The BDA has welcomed the new report from the Care Quality Commission (CQC) on the parlous state of plans, policies and provision for oral health in care homes, publishing 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. 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.
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."
Freedom of information requests on domiciliary visits commissioned and provided in England, NHS England
number of contracts
with domiciliary visits
Number of contracts
with domiciliary activity
corresponding to a
course of treatment
coverage of the population
|2015 - 16||286||26,005||1,329||62,625||1.38%|
|2017 - 18||280||32,454||1,004||58,559||1.27%|
Coverage estimates by the BDA. Public Health England has used 2011 census data covering the population with activity 'limited a lot' owing to health problems or disability as a proxy for calculating domiciliary dental care need. That amounted to 8.3% of the population in 2011. Figures from 2015-18 are generated from ONS midyear population estimates, and modelled against treatments delivered to produce coverage estimates.
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.
· 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.