Historically, providing dental care for frail elderly patients usually meant visiting a nursing home on the way home from a busy day in practice and providing a new set of dentures for one or more of the residents. This however is not the case anymore with many older people retaining their natural teeth, and the NHS regulations stipulating that to carry our domiciliary care, a dentist now needs a specific contract. Of course, there's always the option of private dentistry, but this isn't always affordable for everyone especially if the cost of the actual dental visit is factored into the final bill.

The Community or Special Care Dental Service has a role in supporting these vulnerable patients, but it alone hasn't the workforce to provide comprehensive care to everyone in this ever-growing cohort of patients. So gazing into my crystal ball I see a time in the near future where many dentists working in general dental practice will once again become more involved in providing care for frail patients who live either at home or in a care home, as the NHS realises that this is a huge, unmet need in the general population. Below is my 'rough guide' for providing what I like to think of as 'Pragmatic Dentistry'.

The problem of deteriorating oral health in frail elderly

Deteriorating general health can also mean deteriorating oral health, as Box 1 shows, and whereas some aspects of behaviour and habit are possible to influence, such as diet control and fluoride supplementation, others such as maintaining oral hygiene may prove a lot more tricky.

It is wise to consider the frail elderly patient as being at increased risk from dental disease and therefore a strong emphasis on prevention with reference to Delivering Better Oral Health1 toolkit will form the starting point of any treatment plan. Two of the easiest to implement changes described to reduce the risk of dental caries include fluoride supplementation with professional application of varnish.

Domiciliary care

Domiciliary care has been the traditional way in which many frail elderly patients receive treatment; not only for dentistry but medicine, optometry and podiatry amongst others too. As well as allowing patients with poor mobility who are housebound to receive treatment, patients with dementia may well be more cooperative if treated in familiar home surroundings.

However, when undertaking domiciliary care, there are likely to be compromises necessary in the type of treatment you can actually undertake, compared to ideal surgery conditions. For truly housebound patients, care at their home may be the only option, but for those who are able to make it to the surgery with help from family, friends and carers, you will need to explain the advantages and the additional quality of care you can provide there, against the convenience of getting treatment done at home. It is often possible to mix where the treatment is provided with routine treatments at home but with more complex treatment such as extraction being carried out at the clinic/hospital.

Types of treatment which can be provided at home include:

  • Prosthetics

  • Relief of pain

  • Simple cons and extractions

  • Simple oral medicine

  • Prevention.

Restorative treatment should be kept simple and can often involve stabilising with Glass Ionomer cements, remembering that those which are resin re-enforced are more likely to last longer than those which are not. Realistic equipment choices are going to involve a battery powered motor, which can be used for with a slow handpiece for simple cons and a straight handpiece for adjusting dentures. It's very unlikely that you'll have one of the specialist units which has a 3:1 syringe, air rotor, ultrasonic scaler and even in some cases a suction unit!!

Another restorative technique worth considering, is Atraumatic Restorative Technique or ART.2 This involves a minimally invasive technique with removal of softened dentine with hand rather than rotary instruments and filling/sealing residual carries with high viscosity glass ionomer.

Extractions in the domiciliary setting can be daunting and ideally should be kept to nothing but the easiest extractions, especially in the absence of any radiographs. However, the therapeutic benefit from extracting a very loose tooth on a frail patient, who's struggling to eat because of it, can't be over-stated.

Prosthodontics is usually limited to simple acrylic dentures, rather than more complex types of removable appliances and/or crown and bridgework.

The British Society of Disability and Oral Health (BSDH) provide excellent guidelines for any budding domiciliary dentists.3 The CQC (agreed by the GDC) have also provided some excellent and pragmatic advice on the age old question of 'what emergency drugs and equipment do I need?'4 In essence:

  • Carry out a risk assessment to see what type of work you'll be doing. This will include whether a care home has equipment and drugs which can be used, and should you be attempting certain riskier treatments anyway

  • Non-invasive - assessment and prosthetics would need to take drugs as per GP, district nurse etc. but not necessarily additional equipment.

  • Invasive - May need O2 and defibrillator but the advice is to do the treatment at a time when this equipment isn't necessarily needed at the practice, if you have only one set.

Not all retained roots are painful

When starting out on providing domiciliary care, one thing you're sure to notice is an abundance of retained roots. In the ideal world all of these will have the appearance of hard, black sclerosed dentine, the mark of arrested caries. However, in reality many won't.

It does appear that the natural ageing process, where the deposition of secondary dentine within the pulp chamber leads to reduced pulpal tissue, has a protective effect for older teeth; and less chance, when compared to teeth in younger patients, of developing pulpitis. Care is needed however to check for sepsis in the buccal sulcus alongside any retained roots, especially if radiographs aren't available. Where retained roots are left, ensure that the patient or their family and carers are aware of their presence and ensure they are carefully reviewed. Additionally, promote plenty of preventive care such as careful brushing, fluoride application/supplementation and the control of any destructive dietary habits in an attempt to stabilise/arrest the root caries. Healthy retained roots can also be used as overdenture abutments.

Periodontal disease

Successful periodontal treatment relies on removal of plaque biofilm. Problems with oral hygiene due to either physical or cognitive disability will have the potential to cause problems with periodontal health, especially in cases where conditions were previously stable. This means a definite push towards optimising oral hygiene as a priority over removal of calculus in a difficult setting and root surface debridement. Different strategies are numerous but involve personalising care in such a way to minimise stress and promote cooperation, as shown in Box 2.

Finally if the patient has been fortunate to reach an age of 80+ with very little or no loss of horizontal bone, this suggests that they have perhaps some natural resistance to periodontal disease, with perhaps limited risk of losing a lot of attachment over a comparatively short future time period.

Capacity and consent to treatment

Many frail elderly patients will lack capacity to consent and as such, treatment decisions will need to be made in their best interest after agreeing a way forward using a formal method, with family, friends and carers of the patient. Many patients with declining cognition due to ageing will have made one of their family members a Lasting Power of Attorney and discussion over healthcare arrangements will be made in consultation with them. Advice exists in many forms, however if formal training on working within the Mental Capacity Act can be obtained, it is highly recommended.

It is paramount when agreeing best interests to communicate empathetically and openly with the patient's advocates looking at the issue on a broader spectrum than periodontal/caries experience of the teeth alone. Comfort, ability to eat, aesthetics, as well as for the patient not to undergo lengthy, possibly psychologically traumatic dental procedures unless absolutely necessary are all factors to be taken into consideration. Also the risks and downside of extensive treatments need to be emphasised such as with sedation and general anaesthesia. After many years of treating patients with the involvement of their family, in my experience they usually wish to keep treatments straight forward with very few having the dreaded 'unrealistic expectations'.

Summary

The objective of this piece is to help de-mystify care for the elderly frail which is more often than not going to take place in a domiciliary/care home setting. I've tried to keep it simple, not to over complicate things as to encourage as many practitioners as possible to explore delivering this aspect of care.

YouTube. 'How to Help a Person with Dementia Brush their Teeth' with Teepa Snow. Available online at: https://www.youtube.com/watch?v=93ixNssks1c&t=17s (Accessed November 2019).