A consultant in Special Care Dentistry tells us how COVID-19 impacts the oral health of older people and how dentists should work with medical and social care providers to protect older patients.
The COVID-19 pandemic is having a negative impact on the oral health of many older people.
There are significant challenges. We've seen that patients who are being treated in hospital with COVID-19 are more likely to experience poor oral health. Oral care standards may also be slipping in care homes, where inadequate supplies of personal protective equipment (PPE) may be making staff anxious about cleaning mouths. Access to urgent dental care for those who are shielding may also be more challenging. However, there are potential roles for the dental team to help support the care of older people.
Supporting mouth care during COVID-19
People being treated for COVID-19 will often spend long periods on oxygen, this can cause the mouth to become very dry and sore, and become coated with debris. Patients who have been ventilated may develop pressure ulcers on their lips, tongue and gums from endotracheal tubes. It is important that staff caring for these patients carry out regular mouth care and that this continues when they are discharged from the hospital.
Public Health England have released
mouth care guidance for people with COVID-19. As the virus is spread via the mouth through respiratory droplets and coughing, all staff providing mouth care require PPE including gloves, plastic apron, fluid-resistant surgical mask and eye protection.
"Given the concerns about standards of mouth care in care homes, dental practices could be remotely partnered with local care homes to champion oral health"
We've seen many hospital dental nurses being redeployed to medical wards, including intensive care settings. Many have been championing the importance of mouth care within their new teams, as well as supporting general care needs.
I'd argue that, given the concerns about standards of mouth care in care homes, dental practices could be remotely partnered with local care homes to champion oral health. This would help protect older people at this, particularly vulnerable time.
Providing urgent dental care to older people
Community Dental Services are generally managing the urgent dental care needs of older vulnerable people, but there are additional challenges brought about by COVID-19.
"Often, families would raise dental concerns and organise appointments, but currently most care homes are not allowing any visitors"
Over the phone, triage can be difficult for people with cognitive conditions, such as dementia, who are unable to verbally articulate if they have oral pain. We rely on carers noticing changes in eating or behavioural patterns, facial swellings and broken teeth. Often, families would raise dental concerns and organise appointments, but currently, most care homes are not allowing any visitors. Families may also not be able to visit relatives who are self-isolating at home.
Even once the decision is made that someone needs to be seen urgently, there are additional things to consider. Currently, many care homes are trying to avoid residents leaving the home and people entering to minimise the risk of contracting the virus. People living alone may rely on friends or family to take them to dental appointments which again may not be possible.
For some patients where we have established that dental treatment is relatively straightforward, for example, extraction of a mobile tooth, it may be more appropriate to provide domiciliary care. However, appropriate PPE must be used to minimise the risk of the dental team being asymptomatic carriers introducing infection to an isolating care home.
When treating patients wearing full PPE, the mask makes it harder to communicate, and express emotion. Further complicating this, many older people will have hearing issues. There will also be some patients who are unable to tolerate treatment under local anaesthesia. For older people with comorbidities, the overall risk of sedation versus the benefit will need to be carefully considered.
Oral health is essential
Concerns about the oral health of older people are not new. The 2019 CQC report,
Smiling Matters, found alarmingly poor standards of mouth care in older people and limited access to dentistry, especially for urgent dental conditions.
Attention to mouth care for older people matters. Dental pain, oral infection, dry mouth and poor oral hygiene can lead to malnutrition and dehydration and impact on dignity and quality of life. There is also evidence linking oral bacteria with aspiration pneumonia.
"The way we provide dental care will change for a considerable time and may involve maintaining clinics for 'at risk' and 'shielding' groups."
Looking ahead, it's clear that lifting lockdown restrictions will take longer for the older population.
The way we provide dental care will change for a considerable time and may involve maintaining clinics for 'at risk' and 'shielding' groups and increasing the capacity of domiciliary care.
Now more than ever the dental profession needs to work collaboratively with medical and social care providers to ensure the oral health needs of older vulnerable adults are not forgotten.
Mili Doshi, Consultant in Special Care Dentistry
Surrey and Sussex Health Care Trust