With more people living longer, the healthcare system is coming under increasing pressure, especially the dental services available to those living in care homes.

With more people living longer, the healthcare system is coming under increasing pressure, especially the dental services available to those living in care homes. Those on the front line in Northern Ireland say a new oral health strategy to help the ageing is long overdue.

Written by: Stewart McRobert

Oral healthcare for older people in Northern Ireland and elsewhere in the developed world is entering a new stage. Successful dentistry in our younger years, rather than being a boon when we age, is bringing myriad challenges. In Northern Ireland the professionals agree – it’s time for a new strategy to tackle the issues and provide the comprehensive care that is desperately needed. 

Gerry McKenna of Queen’s University Belfast has watched the problems for older people gather pace. He explained: “The issues in Northern Ireland are no different from anywhere else. We have an ageing population whose oral health has changed dramatically. People are approaching old age with some, if not all, of their own teeth. We are now having to deal with chronic dental diseases in older people, centred around gum and periodontal disease, as well as dental caries, particularly root caries.

“This is a challenge for colleagues, particularly those in primary care and the community dental service who are faced with trying to look after large numbers of older patients. Where we are seeing this most acutely is in residential care homes. Older people in homes who have their own teeth are not receiving proper dental care and without access to those services things can deteriorate at a rate of knots.”

He pointed out that systemic diseases can aggravate the problems – patients may have very dry mouths and fail to benefit from the natural protection that saliva provides. Equally, there can be challenging nutritional issues. Care homes often put an emphasis on staving off frailty, and in many cases this is done by giving older people highly calorific foods and drinks with lots of sugars and refined carbohydrates. Again, that can decimate residents’ teeth in a very short time.

“Sadly, I don’t think our system is adapting to this new realism very well,” added Gerry. “My colleagues in the community dental service who are being charged with looking after patients in care homes are really struggling. The service has been significantly underfunded and they’ve had a raft of people retire who have not been replaced.”

Caroline Lappin, Dental Director for the community dental service (CDS) in the South Eastern Trust area, concurs with Gerry’s assessment. She said: “Our salaried services were traditionally set up as what people termed the ‘school dental service’. We would look after children from backgrounds where there were high levels of tooth decay. As the population has changed it has become more difficult for general dental practices to look after the elderly population – few general dental practioners (GDPs) have the time and resources needed to care for our older people.”

“As a result, people in residential homes have increasingly come under the care of the CDS, and it is a major task. In my trust area there are over 100 care homes with a total population of about 3,700 residents.”

According to Caroline, the evolving situation for older people has been witnessed by her own staff. “One of our responsibilities is to screen care homes every 12 to 18 months. That gives an insight on people numbers, age brackets, oral health status, whether someone has a dentist, if they require treatment and so on.

“As time has gone on we have been picking up more and more people who have teeth and/or very good dental work that’s been carried out by GDPs – advanced crown and bridge work, implants and so on. We are now wondering how we support these people so they keep this good dentition for longer.”

However, the CDS is very small in number, especially in comparison to the general dental service. For example, Caroline’s trust area has just 15 dentists. Their job involves covering everything from hospital sessions to looking after patients referred by GDPs, doctors, social services and district nurses, as well as caring for people with disabilities and, whenever there is time, getting involved in oral health promotion.

She believes that one of the most important tasks is to get the preventive message across. People in the wider population need to be made aware of the importance of caring for everyone’s mouths, no matter what age they are. “There’s an awareness project for care homes staff being carried out in
our own area. It is difficult – the staff don’t see brushing residents’ teeth as part of their role.

“This doesn’t have to be clever or complex – it’s about very simple, basic oral care. Although it can be time intensive it certainly delivers rewards. Older people really notice it when their mouth is clean.”

One complicating element is the failure by authorities to make oral health a regulatory indicator. When an inspector visits a care home she/he does not examine its oral health regime. “We would be keen for that to change,” said Caroline. “We know care homes are under a lot of pressure, but if this was made mandatory it would bring great advantages to residents.”

Solutions

Grainne Quinn is Caroline’s equivalent in the Western Trust area. She believes the CDS is trying to find solutions as best it can: “Many people don’t have a dentist of their own when they go into a care home and in that case the CDS provides dental care. 

“We also provide training for care home staff – some of that we do as group training, some as one-to-one. Our hygienists and oral health co-ordinators deliver the sessions. A lot of the patients have dementia, and problems holding toothbrushes or accepting them into their mouths. The one-to-one training gives staff useful tools and techniques.”

Sadly, that training is often not seen as essential by many care homes with the result that staff regularly opt out.  

“The other difficulty,” added Grainne, “is that there is normally high staff turnover. You may deliver training then go back in six months to find people have moved to other nursing jobs or other homes. It means you are starting the task all over again. 

“Similarly, we may train staff who visit people in their own homes only to discover they don’t visit the homes at night when people perform their oral health routine. Trying to get consistency can be an issue.”

On a positive note, transformation funding has been provided to help take forward some initiatives. Part of that money has gone to a fluoride varnish programme for nursing and residential homes. In the Western Trust area dental nurses have been trained to provide the varnish application. The first stage has taken place and it’s hoped to extend that programme in the coming year. 

Beyond the community dental service, Gerry said that those in primary care often struggle to identify and deliver the best treatment for older people. 

“They have to take into account the many medications taken by older people and the impacts of systemic diseases on oral health.

“They may be asked to undertake domiciliary visits to people’s homes. That can be uncomfortable thanks to rules and regulations, especially if they are taking along emergency drugs, oxygen cylinders and so on. It can also involve getting special insurance for their car.”

All the while the remuneration for providing the service is relatively poor. As a result there is little incentive for people to provide that care.

Policy

Throughout the UK and developed world, dental professionals and policymakers are grappling with oral health issues faced by the ageing population. Gerry noted: “Some countries may be dealing with this a little better than others, but no one has cracked it. 

“On the one hand it is hugely positive that older people are retaining their natural teeth, the trouble is the systems and way dentistry is delivered have become outdated. The oral health needs of our older population are now very different. This has implications for dental education and the way services are delivered. We are simply struggling to catch up.”

He insisted that a number of steps need to be taken. “We need an oral health policy targeted toward older people in Northern Ireland. There needs to be a coming together of all of the interested parties – those of us from the academic world, colleagues in the community service and in primary care, as well as those involved in policy making. We also need to involve medical care and the nursing home sector. We need an evidence-based, pragmatic, prevention-driven policy for our older patients.

“We are now having to deal with chronic dental diseases in older people. this is a challenge.”

Gerry McKenna, Queen’s University Belfast

“Similarly, we need a focus on gerodontology in education, both
in terms of what we deliver to undergraduates and what is provided through continuing professional development. We can devise postgraduate courses that can upskill our professionals in the way they deal with and manage older people.”

Caroline believes action is overdue. She said: “In Northern Ireland there’s a lack of direction from the Department of Health. An oral health strategy was published in 2007, but hasn’t been updated since. It would even be good to have some guidance and direction that would help us encourage other stakeholders. 

“It would also help if there was a bigger driver for more multi-disciplinary work. For example, the diabetes and obesity agendas highlight the same risk factors and there is a lot to be gained if we work with others.

“The CDS is there to look after the worst cases, not every care home in Northern Ireland. Our resources mean that’s not sustainable. Our dentists and dental nurses are very aware of the demands on the service. They do the best they can in difficult circumstances. 

“We would be very keen to be involved in developing an overarching policy. We need joined-up thinking and I would like the Department of Health to be listening more. We have a very good relationship with the Health and Social Care Board. Again, though, without a strategy everyone’s hands are tied.” 

Grainne added: “We need an overarching strategy because when you are looking to access funding the first thing you are asked is ‘What policy is this related to, what’s your strategy and plans?’

“Also, if we are going to be training carers and staff we need extra investment. That’s a big issue not only in the CDS but for GDPs too. Many of them are willing to get involved in caring for older people. But over the last few years they have pulled back from providing a service because they have not been properly remunerated. In the CDS we are never going to be able to care for all the older population, so it has to be a joint approach.”

Pressing need

The lack of an executive in Stormont, while important, can’t be an impediment to change. According to Gerry: “Putting our head in the sand and thinking this issue will go away is not the right approach. It’s here now and will become more pressing as we move forward. The oral health community and dental profession in Northern Ireland needs to tackle this now.”

It’s his opinion that the situation requires real leadership so the direction is clear and everyone can begin talking about financial priorities and how we deliver policy.

Despite the problems he detects a readiness to find a way through. “When I speak to people and deliver lectures I see a huge amount of enthusiasm in the profession – everyone realises that this is a huge issue that needs to be tackled. There is engagement from the BDA and some very positive things going on including a major clinical research project (see below ‘A project to test simple interventions’). There are lots of people doing their utmost to manage the issues but it now requires a coming together of all interested parties.

“Most important, it is something our patients want us to move on with. They know this is a crucial area where action is needed and I’m positive we can make strides forward.”

A project to test simple interventions

Dental services for care homes are the subject of a research project involving Queen’s University Belfast among others. It will identify the efficacy of a series of simple interventions that it is hoped will have a meaningful impact for care home residents.

Gerry McKenna said: “This is a collaborative project. It is funded by the National Institute for Health Research (NIHR) and we are working with colleagues in the University of Bangor in Wales, as well as University College London, the University of Newcastle and the University of Glasgow.

“We are all aware that there is an increasing issue around the oral health of older people in nursing homes. It’s fair to say that their oral health has changed dramatically over the last 20 or 30 years.

“I’m also aware that there needs to be a very strong package of education for care home staff. There tends to be very high staff turnover in some places so anything we put in place must be long lasting.”

Part of the impetus for the project are recent NICE guidelines (NG48 Oral health for adults in care homes) and the starting point will be to implement a number of interventions in 12 care homes in Northern Ireland, with another 12 homes in London subsequently taking part.

“We are currently going through ethical approval and will look to recruit care homes from May 2019 onwards. The project will run for 12 to 14 months.” 

According to Gerry there are huge variations in practice across the UK. “In some places the community dental service is very active in looking after residents and in other places private GDPs look after patients – it’s very much on a home-by-home basis. This piecemeal approach has given rise to some of the issues we want to address.  

“We are putting the emphasis on prevention and simple measures from the outset and hopefully getting away from big interventions further down the line, with teeth having to be taken out under general anaesthetic.”

It is recognised that residents may have a multitude of conditions and require a huge amount of help from staff, but it is hoped the project will help emphasise that oral health must be a priority, otherwise the consequences are serious. “There are lots of other things care staff have to consider, but oral health is overlooked and it should be brought higher up the agenda,” said Gerry. 

“It may be that this piece of work we are doing over the next couple of years can contribute to a new overall strategy for Northern Ireland. 

“I would like to see greater emphasis on how we care for older patients, not just those in nursing homes but pragmatic treatment planning for older patients in dental practices.”

For more information on the project see: www.journalslibrary.nihr.ac.uk

BDA puts board on notice

The British Dental Association (BDA) in Northern Ireland has put the health and social care board on notice that action is needed to address the gaps
in oral healthcare for older people and care homes.  

Tristen Kelso, BDA Northern Ireland National Director, said: “Richard Graham, Chair of our Dental Practice Committee, recently wrote to the chair of the Health and Social Care Board to highlight a number of issues, mainly the recent dental budget underspend, the financial pressures GDPs are under and the gaps in service as far as the older population is concerned – the fees currently make it a charitable activity for GDPs to undertake domiciliary visits; it simply doesn’t stack up financially.”

The Health and Social Care Board subsequently asked the Head of Dental Services, Michael Donaldson, to give a presentation to its February 2019 meeting. Both Tristen and Richard Graham attended the meeting. 

According to Tristen, Michael Donaldson was clear that there are big gaps and that is due to the community dental service (CDS) being under very serious resource pressure. He also pointed out the fee issue in the general dental service (GDS) and suggested a joint policy approach between the CDS and GDS to tackle the growing problem of meeting the needs of people in care homes.

“It was very encouraging that the issue was raised with the Board,” said Tristen. “This is such an important issue that has gone unnoticed for years. From a GDS perspective we are really disappointed that we could not use some of the recent underspend in the dental budget and reinvest it in addressing the gaps. Instead it has been lost and taken out of dentistry completely. 

“The BDA has been calling very strongly for a new oral health strategy. If we’d had a new policy in place we’d have seen this issue coming down the track, but now we are firefighting.

“This is disadvantaging a vulnerable cohort significantly.
As far as we are concerned the Board has been put on notice with Michael’s presentation. They can no longer say that they don’t know what the issue is and we expect that action will follow.”

Tags: Ageing, Care, Care homes, Dental care for the elderly, elderly, Old age, patient care, Population