The growing number of older people in the UK presents a unique set of challenges to the profession. The number of people with Dementia and Alzheimer's is on the increase1, and care homes are under growing pressure to cope. The Alzheimer's Society called it 'one of the top three challenges facing the UK, and that's before we even consider the mouth.
BDJ in Practice Editor-in-Chief, David Westgarth, spoke to two experts in the field, Joe Sullivan and Mili Doshi, about the needs of the ageing population and what's out there for them at this very moment.
How would you describe the landscape for vulnerable adults requiring a high level of mouth care in the community?
JS There is a phenomenally high level of need. Not just for older people, but for people with a disability and the challenges they present. Alzheimer's Society are right to label this as one of the top three challenges this country faces. The number of people living with this disease has increased beyond recognition since I qualified, and I believe the dental challenge will only get worse.
We all know and have read how we are living for longer and keeping our natural teeth for longer, but the state of oral health isn't good. The dental contract has overlooked prevention and life-long treatment planning in favour of immediate treatment. The success of dentistry in helping people keep their teeth for longer can lead to problems when personal oral care falters due to age related illnesses. There is very little joined up thinking between dentistry and other health areas.
MD I agree with Joe. The complexities of maintaining good oral health for vulnerable patients is increasing all the time. Nobody wants a painful, unclean mouth, but barriers including a lack of priority of oral health in care homes and in society is a big problem. I'm based in East Surrey Hospital and I see the impact poor oral health has on quality of life and overall frailty.
How is care administered now?
MD My patients are referred in. We provide specialist treatment including treatment under sedation and general anaesthetic, where necessary. Dental disease and poor oral health even later on in life is relatively preventable. Some patients do not get the right support they need when it comes to maintaining oral health in terms of diet and tooth brushing. For some patients this may mean a degree clinical holding or denying them endless cups of tea with sugar. However this may prevent the need for treatment under sedation/anaesthetic later on when they are older and the risks are higher.
JS In the region I work in 40% of residents are expected to pay for their dental treatment. I attend 30 homes across Folkestone and the Shepway District. I take equipment to the care home however with lack of time, resources and funding am only able to provide most essential treatment
What local issues prevent the delivery of care?
JS The large number of care homes. The high demand. The complexities of those demands. Take your pick. It all adds up to a bit of a perfect storm.
Each of these barriers has their own issue, but for me it's the lack of time I have with patients and with no new funding available, it's going to be a struggle. Ever since I qualified in 1975 I have been providing domiciliary care. I have witnessed the number of older adults living with Alzheimer's increase rapidly over that time, and it is difficult for the newly qualified to come in and provide the care they need. I have 'grown up' with the challenges and have found ways to cope.
MD You're quite right Joe. There are lots of barriers and one is the high turnover of staff in care homes and the lack of training and priority on oral health. Sometimes it can be relatively small things like ensuring each person had a toothbrush and toothpaste and recognising the level of support each individual needs.
What work is being done to liaise with other areas of healthcare?
MD There is some degree of crossover in an acute hospital setting. We work with doctors who have very limited training in oral health, speech and language therapists who are passionate about improving mouth care. We talk to local pharmacies about medication and xerostomia. We have worked very hard to raise the profile of oral health among allied healthcare professionals.
JS As I have previously mentioned this area leaves a lot to be desired. There are pockets of good practice where a joined up approach is in place and works but it is not enough. There needs to be a concerted, national strategy to tackle this problem, and let's be honest, the reality is that this is not going to come to fruition any time soon.
So many other areas of daily care for residential patients do not require consent, so I have to ask why intervention in the mouth should be different. I recognise the need to protect the vulnerable, but this very step is a misguided one. It prevents dental teams providing care in the care home setting.
How difficult is it to get oral health on their agendas?
MD It can be difficult but I feel we are getting there. At East Surrey Hospital we have raised the profile of oral health. If for example a patient is refusing food health care professionals will consider that there may be a mouth related cause. This was not done in the past. Educating other healthcare professionals on the links between oral health and systemic health including diabetes and pneumonia is really important and not widely recognised. A holistic approach across all areas of healthcare is required at undergraduate and postgraduate level.
JS I certainly agree with Mili. It's massively difficult. I attended a meeting on dementia and oral care last year and came away believing more than ever that dentistry works in a silo. The nature of a dental practice does this. Getting oral health onto the agenda of care home staff is extremely difficult, which is surprising considering how intimate some of the bathing and cleaning work care home staff have to do. In most care homes there are staff who care about oral health. Regular tooth brushing is not found generally. If such personal care is not high priority for the Manager or carer for themselves, this will be reflected in the care provided for patients.
What changes do you believe are needed in order to remove barriers and establish a nationwide platform for improving the oral health of the elderly?
JS Central leadership and guidance from the CDO's office is imperative. I attended a conference last year and heard the Chief Dental Officer speak about the challenges older people face. With a background in the military and dental public health and with a desire to improve collaborative working between healthcare professionals I am keen to see how these changes progress. Look at the current challenges; an ageing population that must maintain their dentition for longer with increasing co morbidities, a lack of awareness of the importance of oral care. They will be left behind because the next generation will age with complex dental restorations of implants and bridgework which will pose a new set of problems.
Perhaps the most urgent need is for anyone diagnosed with early dementia to have an oral healthcare plan developed where possible problems are identified and resolved and prevention is firmly established long before cognitive deterioration requires carers to take responsibility.
MD Joe is absolutely right. Strong central Leadership. Sara has been very supportive of initiatives such as Mouth Care Matters, which is good to get it on the agenda. More involvement with the CQC in Care facilities will help to put oral care on the agenda. Passionate people in positions of authority will help to overcome these barriers.
BDJ in Practice, Editor-in-Chief
The complete interview can be found in the July 2016 edition
of BDJ in Practice
BDJ in Practice magazine
BDJ in Practice magazine is part of the BDJ portfolio, and is posted out to BDA members monthly, covering the latest issues, trends and information relevant to practising in dentistry today.