Achieving Consensus on Oral Health in Aged Care: Findings From an Australian e‐Delphi Study

ABSTRACT

Objective

To establish expert consensus on the critical factors shaping implementation of oral health assessment in Australian residential aged care (RAC) using an e‐Delphi approach.

Methods

A modified electronic Delphi (e‐Delphi) process, informed by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, was conducted over two iterative survey rounds to refine expert perspectives. 60 experts were purposively sampled from oral health, aged care, policy, and implementation science. Quantitative responses were summarized with descriptive statistics, while qualitative feedback was analyzed through reflexive thematic analysis.

Results

Consensus was reached on the importance of mandating oral health care in national aged care accreditation standards, embedding oral health into broader aged care policies and requiring systematic oral health assessments as part of routine care. Participants highlighted workforce shortages, insufficient training, limited practitioner access, and organizational readiness as key barriers. Enablers included workforce development, simplified and standardized assessment tools, mobile and outreach dental services, policy mandates, and cultural change recognizing oral health as integral to person‐centered care. Round two resolved areas of initial uncertainty, with consensus achieved on all outstanding items.

Conclusion

This study provides the first consensus‐based priorities for embedding oral health assessment tools in RAC, signaling sector‐wide readiness for reform. Applying the EPIS framework, the findings highlight that enforceable accreditation standards must be paired with workforce training, oral health champions, and practical tools to ensure sustainable uptake. These insights offer an evidence‐informed roadmap for policymakers and service providers, reframing oral health from a peripheral task to a regulated element of clinical governance and quality care.

1. Introduction

The global aged care sector is undergoing substantial demographic and structural changes driven by increasing life expectancy and declining birth rates [1, 2]. By 2050, the proportion of people aged 60 years and older is expected to double, placing significant pressure on aged care systems worldwide [1]. There are growing demands for aged care services due to this demographic shift, coupled with increasing healthcare needs and workforce challenges [3]. The increased demand places pressure on healthcare infrastructure, workforce availability and existing funding models [3, 4]. In response, many countries are restructuring their aged care sectors by placing greater emphasis on person‐centered care (PCC) and implementing policy and funding reforms to support long‐term sustainability [5, 6].

PCC has emerged as a key model in aged care, whereby services are tailored to the unique needs, values and preferences of individuals rather than applying a “one‐size‐fits‐all” approach [6, 7]. PCC is an approach which prioritizes the individual's unique needs, values and preferences in care delivery, fostering dignity, autonomy and engagement in decision‐making [6, 7]. Growing awareness of human rights and dignity in aging has heightened scrutiny of aged care practices, leading to regulatory changes and quality improvement initiatives [8]. Rights‐based reforms have been adopted internationally, with countries such as Canada, the United Kingdom (UK) and the European Union implementing enhanced aged care regulations to promote PCC and accountability in service delivery [9, 10, 11]. The UK's Care Quality Commission (CQC) enforces strict PCC guidelines and Canada's long‐term care reform efforts focus on minimum staffing levels and improved oversight to ensure high‐quality care [9, 11].

In Australia, the Commonwealth Government is embedding a rights‐based approach in its new Aged Care Act, introducing a “Statement of Rights” to ensure older individuals receive care which upholds their autonomy and dignity [12]. The Aged Care Quality and Safety Commission is set to implement strengthened Quality Standards from 1 July 2025 [13]. This reform aims to enhance care quality and safeguard resident well‐being by setting clearer expectations for health care providers [13]. The updated standards introduce more rigorous requirements in key areas, including food and nutrition, dementia care, diversity, governance and clinical care [13]. The reform focuses on improving accountability, ensuring PCC and aligning aged care practices with contemporary evidence‐based best practices to address evolving needs within the sector [14]. Despite these efforts, aged care providers continue to face mounting challenges related to workforce shortages, increasing public expectations for accessible, high‐quality care and difficulties integrating reforms into daily practice [15].

While reforms aim to enhance the overall quality of aged care services, a critical yet often overlooked component of PCC is oral health [16]. The World Health Organization (WHO) describes oral health as the mouth, teeth and surrounding structures that support essential functions such as eating, speaking and breathing [17]. It also includes psychosocial aspects like self‐confidence, overall well‐being, and the ability to interact socially and work without experiencing pain, discomfort or embarrassment [17]. Neglecting oral health can lead to pain, discomfort and social isolation, adversely affecting quality of life [17]. As a fundamental component of overall health, oral health plays a critical role in influencing physical, mental and social well‐being [17]. However, despite its importance, oral health remains a low priority in aged care policy and practice, with multiple inquiries and reviews reporting systemic neglect [5, 18, 19].

In Australia, a national investigation into the quality and delivery of care in the aged care sector was undertaken, known as the Royal Commission into Aged Care Quality and Safety. This inquiry identified significant gaps in oral health care within residential aged care (RAC), attributing deficiencies to workforce shortages, inadequate training and a lack of accountability [5]. While Australia's National Oral Health Plan (2015–2024) recognized older adults as a priority group due to their heightened risk of oral diseases, several performance indicators reveal persistent challenges [20, 21]. The prevalence of untreated caries and periodontitis among adults had worsened during the plan period, food avoidance due to dental problems has increased, and more people report discomfort with their oral appearance [21]. Fewer adults have received a dental check‐up in the past 2 years, and access to fluoridated drinking water remains inconsistent [21]. Despite the Australian Aged Care Quality Standards requiring providers to monitor oral health and facilitate access to dental services, resource limitations, workforce shortages, and insufficient organizational readiness continue to hinder daily oral hygiene practices and restrict access to professional dental care [22]. The disconnect between policy intent and practical implementation highlights the urgent need for targeted investment, workforce development and systemic reforms to embed oral health as a fundamental component of RAC.

Despite recognition of the importance of oral health in RAC, its integration into routine care remains inconsistent. Tools such as the Oral Health Assessment Tool (OHAT) provide non‐dental professionals with a structured method to identify oral health risks and facilitate timely referral [23]. However, their adoption is often hindered by workforce and organizational barriers. Implementation science provides useful frameworks for addressing these challenges by examining the factors that influence the uptake of evidence‐based practices [24]. The Exploration, Preparation, Implementation, Sustainment (EPIS) framework offers a lens for understanding the complexities of implementing oral health assessment tools in RAC [25]. In particular, the ‘Preparation’ phase is critical, as it focuses on assessing organizational readiness, identifying key barriers and facilitators, and engaging stakeholders to inform implementation strategies [25]. In complex healthcare settings, such as RAC, where multiple professional groups contribute to oral healthcare, achieving a shared understanding and consensus on key implementation factors is essential for driving meaningful change. Consensus refers to a shared agreement among experts on critical issues, ensuring implementation efforts are informed by collective knowledge rather than isolated perspectives [26]. Without a clear consensus on which factors are most critical for successful implementation, developing evidence‐informed policy and practice reforms remains a challenging task. The e‐Delphi method offers a systematic approach to refine expert opinions and achieve consensus through a structured, multi‐round survey process [27]. This method is particularly useful in identifying and prioritizing key implementation factors, helping to bridge the gap between research and practice in embedding oral health assessment tools into routine RAC care.

Although this study is situated in Australia's aged care reform, its findings have broader policy implications. Focusing on oral health as an often overlooked yet essential element of healthcare, the study addresses a governance blind spot and offers insights relevant to international policy debates on accountability, standards, and workforce reform.

Using the EPIS framework and the e‐Delphi method, this study aimed to engage experts from aged care, oral health, policy and implementation science to systematically evaluate the barriers and facilitators to implementing oral health assessment tools in Australian RAC facilities. The primary goal is to reach consensus on the most critical factors affecting their uptake, ensuring a clearer understanding of the challenges and opportunities in this context. By establishing consensus, the study will provide a foundation for developing evidence‐based strategies to improve the integration of these tools into routine care, ultimately enhancing oral health outcomes for older adults residing in RAC.

2. Methods

2.1. Study Design

An evidence‐informed modified electronic Delphi (e‐Delphi) method was used to reach consensus among experts on the implementation of oral health assessment tools in RAC (Figure 1). The e‐Delphi method was chosen for its structured, iterative approach to refining collective expert judgment and was deemed appropriate for synthesizing diverse perspectives across oral health, aged care and implementation science [28]. To ensure methodological rigor and transparency in the e‐Delphi process, this study adhered to the Guidance on Conducting and Reporting Delphi Studies (CREDES) framework [29].

FIGURE 1.

Modified e‐Delphi methodology. [Color figure can be viewed at wileyonlinelibrary.com]

2.2. Expert Panel

Participants were purposively sampled to ensure diverse representation across oral health, aged care, policy, health services research and implementation science in Australia. Eligible participants had relevant professional experience in at least one of these domains and included dental practitioners, aged care managers, registered nurses, personal care workers, policymakers, academic researchers and health service providers. To achieve national coverage, invitations were extended to experts from all Australian states and territories, drawn from both rural and regional settings, and representing public and private sectors. Participants were recruited nationally through professional networks, national organizations and referrals. 60 experts were invited to participate and received an email outlining the study objectives and e‐Delphi process. A desired sample size of 30 participants was set to allow for meaningful engagement and consensus‐building, while ensuring diverse representation across stakeholder groups.

2.3. Survey Development

A reflexive qualitative enquiry of the Royal Commission into Aged Care Quality and Safety transcripts were undertaken to explore systemic barriers and facilitators related to oral health in RAC. Key themes were synthesized and mapped, informing the development of the e‐Delphi survey items. Survey items were drafted by the research team and reviewed by a focus committee consisting of two dental practitioners, one health informatic specialist and three academic researchers with expertise in the aged care sector. The draft survey was piloted with three independent experts to ensure clarity, comprehensiveness and usability within the online survey platform Qualtrics [30]. Feedback was used to refine wording and item structure. The survey was then disseminated to invited participants using Qualtrics [30].

2.4. Delphi Rounds

The CREDES framework for conducting and reporting Delphi studies (Table 1) suggests that while surveys may involve between one to five rounds, most studies included in their systematic review utilized two or three rounds [29]. The researchers agreed that a consensus on the barriers and facilitators to implementing oral health assessment tools in RAC could be achieved in two to three rounds.

TABLE 1.

CREDES checklist for reporting a Delphi study.

Item	Description	Page number
1. Title and Abstract	Clearly identify the study as a Delphi study in the title and abstract.	1–2
2. Rationale for Delphi	Explain why the Delphi method was appropriate for your study aims.	8
3. Objectives	State the study objectives clearly.	7
4. Expert Panel	Describe participant selection criteria, recruitment methods, sample size, and participant characteristics.	8
5. Number of Rounds	Specify how many Delphi rounds were conducted and provide a rationale.	9–10
6. Questionnaire Development	Explain how the items were developed (e.g., based on literature, qualitative findings, expert input).	9
7. Consensus Definition	Define what was considered consensus (e.g., ≥ 75% agreement). Justify this threshold.	10
8. Data Collection and Analysis	Describe how data were collected, analyzed, and used to determine consensus.	10–11
9. Feedback Between Rounds	Report how feedback from previous rounds was shared with participants.	9–10
10. Ethical Considerations	Mention ethics approval, informed consent, and data confidentiality measures.	11
11. Results	Present the final consensus items and summarize participant characteristics and responses.	11–15
12. Discussion and Limitations	Discuss implications, strengths, limitations, and how the findings may be applied.	15–18
13. Funding and Conflicts of Interest	Disclose funding sources and any potential conflicts of interest.	1

2.4.1. Round One

Round one included structured Likert‐scale items (Strongly Agree, Somewhat Agree, Neither Agree nor Disagree, Somewhat Disagree, Strongly Disagree) and ranking exercises. These were organized under key themes, including policy and regulation, funding models, organizational readiness, systematic oral health assessment, models of care, general care plans and communication. Participants were invited to provide qualitative, open‐text feedback to elaborate on their responses regarding the barriers and facilitators to implementing oral health assessments in RAC. This input informed the refinement of round two items and helped identify why responses differed by professional background, providing deeper insight into areas of agreement and disagreement.

2.4.2. Round Two

Round two provided participants with a summary of items from round one that did not achieve consensus, alongside refined or reworded items for re‐rating. To reduce ambiguity and encourage more definitive responses, the “Neither Agree nor Disagree” option was removed in this round. This allowed participants to reconsider their positions following the group‐level feedback and move toward a consensus. No qualitative input was requested in round two, as this had been comprehensively explored during round one.

2.5. Consensus Process

Consensus was defined a priori as ≥ 75% of participants rating an item as “Agree” or “Strongly Agree” on a Likert scale, or “Somewhat Disagree” or “Strongly Disagree” for items intentionally worded in the reverse to allow agreement with a negatively worded statement. The 75% threshold was selected to balance inclusivity with methodological rigor, consistent with previous Delphi studies [29, 30]. Sensitivity to panel attrition was considered acceptable, as consensus levels remained strong and broadly distributed across professional groups.

2.6. Data Analysis

Quantitative data from both e‐Delphi rounds were collected using Qualtrics and exported for analysis in IBM SPSS Statistics (Version 29) [31, 32]. Descriptive statistics, including frequencies, percentages and mean scores, were calculated for each item to assess overall levels of agreement. Comparative analysis across rounds was conducted to identify shifts in participant responses and areas where consensus was achieved or remained unresolved.

Qualitative feedback was captured through open‐ended questions included in round one and analyzed using inductive reflexive thematic analysis, independent of the EPIS framework. This approach allowed themes to be generated directly from participant responses without imposing a priori theoretical categories. All written responses were exported to Microsoft Excel, coded inductively and then synthesized into overarching themes describing barriers, facilitators and implementation needs. Initial coding was undertaken to identify recurring concepts, which were then grouped into preliminary categories and refined into overarching themes capturing the key barriers and facilitators influencing implementation.

Triangulation occurred through an integrated synthesis process. Themes generated from qualitative analysis were used to refine and clarify round two items and to interpret areas of divergence or uncertainty in the quantitative findings. Qualitative insights were then aligned with the corresponding quantitative patterns to provide contextual explanation for why agreement strengthened, weakened, or remained variable across rounds.

2.7. Ethical Considerations

Ethical approval was obtained from the University of Queensland Human Research Ethics Committee (2024/HE001097). All participants provided informed consent prior to participating. Data confidentiality and anonymity were maintained throughout the study, and responses were de‐identified for analysis and reporting.

3. Results

Of the 60 participants invited to participate in the study, 30 consented. Three did not complete the round one survey and were excluded from further analysis, resulting in 27 eligible participants. Participants represented a diverse range of backgrounds, including aged care, policy, health services research and implementation science in Australia. Most were oral health professionals, policy advisors and nursing staff working in RAC or involved in aged care research and policy advocacy.

All 27 eligible participants were invited to complete round two of the e‐Delphi survey. Of these, 25 completed the second survey, with two participants lost to follow‐up. Recruitment and retention across both survey rounds are illustrated in Figure 2.

FIGURE 2.

Participant recruitment and retention flowchart. [Color figure can be viewed at wileyonlinelibrary.com]

No meaningful differences were identified between professions in levels of agreement across Delphi items. Where variation existed in round one, qualitative explanations showed that differences reflected role‐specific perspectives rather than systematic divergence. As consensus thresholds were reached across all professions in round two, this suggests that the panel's final agreement reflected multidisciplinary alignment rather than discipline‐specific influence.

3.1. e‐Delphi Round One

Participants responded to 33 questions. Of these, 25 were structured as Likert‐scale items designed to assess levels of agreement on key implementation strategies. Among the structured items, 21 (84%) met the predefined consensus threshold of ≥ 75% agreement, reflecting strong agreement among participants on key strategies for enhancing oral health in RAC (Figure 3). Unanimous consensus (100%) was achieved on several foundational policy recommendations, including mandating oral health care within aged care regulations, integrating oral health into broader aged care policy frameworks, and embedding oral health standards within national aged care quality frameworks (Table 2).

FIGURE 3.

Delphi round one—stakeholder agreement on oral health implementation in residential aged care (n = 27). [Color figure can be viewed at wileyonlinelibrary.com]

TABLE 2.

Statements that reached ≥ 75% consensus by themes (Delphi round 1 and 2).

Item number	Survey statements
a = Round 1
b = Round 2
Theme: Policy and Regulatory Frameworks
1a	Mandating regular oral health care as part of residential aged care regulations is important for improving residents' oral health outcomes.
2a	Integrating oral health care into broader aged care policies, alongside other health areas such as nutrition and mobility, is important for improving resident well‐being.
3a	Policy changes (e.g., mandating oral health care or integrating oral health care into aged care standards) are important for prioritizing oral health care in residential aged care settings.
4a	Incorporating oral health standards, including regular oral health assessments, into national aged care quality frameworks is important.
5a	Making oral health assessment a mandatory reporting requirement would positively impact the oral health of aged care residents.
6a	Including oral health care outcomes as a performance metric in residential aged care facility accreditation is important.
1b	Most residential aged care facilities currently have the necessary resources (training, policies, staff and time) to implement oral health assessment tools effectively.
2b	Most residential aged care facilities lack adequate funding and workforce capacity, which limits their ability to implement oral health assessment tools.
Theme: Funding Models and Resource Allocation
7a	Integrating oral health assessment into broader aged care funding systems is important for improving access to oral health care services for aged care residents.
8a	The current funding model for providing oral health care in residential aged care settings is effective.
9a	Incorporating oral health care into residential aged care accreditation processes (like other health services e.g., nutrition) is important.
10a	Oral health care should be included under Medicare to address the oral health needs of aged care residents.
Theme: Organizational Readiness and Staff Training
13a	Leadership support improves organizational readiness for oral health care initiatives.
14a	Staff training in oral health care is critical for improving readiness to implement oral health assessment tools.
17a	Staff turnover impacts the consistency of oral health assessment and oral health care in residential aged care.
3b	Digital training of oral health assessment tools for aged care staff is most effective when supplemented with hands‐on practical sessions.
4b	Digital oral health training should be introduced as a mandatory component of professional development for aged care staff to support ongoing skill development and competence in oral health care.
10b	Simplified oral health assessment tools and checklists would encourage greater compliance among aged care staff.
11b	Digital tools for oral health assessment would reduce time constraints and increase compliance.
12b	Oral health assessments should be integrated into general care plans to reduce time barriers.
13b	Increasing staffing levels and workload support for registered nurses would improve the frequency and quality of oral health assessments.
14b	Upskilling nursing assistants and personal care workers in implementing oral health assessments would help mitigate time constraints.
Theme: Systematic Oral Health Assessments
18a	Evidence‐based oral health assessments are important for improving the oral health outcomes of aged care residents.
20a	Resource constraints are a significant barrier to implementing systematic oral health assessments in residential aged care facilities (e.g., staffing shortages, funding limitations, time constraints, and training gaps).
5b	Establishing a national standard would provide clear guidelines on the timing and frequency of oral health assessments, ensuring residents receive regular and appropriate oral health care regardless of their location or provider.
6b	A one‐size‐fits‐all approach to oral health assessments in residential aged care is not effective. Oral health assessments should be risk‐based and personalized.
7b	Residents at high‐risk for oral disease (e.g., those with cognitive impairment, poor oral hygiene, or complex medical conditions) should receive a oral health assessment every 3 months.
8b	A bi‐annual (6‐month) oral health assessment is sufficient for aged care residents who are low risk for oral disease.
9b	Annual (12‐month) oral health assessments should be the minimum requirement in residential aged care.
Theme: Integration of Oral Health into General Care Plans
22a	Integrating systematic oral health assessments into daily care routines in residential aged care is feasible.
23a	Systematic oral health assessments should be conducted by non‐dental professionals in residential aged care facilities with support from dental professionals.
Theme: Collaboration and Communication
25a	Collaboration between dental professionals and residential aged care staff is important in ensuring effective oral health care for residents.
26a	The lack of shared understanding of roles between dental professionals and residential aged care staff impacts oral health care for residents.
Theme: Models of Care
27a	Embedding oral health practitioners within residential aged care facilities would improve residents' oral health (e.g., dentists, dental hygienists, oral health therapists).
28a	Ongoing support and training from oral health practitioners is important for residential aged care staff to enhance collaboration and improve oral health care.
29a	Which onsite preventive care model do you believe would be most beneficial for improving residents' oral health care in residential aged care?
15b	All residential aged care facilities should be mandated, as part of accreditation standards, to ensure residents have access to either an embedded oral health practitioner or regular outreach dental services.
16b	Residential aged care facilities should be mandated to document and report how they provide residents with access to oral health care as part of accreditation requirements.
17b	Embedding an onsite oral health practitioner in Residential aged care facilities would improve timely detection and management of oral health issues, leading to better overall oral health outcomes for residents.
18b	Mobile outreach dental services should provide routine oral health assessments in addition to treatment‐based visits to support ongoing oral health monitoring in Residential aged care facilities.

Four items did not meet the consensus threshold in round one, indicating variability in perspectives or uncertainty regarding implementation. These items related to perceptions that RAC facilities were unprepared to implement oral health assessment tools, the effectiveness of embedding digital training modules into aged care staff education, the feasibility of integrating systematic oral health assessments into daily care routines, and whether the time required to complete assessments hindered consistent implementation. In addition to the structured items, qualitative analysis was conducted for seven open‐ended or ranking responses to survey items 11, 19, 24, and 29–33 using inductive, reflexive thematic analysis, with all participants providing responses to these items.

The frequency with which systematic oral health assessments should be conducted generated mixed responses, with no clear consensus among participants. Many emphasized an individualized approach which responded to the residents' circumstances, noting it may “depend on the person's ability to clean their teeth and what they eat,” be “situational depending on the individual and align with care plan updates,” or occur “upon admission to the facility.” When exploring models of care, most participants preferred regularly scheduled dental outreach services, such as mobile oral health practitioners. Fewer supported an embedded onsite practitioner, with cost, feasibility and infrastructure cited as barriers, reflected in comments such as “there's no funding for embedded onsite dental professionals” and “where would onsite be housed.”

Workforce knowledge, skill and training were frequently described as insufficient. Participants called for greater staff education on the relationship between oral and general health, with one participant commenting, “staff education about the importance of oral health and general health impacts on the body would be beneficial.” Staffing levels, time and workload were persistent constraints resulting in a deprioritisation of oral health. Participants believed that these challenges were compounded by high turnover and reliance on agency staff, with participants summarizing that facilities are often “time poor” and “short‐staffed.”

Access to oral health practitioners was described as limited by funding, geographic isolation and mobility challenges for residents. One participant reflected, “it is not profitable for dental providers to go to RACFs as its poorly funded.” Organizational and policy barriers included the lack of embedded oral health programs in facility procedures and the absence of mandatory quality indicators. Financial and resource constraints also restricted the capacity to employ dedicated oral health practitioners or purchase necessary equipment. Resident‐related challenges, particularly dementia, cognitive impairment, and resistance to care, were described as making oral care delivery “extremely difficult.” Cultural and attitudinal factors, including low prioritization of oral health by some staff, residents and families, further undermined efforts to provide consistent care.

Despite the barriers described, participants also identified clear facilitators and supports that could enable improvement. Six overarching domains were identified: education and training, funding, workforce expansion, policy and standards, service models and cultural change. Education and training encompassed targeted oral health education packages and ongoing professional development, with one participant recommending “creation of a simple oral health education package covering patient positioning, effective plaque removal, and key oral health issues frequently seen in residents in RACFs.” Funding priorities included sustainable oral health funding streams, expansion of Medicare or a Senior Dental Benefit Scheme and provider incentives, with suggestions such as “federal funding to meet the Royal Commission into Aged Care Recommendations” and a “means‐tested seniors dental scheme.”

Workforce expansion focused on creating dedicated oral health practitioner roles in aged care and delineating roles between nursing and care staff. One participant proposed “a specific role description and position for dental professionals to work primarily with aged care and oversee RACFs”. Policy and standards were recognized as crucial to sustainability, including the integration of oral health into clinical care standards, the requirement for assessments, and the connection of oral care to quality indicators and accountability mechanisms. Service models incorporated mobile and tele‐dentistry, integrated care approaches and embedding dental practitioners within facilities, with participants advocating to “utilize mobile dentistry and establish partnerships to improve access to care.” Cultural change involved a shift in attitudes to recognize oral health as integral to wellbeing, underpinned by “acknowledgement and acceptance of the concrete benefits of good oral health in residents.”

3.2. e‐Delphi Round Two

Following the areas of uncertainty identified in round one, a second round of the e‐Delphi process was conducted to further explore stakeholder perspectives. The researchers re‐evaluated the four structured items that did not achieve consensus in round one and developed 18 Likert‐scale questions to deploy in round two. Applying the predefined consensus threshold of ≥ 75% agreement, all 18 items achieved consensus, demonstrating a strengthened convergence of participant opinions (Figure 4).

FIGURE 4.

Delphi round two—stakeholder agreement on oral health implementation in residential aged care (n = 25). [Color figure can be viewed at wileyonlinelibrary.com]

Consensus was achieved on several core system‐level strategies to support implementation (Table 2). These included mandating oral health assessments as part of national accreditation standards and requiring RAC facilities to document and report how residents are provided with oral health care. Participants strongly endorsed the inclusion of oral health assessments within routine care planning, recognizing the value of embedding oral health into existing workflows.

One item, “Upskilling nursing assistants and personal care workers to implement oral health assessments”, received 76% agreement. While the level of agreement was lower than that of other items, this suggests growing support for leveraging the broader aged care workforce to help alleviate time constraints and enhance the integration of oral health assessments into routine care.

Although the study was not powered for formal subgroup analysis, the descriptive patterns did not indicate systematic differences in agreement across professions. Minor variations that appeared in Round One reflected role‐specific views rather than discipline‐based divergence. Final consensus was reached across all items with mixed representation from all professional groups.

4. Discussion

This study achieved consensus on recognizing that oral health is essential to PCC and a sector‐wide readiness to act. Although accreditation standards and policy levers provide accountability for change, effective implementation in daily practice relies on enablers such as workforce development, oral health champions, and simplified oral health assessment tools.

The most impactful finding from this study was the unanimous agreement that oral health assessments should be mandated through aged care accreditation standards. This marks a substantial shift in how oral health is positioned in RAC, from a peripheral aspect of personal care to a regulated component of clinical governance and resident well‐being. Despite decades of research and advocacy, both locally and internationally, oral health has remained marginalized in aged care practice and policy [16, 17, 22]. Consensus regarding enforceable accreditation requirements provides a mechanism for accountability and creates structural impetus for providers to embed oral health into routine care delivery. This is particularly timely as Australia prepares to implement the Strengthened Aged Care Quality Standards, introducing more explicit expectations around clinical care, including oral health [13].

From a policy reform perspective, accreditation‐linked requirements are among the most powerful levers driving system‐wide change in aged care, shaping organizational behavior, guiding resource allocation and influencing workforce priorities [33]. This mirrors successful reform in other areas, such as nutrition and infection control, where enforceable standards led to measurable improvements in care quality and provider compliance [33, 34, 35, 36, 37, 38]. In contrast, areas without clear accountability, such as continence care and falls prevention, have seen inconsistent implementation despite widespread awareness of their importance [39, 40, 41].

Implementation science demonstrates that policy mandates alone are insufficient for achieving sustainable change, and that key enablers are necessary to support practical uptake [42]. Enablers include building workforce capacity through targeted training and embedding dedicated oral health champions within care teams [42, 43]. Empowering frontline staff with the skills, confidence and support to deliver oral health as part of their routine practice is essential [42]. Support for upskilling personal care workers and integrating dedicated oral health practitioners signals a move toward a more sustainable, team‐based model of care [44, 45]. These findings carry broader implications for health professions education, highlighting the need to strengthen oral health literacy and capability across the aged care workforce to ensure oral health is consistently prioritized. Such an approach moves beyond reliance on registered nurses or external oral health professionals, instead equipping a broader range of staff embedded in RAC to share responsibility for oral health as part of everyday care. This approach is consistent with best practice in other complex care domains, such as dementia and palliative care, where building internal capability and appointing clinical “champions” have improved implementation fidelity and care outcomes [46, 47, 48, 49]. In implementation science, “champions” are individuals within an organization who actively promote, support and drive the uptake of new practices [49]. Future research should examine how workforce models can be adapted, scaled and sustained across diverse aged care settings, evaluating their impact on resident oral health outcomes, staff confidence and the capacity of aged care services to deliver coordinated, consistent and efficient oral health assessment and care.

Beyond workforce enablers, there was support for simplified and standardized oral health assessment tools. These tools provide clear, easy‐to‐follow guidelines for staff with varying levels of clinical expertise to complete oral health assessment. This reflects a pragmatic understanding of the aged care workforce, where time pressures and varying levels of clinical expertise make it difficult to implement interventions [50]. The preference for simple, easy‐to‐use tools highlights the need to align implementation strategies with end‐user capabilities. This reflects a well‐established principle in implementation science, where perceived ease of use and workflow compatibility are key uptake drivers [49, 51]. This contrasts with past system‐wide rollouts, such as electronic health records (EHRs), where poor alignment with frontline realities contributed to poor adoption and disengagement [52]. These findings also reflect international experiences. Countries like Canada and the UK have developed structured oral health standards and clinical guidelines for aged care [53, 54, 55]. However, uptake remains variable. Despite the existence of policy frameworks, implementation has often stalled due to inadequate training, weak monitoring systems and the absence of enabling infrastructure [18, 19, 22, 53]. These findings reinforce international lessons that clear standards, while necessary, are not sufficient. For policy to translate into practice, enabling infrastructure, monitoring systems and workforce investment must accompany regulatory change. This dual focus on policy and implementation is relevant to aged care reforms worldwide.

The consensus achieved through this e‐Delphi study creates a foundation for developing implementation strategies based on implementation science theory. Aged care providers, policymakers, regulatory bodies, educators and researchers should utilize these statements to inform service design, workforce training and quality improvement. These statements have the potential to elevate oral health within aged care, positioning it as a core element of clinical governance, organizational culture and daily care practice. Strategic advocacy will be crucial to ensure that oral health is emphasized within national reform agendas, appropriate funding and workforce planning are secured and awareness supports sustained cultural and policy changes.

This study has limitations that should be considered when interpreting the findings. The expert panel, although multidisciplinary, was primarily composed of oral health and aged care professionals and did not include residents, their families or consumer advocates. Consent to participate was not obtained from medical practitioners or First Nations peoples, which limits the extent to which the findings reflect lived experience perspectives. Additionally, round two did not include open‐ended questions, which may have constrained participants' ability to provide further contextual or explanatory feedback. While this approach is consistent with common Delphi practice, it may have limited the opportunity for additional qualitative insights to inform final consensus. Although some attrition occurred between rounds, participation remained strong, with contributors from a broad range of professional domains, including aged care, oral health, policy, research and allied health, retained across both rounds. While the findings have international relevance, their transferability should be interpreted with caution, given contextual differences in governance, funding and workforce models.

5. Conclusion

This study revealed more than professional consensus. It signals a sector‐wide readiness to move beyond fragmented efforts and take coordinated, scalable action. Future research should focus on developing practical, attainable strategies to support implementation efforts. Co‐designing oral health assessment processes with key stakeholders will ensure they are person‐centered and feasible. Future studies should explore the cost implications and potential implementation efficiencies, the role of digital tools in supporting oral health assessment and continuity of care, and how organizational culture, leadership and change processes influence uptake. Applying implementation frameworks can help guide this work to ensure efforts are systematic, contextually tailored and sustainable across RAC settings. The level of consensus achieved across both e‐Delphi rounds indicates that the sector is no longer debating whether oral health should be addressed in RAC, but rather, how best to operationalize its integration.

Funding

This work was supported by the Australian Dental Research Foundation, PJ‐0000008.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.