Health and Social Care Committee

Inquiry into residential care for older people

RC5 – British Dental Association

British Dental Association

National Assembly for Wales, Health and Social Care Committee inquiry into residential care for older people.

December 2011

The British Dental Association (BDA) is the professional association for dentists in the UK. It represents over 23,000 dentists working in general practice, in community and hospital settings, in academia and research, and in the armed forces.

The British Dental Association is disappointed that they were not included in the original list of organisations asked to contribute to this inquiry – oral care for the older person is important, contributes greatly to the quality of their lives but planning for services is so often forgotten.

The sixth age shifts
Into the lean and slipper'd pantaloon,
With spectacles on nose and pouch on side,
His youthful hose, well saved, a world too wide
For his shrunk shank; and his big manly voice,
Turning again toward childish treble, pipes
And whistles in his sound. Last scene of all,
That ends this strange eventful history,
Is second childishness and mere oblivion,
Sans teeth, sans eyes, sans taste, sans everything.

Shakespeare ‘As you like it’

So often it is assumed that when you get old you will also have lost your teeth but the Adult Dental Health Survey of 2009[i] revealed the following trends:

Ø In 1978, thirty-seven per cent of all adults in Wales had no teeth. This had fallen to ten per cent in 2009.

Ø Eighty-two per cent of people over the age of 75 in 1988 had no teeth. This had fallen to forty-two per cent in 2009.

Ø The most dramatic fall in edentate incidence is in the age 55-64 group – tomorrow’s older people.

Dental status by characteristics of adults

All adults					Wales: 2009
Characteristics of adults		Dental status		Unweighted Base	Weighted Base (000s)
		Dentate	Edentate (No teeth)	Unweighted Base	Weighted Base (000s)

All	%	90	10	1,000	2,437

Age
16-24	%	100	-	90	355
25-34	%	100	-	100	301
35-44	%	98	2	150	396
45-54	%	98	2	170	384
55-64	%	92	8	170	371
65-74	%	79	21	170	338
75 and over	%	58	42	140	293

Proportion of edentate adults: 1978-2009

All adults

Wales: 1978 - 2009

Edentate

1978

1988

1998

2009

Percentage

All

Age

16-24

25-34

35-44

45-54

55-64

65-74

87

75 and over

Associated with continuing improvement in restorative dentistry techniques:

Ø Eighty-six per cent of adults with teeth have fillings, the average being seven.

Ø Thirty-seven per cent of people in Wales have at least one crown.

Ø Only ten per cent have complete dentures.

And, with increasing age, the teeth that have been retained and the person attached to them tend to require treatment that may be more complex and / or may require more time. This is compounded by general health status and the effects of complex pharmacotherapy.

Number of natural teeth by age: 1978-2009

Dentate adults				Wales: 1978 - 2009
	Mean number of teeth
	1978	1988	1998	2009

All	22.4	22.9	24.2	24.3

Age
16-24	26.0	26.9	28.0	28.3
25-34	25.1	26.0	27.9	28.2
35-44	23.0	23.6	26.3	26.9
45-54	17.3	20.4	24.1	25.2
55 and over	13.8	15.9	16.9	19.4

Mean number of restored, otherwise sound teeth by age: 1978-2009

Dentate adults						Wales: 1978-2009
	Mean number of restored otherwise sound teeth
	1988 criteria			1998 criteria
	1978	1988	1998	1998	2009 (adjusted)*	2009 (unadjusted)

All	7.3	7.7	8.1	7.9	6.7	6.7

Age
16-24	7.2	6.2	4.3	4.2	2.1	1.9
25-34	8.9	9.6	6.8	6.7	5.5	5.8
35-44	8.3	9.1	11.5	11.3	7.2	6.6
45-54	5.6	8.4	11.0	10.8	9.5	9.3
55-64	3.6	5.3	7.1	7.9	7.8	8.4
65 and over				5.6	7.9	7.8

In 2003, the BDA commissioned a piece of work entitled ‘Oral Healthcare for Older People – 2020 Vision’. Many of its recommendations hold true today.

The Executive Summary is reproduced below.

Demographic change

The UK population is ageing. Increased life expectancy and mortality, coupled with a falling birth

rate, mean that by 2020 the proportion of people aged 65 and above is projected to rise from a

current figure of 15.7 per cent to 18.9 per cent. At the same time as the population of older people is

growing, it will become more ethnically diverse; and the imbalance in numbers between women and

men will continue to increase.

Older people in 2020 will exhibit a broad spectrum of dependence. They will largely continue to live

in their own homes. Nursing and care homes will provide accommodation for a group of older

people who are most likely to be frail with complex clinical needs. Ensuring access to appropriate oral

healthcare for dependent older people will continue to be an issue for the National Health Service.

There will be a broadening disparity between the amount of disposable income available to wealthier

older people compared to that available to poorer sections of this population, with a significant

number of people who can fund their own oral healthcare and a significant number who cannot.

Changing clinical needs

The change in the composition of the UK population will have an effect on dental practice and an

impact on the training and skills required by health and social care professionals. There will be

increasing numbers of older patients who need, and would like to have, complex restorations to

ensure that they retain many of their natural teeth. Conditions such as root caries and dry mouth will

continue to be prevalent, although new clinical technologies may be developed to prevent and treat

them. Dental teams will be providing oral healthcare to a greater proportion of older patients with a

range of complex needs for which they will require appropriate training and experience.

As well as changing clinical needs, older people will have increasing expectations about retaining good

oral health and appearance in old age; and many will have the resources to take advantage of advances

in cosmetic procedures. They (and their relatives and carers) will also expect to relate to dental teams

as consumers, and to receive both full information and a range of options relating their oral healthcare.

The combination of greater numbers of older people with more teeth needing restoration adds up

to more and more complex work for the dental team:

More older patients + More teeth x Wider range of clinical issues

=CHALLENGES

The challenge for both the government and the profession

is how this increased demand will be met.

“By 2020 the proportion of people aged 65and above is projected to rise” “As well as changing clinical needs, older people will have increasing expectations about retaining good oral health and appearance in old age”

Improvements in service provision

Changes in delivery of oral health services for older people will need to be made and subsequent

education and training of health and social care professionals will be required.

Services will need to be more accessible and dentistry will need to be fully integrated within the NHS.

General dental practice will remain at the heart of care provision; the role of the Community Dental

Service as a provider of specialist care and advice for older patients will also need to be developed.

Residential and nursing homes must offer residents preventative oral healthcare and access to

treatment that is appropriate for the individual.

Information and advice on self-care and accessing oral health services need to be much more widely

available in formats and media that are used by older people, particularly those who are part of

hard-to-reach groups. The dental trade is an important and often forgotten source of oral health

information for the public and very often its marketing strategies and products completely neglect

older patients.

Care planning for older people must be undertaken on an organised basis, with a strategic approach

adopted for patients who are at risk of requiring complex restorative care in the future. Delivering

preventive care and advice, as well as screening for oral cancer for older patients should also be part

of readily accessible services.

Education and training of health professionals providing oral healthcare services to older people is a

priority. This should encompass the undergraduate curriculum, including experience of providing

care in a variety of settings, as well postgraduate and CPD courses.

2020 Vision

In 2020, oral healthcare services for older people will need to be:

■ recognised as an integral part of strategies to tackle inequalities in older people's health and to

increase the quality of older people's lives;

■ joined up and integrated at a local level with other health and social care services;

■ accessible, of a high quality, available to all and patient centred;

■ reflective of the diversity of the older persons population;

■ in line with Government health policy (for example, helping enable older people to remain

independent for longer);

■ available equally to all older people on the basis of clinical need, regardless of age, geography or

home circumstances.

Recommendations

The recommendations referring to residential homes are highlighted in red:

1. The new locally commissioned system for the delivery of NHS primary care dentistry in England and Wales must take account of the needs of older people, and the demographic and clinical changes

identified in this paper.

2. Local health authorities must look creatively at dental provision for older people and tie in

dentistry with other services, such as General Medical Practice, chiropody and pharmacy.

Voluntary organisations and day centres are also means through which care can be brought to

people (using mobile units).

3. Work on new NHS Clinical Pathways for dentistry must reflect the needs of the older persons

population and ensure that further clinical challenges for dentists treating older patients in the

future are not inadvertently created.

4. A free oral health risk assessment should be available to patients from age 60, with referral to a

dentist for a strategic long-term oral healthcare plan offered to those identified as likely to need

complex restorative care.

5. Residential care homes should be required to provide potential residents and their carers with

basic information on quality-of-life indicators relating to oral health. This would enable potential

residents to prioritise their oral health requirements, thereby facilitating freedom of choice. There

should also be basic local standards relating to the oral healthcare of residents with which homes

would have to comply – for example, scheduled visits by a dental professional.

6. Marking of existing dentures for easy identification in residential homes should be available free

to patients on the NHS.

7. Local health authorities should be encouraged to place simple contracts with local practices to

provide care to a small number of residential care and nursing homes, with portable equipment

for domiciliary work being made available on loan.

8. England, Wales and Northern Ireland should follow Scotland in passing legislation to enable

people suffering some form of mental incapacity to appoint a Welfare Power of Attorney,

normally a relative or carer, empowered to make decisions as regards appropriate healthcare on

behalf of the person.

9. The BDA (with others) should produce information templates for older people, carers and

residential care homes, about oral healthcare, services and costs that can be adapted by local

health authorities and voluntary organisations.

10. Research, including controlled trials, should be undertaken, exploring ways of encouraging

effective self-care by older people; and the results should be piloted.

11. NHS dental information and forms should be available in a variety of languages, in Braille and in

large print format.

12. Information about full and partial exemption from NHS dental charges should be simplified and

publicised to older people and carers.

13. Translation services and health advocates should be widely available, to make oral health services

more accessible to older people from ethnic minorities.

14. Planned reform of NHS dental charges should take account of the growth in the older persons

population and the fact that older people are more likely to require more complex treatment and

also tend to be among the least able to afford to pay. Free NHS examinations should be available

to patients aged 65 and over across the UK.

15. The undergraduate dental curriculum should continue to include teaching of complete and

partial dentures, and should also give students experience of domiciliary visits and care homes.

16. CPD and postgraduate courses must be offered to equip dentists and PCDs with the clinical and

communication skills they will need to treat the large caseload of older people by 2020.

17. Special care dentistry must become a recognised speciality.

18. Community Dental Services should be resourced properly, to enable CDS dentists to provide

specialist services and clinical leadership to dentists and PCDs providing care for older people.

19. Anti-discrimination training should be introduced as part of the curricula for dental undergraduates

and student PCDs.

20. Companies dealing in products related to oral health should recognise the potential market represented by older people who want to preserve their good oral health and appearance and develop

appropriate products and advertising campaigns.

21. Dentists should be able to prescribe any drug in the BNF for NHS patients for dental use. The

de facto inability of dentists to prescribe artificial saliva makes this of particular relevance to the

treatment of older people.