Oral health improvement strategy for priority groups

Chapter Nine Recommendations: What we will do Next

This chapter makes recommendations and describes how they relate to each of the priority care groups.

9.1 Assessment of Need

Smile programmes should incorporate an assessment of an individual's oral health needs.

This will help to establish what care and treatment is needed for each individual patient and will help to plan this.

What should happen now?

9.1.1 Older People and those with Special Care Needs

• For dependent people being cared for at home, the District Nurse (DN) should provide the initial link between the medical team and local dental teams, providing a first point of contact for an preliminary assessment of oral healthcare needs which would facilitate referral to a dentist for a full clinical examination.^E
• For care home residents, an oral health risk assessment should ideally be undertaken within 48 hours of admission, as part of the overall health assessment in line with the NHS QIS Best Practice Statement. This risk assessment can be undertaken by an appropriately trained nurse or carer. Any issues of concern should trigger an immediate referral to a dentist for a full clinical assessment.
• Arrangements should be in place for patients to access routine dental care. These should be documented.
• Assessment of oral health needs should lead to the development of an individual care plan which shows the daily oral healthcare support needed by the dependent adult. The process should incorporate an ongoing review of patient needs on a regular basis.

9.1.2 Homeless People

• All homeless people should have the opportunity to have their oral health needs assessed by referral to a dentist.^E
• A basic care plan should be provided to homeless people attending for dental care, a copy of which should be retained by the patient and updated at dental visits.

9.2 Evidence-based Prevention

Smile programmes should should be underpinned by effective, evidence-based activity.

It is important that people have the opportunity to prevent dental disease in ways which we know are effective.

What should happen now?

9.2.1 Older People and those with Special Care Needs

• Future revisions of the national care standards for care homes for older people should reflect the impact of sugar consumption on the development of dental caries.
• Prevention of oral disease and the maintenance of good oral hygiene amongst dependent people should be an integral part of the routine personal care undertaken by care staff.
• All residents should have the opportunity to brush twice daily with a fluoride toothpaste containing at least 1,350 ppm fluoride. Daily oral care should be documented.
• Managers of care establishments should offer a range of healthy food choices which will allow clients to limit the amount and frequency of consumption of sugary foods and restrict sugary foods to mealtimes, whilst taking account of the needs of the nutritionally vulnerable.
• To avoid dehydration, clients should be encouraged to drink water in preference to sugar-containing drinks.
• Those at particularly high risk or with special needs should use a fluoride mouthwash^F on the advice of a dentist or other healthcare professional (0.05% Na F) in addition to toothbrushing.
• Those at high risk of caries should have fluoride varnish professionally applied twice yearly (2.2% F).
• Those with active crown or root decay should have the opportunity to have 2,800 or 5,000 ppm fluoride toothpaste prescribed professionally.
• Prophylactic use should be considered following consultation with a dentist in those at high risk of decay.
• Toothbrushes and interdental cleaning aids should be available to care home residents.
• Those who are ill or disabled should have the opportunity to use Chlorhexidine mouthwashes* (10 ml of 0.2% or 15 ml of 0.12 %) with toothbrushing.

9.2.2 Homeless People

• Homeless people should have the opportunity to brush twice daily with a fluoride toothpaste containing at least 1,350 ppm fluoride.
• Dental packs containing toothbrushes and paste should be distributed at key facilities such as hostels and night shelters.
• Drinking water should be available at key facilities used by homeless people to encourage hydration using non-sugared drinks and to encourage toothbrushing.

9.3 Accessible Information

Smile programmes should ensure that suitably tailored oral health information should be made available to vulnerable individuals and to those who care for them.

People should have access to information which informs them how best to maintain oral health and allows them to take responsibility for their own oral healthcare in the best way possible. Where this is not an option, those caring for them, or with responsibility for their well-being, should have the information they need to provide the best care possible. Staff should know when to refer someone in their charge to a dentist when this is needed.

What should happen now?

9.3.1 Older People and those with Special Care Needs

• NHS Health Scotland, together with the National Older People's Oral Health Improvement Group should support, develop and distribute an information resource focussed on the prevention of oral disease and improvement of the oral healthcare of older people. This should be used by those with responsibility for the care of dependent older people: carers, families, care home managers and relevant organisations.
• Care home managers should be made aware of the NHS Quality Improvement Scotland (QIS) Best Practice Statement (BPS) Working with Dependent Older People to Improve Oral Health.
• Care home managers should ensure that on admission, all care home residents are made aware of oral health issues within the national care standards for care homes for older people.
• Care home managers should work in collaboration with key stakeholders, including Healthcare Improvement Scotland, Scottish Care and corporate care providers to implement the national care standards.
• Supporting resources for other adults with additional care needs should be tailored to take account of the specific needs of younger dependent people.

9.3.2 Homeless People

• Oral health education materials should be available to homeless people at key locations used by homeless people.
• NHS boards should maintain a list of contact details for dedicated drop-in dental care facilities for the homeless and disseminate this to key services for the homeless.
• NHS boards should maintain a list of NHS dentists willing to accept homeless clients.
• Information leaflets and posters providing a list of useful telephone contact details, including NHS 24, local Primary Care Services and local dental care providers, should be displayed at places in which homeless people are accommodated and at local pharmacies.

9.4 Staff Training

Smile programmes should include staff training on key oral health messages and should be provided for all staff caring for vulnerable groups.

Staff caring for dental priority groups who are vulnerable to poor oral health should have access to training on key oral health messages and should be aware of when dental professional help is required. Messages should be reinforced at regular intervals.

What should happen now?

9.4.1 Older People and those with Special Care Needs

• The Salaried Dental Service and oral health promotion teams should play a lead role in the delivery of training to staff with responsibility for caring for dependent people and those with special needs.
• Training for care home staff should be undertaken as part of an ongoing programme and should be based on an appropriate training tool such as "Caring for Smiles" which was developed for this purpose.
• All care home staff, including managers should attend training on the delivery of day to day oral healthcare to residents.
• Oral health champions should be identified to promote ongoing awareness of oral health issues within the care home setting. Such individuals should attend ongoing training to support their role.

9.4.2 Homeless People

• The Salaried Dental Service should continue to play a lead role in services for homeless people, including training in conjunction with oral health promotion teams or oral health champions.
• Oral health champions should be identified from within establishments which work with homeless people and should be offered training to support the oral health of homeless people. This should be based on the Smile4Life Intervention.

9.5 The Right Services

Smile programmes should develop services for priority groups which are flexible and are developed in ways which maximise the contribution of new roles.

We know that making best use of a number of services and using the combined skills of the whole dental team will provide the best approach for preventing oral diseases and improving oral health for vulnerable people.

What should happen now?

9.5.1 Older People and those with Special Care Needs

• NHS boards should work with dental clinical leads to raise awareness amongst key stakeholders of the role of the salaried services in providing dental services to those with special care needs. Such key stakeholders might include non-dental staff such as Public Health Nurses, District Nurses, carers, Social Work staff and voluntary organisations.
• Any future revisions of the national care standards for care homes for older people should highlight the role of the Salaried Dental Service in the provision of oral healthcare care to those who have special care needs.
• Referral protocols should be developed to ensure the smooth and timely referral to appropriate services for those with special care needs.
• Appropriate through care protocols and referral pathways should be developed to ensure a smooth transition to adult services for children with special care needs.
• Dental Care Professionals such as Extended Duties Dental Nurses and Clinical Dental Technicians should play a key role in a preventive programme for older people.
• NHS boards across Scotland should support the employment of Dental Health Support Workers to provide ongoing support in the delivery of oral health messages to care home staff.
• Registered dental staff should continue to provide support for Dental Health Support Workers within the care home setting.
• Dental Health Support Workers should provide a key link between public health nurses and dental health professionals in providing ongoing support on oral health matters to those being cared for at home.

9.5.2 Homeless People

• Community dental services and salaried services should continue to play a key role in encouraging homeless people on low incomes to utilise services.
• NHS boards and local authorities should ensure that dental services are closely aligned with other successful health initiatives and in close proximity to other services used by homeless people if these are provided locally to encourage uptake.
• Local authority staff such as health and homeless outreach teams, hostel staff and public health nurses should play a key role in assisting those who have difficulty in obtaining information about dental services, making appointments to help maintaining continuity of care.
• NHS boards should provide dental drop-in services as required, where homeless people can access an assessment of oral health needs and a care plan based on their individual needs.
• A staged approach to services should be adopted to allow those who are homeless and unwilling to access routine care to access care on an ad hoc basis.