In our recent report 'Better care for frail older people' we acknowledged that improving the experience and outcomes for frail older people requires action on three fronts: physical and mental healthcare, social care and place of care. One area that we didn't cover, however, was the challenge of maintaining the oral health of older people. Research into this challenge has identified that timely access to good dental care is critically important for frail older people but that increasing dependency, reduced mobility and failing health means access is particularly difficult and the costs and consequences of poor oral and dental health are very high.
A clean, healthy mouth is fundamental to everybody's quality of life. Although many older adults have good oral health and access to services, a significant percentage of dependent older people struggle to access services. Poor access to routine preventive and expert dental care can lead to poor oral health, with a devastating impact on overall health ranging from pain and ulcers caused by ill-fitting dentures, to dehydration, malnutrition and mortality. Poor oral health can also have a negative impact on older peoples' ability to interact with their peers and carers and, by affecting their self-esteem, can exacerbate problems of isolation and loneliness.
Achieving and maintaining good oral health for older people is challenging, especially for older people in care homes or in receipt of domiciliary care who rely on care staff to help maintain their oral health. Research also shows that older people rarely complain unless their symptoms are particularly severe. Care staff therefore need to understand the importance of good oral hygiene and know how to deliver this aspect of personal care.
As the number and proportion of frail older people increases, the number of older people retaining at least some of their natural teeth is rising at levels not seen before. The Adult Dental Health survey shows rapid improvement in the number of adults that have 21 or more natural teeth; which rose from 74 per cent in 1978 to 86 per cent in 2009. Fifty-three per cent of those in the 85 or over age group had some of their natural teeth, while just over a quarter retained 21 or more natural teeth. While the increase in older people retaining their own teeth is to be welcomed, the current generation of older people will typically have many large fillings - the 'heavy metal generation' – who require large amounts of maintenance as well as the additional care required for their unrestored teeth.
There is limited information available about the uptake of professional dental care by care home residents in the UK. The information that is available suggests high levels of unmet need. One study of care homes in the Avon area found that 71 per cent of the residents had not seen a dentist in the last five years. Similarly, less than half (48 per cent) of the care homes in a Welsh survey had mechanisms in place to ensure that residents attend regular dental check-ups. A survey of residential and nursing home residents in Glasgow reported that dental treatment was needed by approximately half of residents, with 6 per cent needing urgent treatment. Other research points to under-use of services by frail older people and that the rate of domiciliary care provided by Primary Care Dentistry has been reducing year on year.
A report by the British Dental Association (BDA) in 2013, based on interviews with 13 care homes, its annual survey of Clinical Directors of Salaried Primary Dental Care Services and a literature review, identified high levels of unmet dental need in care home residents and that the provision of dental care was less than ideal. Levels of oral health training among care home staff were patchy and formal input from a dental professional was rare. High staff turnover and staff attitude towards performing oral health functions, often regarded as the least desirable aspects of providing care, exacerbated the problem. Furthermore, while knowledge and care appeared to be improving, there was still a lot to do to develop standardised care and integrate oral hygiene into the daily routine of residents.
The negative impact of poor oral on the quality of life of older adults is an important and costly public health issue, needing urgent attention. Oral healthcare needs to be less marginalised and dental care commissioning for older adults needs to be improved. While dental care may appear to be only one aspect of health, it plays an important role in safeguarding personal wellbeing. Indeed, regular oral health assessments and check-ups with a dental professional should be seen as an essential part of maintaining older people's health and wellbeing. While aspects of oral health may continue to improve, thanks to access to fluoride toothpaste, the financial constraints on the NHS and associated system reforms, provide an opportunity to re-evaluate priorities and assess how dental and oral health can be delivered as part of an integrated health and wellbeing strategy for older adults.
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