Oral health improvement strategy for priority groups

Chapter Seven Discussion

7.1 Older People and those with Special Care Needs

It is important that future oral health improvement programmes and dental services for older people and those with special needs reflect the changing needs of society, including the expectations of a generation of adults, many of whom will retain natural teeth throughout life. Deprivation, cost, access barriers and the low priority placed on oral health by individuals, carers and family have all been cited as factors which may contribute to poor oral health for frail or dependent people, many of whom may also have potentially complex dental care needs. These issues are likely to have a significant impact on demand for dental care, and on the resources and nature of services needed to meet the needs of the population.

Dependent and disabled adults face constraints on health and mobility which may make accessing dental care from the "family dentist" within the community more difficult. Oral health services for such vulnerable adults should therefore be flexible enough to meet their needs in circumstances where they may not be able to access services through traditional routes. The Salaried Dental Services have a key role to play in signposting patients to appropriate services, providing special care dentistry where required, and in providing leadership in the training of staff who provide day-to-day care for frail older people and those with special care needs. Oral Health Educators also have a key role to play in providing training to key staff groups.

Local authorities and NHS boards both play a key role in the delivery of services to such individuals and must work in close partnership to develop high quality services which fully meet the health and social care needs of those with special care needs.

The Single Shared Assessment (SSA) process includes an assessment of health, housing and social care needs, providing an opportunity for streamlining the process of care for individuals. Currently, the Single Shared Assessment makes brief reference to oral health issues and includes "dental services" in the Core Plan Data Set, but with no further guidance on the specific criteria to be measured.

Local SSA protocols for older adults have been developed in local authority/NHS areas. However, there is considerable variation as to whether oral health issues have been included. Subject to successful evaluation of ongoing pilots, consideration should be given to incorporating an assessment of oral health into any future revisions of the Single Shared Assessment.

Despite much good work, oral healthcare for vulnerable people is not always consistently good across Scotland. Policies and protocols for oral health needs assessment and care are not always available within the residential care home setting. Staff training is inconsistent, resulting in a lack of knowledge in relation to oral health and disease, despite a willingness amongst staff to assist residents with oral care. Carers are frequently the gatekeepers to a professional oral health assessment and to routine and specialist dental services. The role of the "informed carer" as gatekeeper to care is particularly important in relation to oral cancer detection and prevention.

Training programmes such as Caring for Smiles provide a valuable resource for dental professionals training care home staff in the delivery of day-to-day oral healthcare. The resource helps to raise oral health awareness amongst carers and to support the delivery of good oral healthcare practice amongst staff working with frail and dependent older people. Work is ongoing with key stakeholders including Healthcare Improvement Scotland, Scottish Care and corporate care providers to ensure successful roll out across Scotland.

The Fife Oral Care Award provides encouragement to key staff to achieve excellence in the provision of oral care to clients and also provides a demonstrable measure of achievement. Such an approach may be helpful in rewarding good practice in oral healthcare across the sector and consideration should be given to adopting this approach more widely across Scotland.

7.2 Homeless People

Those experiencing homelessness are a diverse group including both individuals and homeless families.

Circumstances leading to homelessness, including ongoing physical or mental health issues affect an individual's readiness to engage with services. The experience of homelessness may be either short or long term. Therefore a number of factors will determine the type of support and services which are required to meet the needs of this population. A common risk factor approach will benefit both oral and general health. Community planning processes should take account of the oral health needs of homeless people and oral health promotion should be included in the development of Single Outcome Agreements, NHS Boards' Health and Homelessness Plans and Local Authority Shared Assessments.

Those who find themselves temporarily homeless may be able to maintain links with previous health service providers and access services in the normal way. Here, efforts should focus on supporting people to keep connected with their regular healthcare providers during a short period of homelessness. Continuous dental registration will make it easier for such individuals and families to achieve this.

For those who are experiencing homelessness for an extended period, maintaining links with primary care providers may become very difficult as contact with the former home and associated local health services is lost. Moreover, the lack of continuity of health service provider acts as a major barrier to accessing health and dental health services. For these individuals and families, information on how to access services appropriate to their needs, and the provision of tailored oral health education messages, which recognise the barriers imposed by their current life circumstances, will help homeless people to engage with services which meet their needs and improve their oral health. Support staff in settings where homeless people stay have a valuable role in providing information for clients and signposting clients to dental services.

Stigmatisation and poor self-esteem may make it particularly difficult for vulnerable homeless people to approach health traditional oral health services. Providers of oral healthcare in turn may find it difficult to deal with mentally ill or addicted homeless individuals and may be reluctant to accept such patients for treatment within general dental practice.

There is currently little information on the extent to which general dental practitioners offer care to homeless individuals. The introduction of enhanced payments to practitioners for treating patients from the most deprived postcodes, may encourage dentists to accept more homeless patients for treatment. However, for homeless people, the requirement to produce a full and valid postcode a may still be perceived as a barrier to care within the general dental services.

The Salaried Dental Services therefore play a key role in the delivery of services to special needs groups, including homeless people whose chaotic lifestyles may make it difficult for them to complete their care within a general dental practice setting. It is important that there are dentists able to work closely with health promotion colleagues and who can work to strengthen links with providers of services to those experiencing homelessness.

Good dental health depends on good oral hygiene and the ability to restrict sugar consumption through access to suitable, non-cariogenic foods. For the homeless, maintaining good health, including oral health, often competes with meeting more pressing personal needs. Low incomes restrict food choices, making it more difficult to restrict sugar and to choose foods appropriate to the maintenance of good dental and general health. Lack of access to suitable cooking facilities increases reliance on ready-prepared foods. Access to fresh drinking water may also be limited. Lack of ready access to fresh water encourages reliance on soft drinks and may make tooth cleaning difficult or impossible. Lack of access to suitable cooking facilities encourages increased sugar consumption through unsuitable foods and snacks and soft drinks.

Local actions to improve oral health for homeless people should include measures to make it easier to carry out routine toothbrushing as a means of the delivering fluoride to the teeth to minimise the impact of poor diet and oral hygiene, e.g. the provision of toothbrushes and toothpaste as part of hygiene packs. Staff should be trained to be aware of the importance of oral health and know how to assist people to access key oral health services.

Smoking and excessive alcohol consumption are closely linked to the development of oral cancer and it is important that information is provided to people who are homeless to raise awareness of these links and to encourage smoking cessation and alcohol moderation.

Figure 4. Key Elements of the Core Preventive Programme for Improving the Oral Health of Dental Priority Groups