or dental hygienist in every aged care facility in Australia. She has already made a start. In 2013, she received a grant from Medicare Local Erina to put a qualified hygienist into five facilities on the Central Coast and investigate the results.
“That research project was very successful,” she says. “It showed us that we need someone in these facilities who has an oral health background with
a preventative focus—that we need dental hygienists and oral health therapists—because, without them, oral health in a lot of facilities is still managed in an ad hoc fashion.”
Out of that research, Dr Wallace has developed what she calls the Senior Smiles model. The linchpin of the model is the dental hygienist or oral health therapist who she describes as a “boundary spanner” and who becomes the link between centre staff and management, residents, their families and public and private dentists outside the facility.
“In the Senior Smiles model, the hygienist or oral health therapist only needs to visit the facility perhaps once a week. They do oral health education, risk assessments and care plans. They look at what sort of toothpaste the residents need, check whether they need something for dry mouth, whether they are in pain, whether they need a referral to a dentist, and so on. Once they’re embedded in the facility, they can manage things like consent, medical history, appointments, even transportation, and that makes the dentist’s role so much smoother.
“The oral health therapist will have a referral pathway set up to a private practitioner within the area and to the public sector if the resident qualifies for public sector dentistry.”
The Senior Smiles model is already up and running in a handful of Central Coast and Hunter Valley facilities, and negotiations are underway with health funds in the hope of introducing the model more widely.
Dr Adam Barrett at Seascape Dental at the Entrance, also on the Central Coast, has been working with the program. Dentists from his practice have travelled to the facility, with portable equipment, to see residents who couldn’t be transported to the surgery. For those who could travel, Seascape Dental provided a transport service to and from the practice at no cost to the resident. “He has been fantastic,” she says.
Dr Wallace speaks highly of a previous model, Better Oral Health in Residential Aged Care, which provided training resources for carers, and Senior Smiles still uses many of those resources today. However, she believes the ‘train the trainer’ model was only partially successful because “there are many, many demands on staff in residential aged care facilities and they do their best but they can’t do everything”.
“My model goes one step on from that,” she insists. “Facilities have physiotherapists and podiatrists who go in. To manage oral health, we need oral health practitioners to go in too. We need professional people who are trained in that area.”
The Senior Smiles model is much needed now and, she points out, demand is going to escalate quickly in years to come. “There is already a huge demand and we have an ageing population. That is something we need to look at and plan for on a long-term basis. Senior Smiles is a model that works and can be transported anywhere. It’s just a matter of getting those key people involved, especially practitioners who are interested in oral health for the elderly.
“Elderly people are in their most vulnerable stage of life and being able to provide them with a level of preventative oral health care in the facility is of great benefit because we know that oral health is linked to good general health.
“By enabling that on a day-to-day basis, by getting the residential care facility staff trained up to sustain that, and giving oral health a higher profile within the facility because you’ve got someone in there regularly, and then by building that link with private and public sector dentists, it creates a complete model of care.”
In the immediate future, Dr Wallace is negotiating with more centres and health funds to take on Senior Smiles, and has just expanded the student placement program to the geriatric rehabilitation ward at Woy Woy Hospital. “I really am committed to getting oral health practitioners into all aged care facilities and hospital wards,” she says.
“It’s my job but it’s also something I’m passionate about. There are so many things I want to achieve that I can’t imagine ever retiring. I’ll probably be the oldest academic in history.”