As a special care dentist, I daily see the impact poor oral health has on quality of life and overall health for people living in care homes. We do see residents with excellent care are support with their mouth care but also see many people who are suffering unnecessarily as a result of poor oral health.
One case that really made a mark on me was a 45-year-old woman with learning disabilities and autism.
When she attended for a dental check-up at a Special Care Dental Service, the staff all complemented her on how well she was dressed. Purple clothes with matching shoes. She had had her nails done and sported a matching handbag and a nice hairstyle.
Her carer told staff that while she was non-verbal she took immense pride in the way she looked and would choose her outfit every day.
But on examination when she opened her mouth there was powerful smell. Her mouth was very dirty with plaque covering all the teeth, gums swollen and bleeding - see the picture above.
She let the dentist, who she had met for the first time, clean the teeth with a toothbrush in short bursts.
When carers were asked about the support they gave the patient they said sometimes the patient refused mouth care.
The result was the dental service arranged for an oral health promoter to attend the care home. It transpired that there was no mention in the care plan about the patient needing support, or how to provide mouth care.
The patient has an electric toothbrush, but it was not charged, and the charger was missing.
The oral health promotor provided some training for the carers, focusing on ways to encourage the patient to brush her teeth, and how to support her to try again later, if she refused. Staff were advised if the patient refused, then it needed to be documented and attempted at another time. The patient liked music and staff were advised to play her favourite music when brushing, which helped.
This case showed so clearly the lack of emphasis that care homes put on oral health.
And the latest report from the CQC starkly illustrates the two major problems that are facing individuals in these settings face:
- Residents who are dependent on a carer for support with mouth care are not receiving this essential element of care.
- Residents are often not able to access appropriate dental services in a timely manner especially with regards to domiciliary dental care and out of hours' urgent care.
The report highlights that supporting people with mouth care is not considered an essential part of personal care but an optional extra. Mouth care is not part of their mandatory training, care home admission assessments do not include oral health, and so it is not seen as a priority.
The consequences of this is often a rapid deterioration in oral health for people after admission to a care home, which can lead to oral-related pain and infection and impacts on overall health as well.
There is an increasing evidence base of the links between oral health and general health, including respiratory infections which have high mortality risk and can often lead to hospital admission, putting yet more pressure on scant NHS resources.
Residents in care homes are also faced with the problem of accessing appropriate dental care in a timely manner. As the populations ages with increasing complexities, there will be a greater demand for domiciliary care which is currently under resourced.
Dental services for people in care homes needs to be commissioned appropriately and this should include domiciliary care, and maximising the use of all dental care professionals visiting care homes and providing hands-on training and support.
In England, we are struggling to meet that demand now and we haven't yet seen any concrete or workable plans to cope with the need 5, 10 or even 15 years into the future.
I have had the privilege to lead a progamme focusing on improving the oral health of patient in hospitals, working as part of a multidisciplinary team, using dental care professionals to lead oral health improvement programmes. We need to see a similar coordinated national initiative for oral health in the community.
The BDA has led the calls for action, and as Charlotte Waite has said, we need nothing short of a revolution to the approach to dentistry in care homes.
I think it is fundamental that oral health training is made mandatory for all care home staff and is part of the care certificate. That way, proper mouth care will be known about by all staff, and prioritised. I'd also like to see dental services for residents in care home to be commissioned, including domiciliary care and maximising the used of dental care professionals.
The long-term plan states that individuals are supported to have good oral health and we strongly support this, there is a need to promote the concept of 'Ageing well with good oral health'.
Everyone deserves the right to good oral health and an increased focus by the CQC in care homes can help to put this on the agenda.
Mili Doshi, Consultant in Special Care Dentistry
Surrey and Sussex Health Care Trust
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