A new Care Quality Commission report has found that care home residents do not always have access to dentists and are not getting the support they needed to look after their teeth.

The CQC has published its own analysis of official figures indicating funding is currently supporting access for as little as one in a hundred of those who, due to limited mobility, may require access to domiciliary services.

Based on findings from 100 care homes, the CQC found that 52% did not even have an oral health plan for residents and 47% of staff never receiving training specific to dental care. 73% of care plans only partly covered or did not cover oral health at all, with homes specialising in dementia less likely to do so.

The CQC reports that one of the main challenge in providing access to NHS services was lack of domiciliary care provision. Freedom of Information requests by the BDA suggest levels of commissioning are low and falling, equivalent to providing coverage to under 1.3% of the population whose activity is significantly limited by disability or ill health.

Dentist leaders have backed CQC calls for swift implementation of NICE guidelines among care home providers, and for comprehensive training for staff. The BDA has stressed that appropriate commissioning, underpinned by robust needs assessment is now key to ensure all those most in need of NHS care can receive it, in the right place and at the right time. In light of the CQC findings this would need to cover mainstream, urgent and domiciliary care.

NHS services have been struggling to meet the demand of an ageing population who are keeping their teeth longer, and often have complex medical histories. While some local initiatives such as the innovative Residential Oral Care Sheffield (ROCS) scheme have delivered comprehensive dental coverage for adults in care homes, the BDA has expressed concern over the postcode lottery of provision and the horrific cases that have emerged from the sector [3].

The NHS Long Term plan has committed government to adopt an 'ageing well' model but has offered scant detail on the place of oral health.

The British Association of Dental Nurses (BADN) welcomed the report and backed calls from the CQC and the British Dental Association (BDA) for swift implementation of NICE guidelines among care home providers and for comprehensive training for staff; and agrees with the BDA view that 'appropriate commissioning, underpinned by robust needs assessment is now key to ensure all those most in need of NHS care can receive it, in the right place and at the right time… this would need to cover mainstream, urgent and domiciliary care.'

The Oral Health Foundation (OHF) has also called for the Government to take action to ensure that 'oral care for our elderly is not neglected'.

BADN also supports the suggestion by the British Society of Gerodontology that the hospital model, utilisng dental nurses as leads for oral health, could be replicated in care homes and that dental nurses could 'connect with and visit care homes on a regular basis to provide support and maintain consistent training'.

'Funding to allow more effective use of the dental team skill mix and in particular the skills of registered dental nurses,' said BADN Chair Jane Dalgarno, who is a member of the Delivering Better Oral Health Working Group. 'Whilst obviously not solving the complex problem of inadequate oral health care in care homes, would be a first step in the right direction. Given that the number of over-60s is expected to double in the next thirty years, plans must be made now to tackle this problem. BADN looks forward to working with the CQC, BDA, OHF and other appropriate organisations to develop such plans.'

BADN participated in yesterday’s roundtable discussion of the CQC Report at the BDA office, along with Age UK, the Alzheimer’s Society, the National Care Association, and the Relatives and Residents Association.

Charlotte Waite, Chair of the BDA's England Community Dental Services Committee said: 'This welcome report shines a light on services that are failing some of the most vulnerable in our society.

'There are residents left unable to eat, drink and communicate, as an underfunded and overstretched NHS struggles to provide the care they need.

'We require nothing short of a revolution in the approach to dentistry in residential homes. Oral health can no longer remain the missing piece when it comes to care planning and budgets.'

Mili Doshi, Consultant in Special Care Dentistry, and President of the British Society of Gerodontology said:

'Sadly this report shows that supporting people with mouth care isn’t considered an essential part of personal care but as an optional extra.

'It’s a toxic mix. Admission assessments rarely include oral health, staff lack adequate training, and dedicated services are thin on the ground.

'There is a growing evidence base of the links between oral health and general health including respiratory infections, which carry a high mortality risk.'

Case Study: Patient C

Patient C: 93-year-old female. Patient was blind, with advanced dementia, had poor mobility and resided in a care home.

Patient C was brought in to A & E by her daughter as dentures were stuck in the mouth.

When her daughter visited her at the care home she noticed that there was an unpleasant smell from her mouth and that her mother was not eating.

The daughter spoke to the carer who said they could not get the denture out of her mouth for the past week.

The daughter tried to contact a dentist to come to the home as the patient was unable to access her regular dentist. She was advised by the dentist to call the local community dental service but was told that the wait for a domiciliary visit was 8 weeks.

The daughter then took her mum to the local accident and emergence service.

The hospital did have an onsite dental service and she was seen by a dentist that day. The gums were inflamed and had grown over the metal clasps holding the lower denture in.

This denture had not been removed for a significant period (more like a month). The denture needed to be surgically removed from the mouth under local anaesthetic. The denture was very unclean and the gums underneath were inflamed and ulcerated.

The patient was discharge that day and the daughter reported a few days later that her mother had started eating again.

Key points:

  • At some point the dentures were not removed from the mouth and this led to a very vulnerable adult suffering. A discussion with the patient’s key worker raised the issue of a lack of training for care staff.
  • There is also a need for an urgent dental service for patients like this that may involve domiciliary care.

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