In the first of a two-part series, Caroline Holland looks at the programmes underway to improve mouthcare of residents of care homes and hospitals.

figure 1

'Putting the mouth back in the body' is a mantra that is often heard in the context of health policy. Yet there is still an uphill battle to embed adequate oral care among care home residents and hospital patients. Today a lifespan of 90 years is not unusual. People living longer lives are remaining dentate. The result is a growing demographic with high needs combined with increasing dependence.

Those working in the fields of special care dentistry and gerodontology, such as Consultant in Special Care Dentistry Mili Doshi, want recognition for the role that a healthy mouth has in keeping people independent and well. Mili was the clinical lead of the Mouth Care Matters programme which trains hospital ward teams in mouthcare. In 2015 a CQC report showed many older patients at East Surrey Hospital where she works were suffering from dry mouth. Mili was given funding to develop a programme and was supported by the CEO of her trust. With her team, she observed the regimen on hospital wards and saw that mouthcare was not a consideration. In conversations with non-dental colleagues, she was struck by how little was understood about dental issues by those working in healthcare. She recalls saying: 'If only mouthcare mattered' and it was this outburst which gave rise to the name of the Mouth Care Matters (MCM) programme.

figure 2

MCM works, says Mili, because it was designed to be pragmatic and simple. Initially, it was rolled out across acute hospitals in Kent, Surrey and Sussex; dental nurses, nurses and speech and language therapists were recruited as Mouth Care Leads so that they could in turn train and mentor the medical nurses and healthcare assistants and work to raise standards. Mili adds: 'The ambition was that MCM would be translated across all ages and settings'.

MCM is no longer being funded by Health Education England although its ongoing legacy is still visible on its website,1 an educational video on YouTube2 and it lives on among the dental nurses who work as mouthcare leads at a number of hospitals, mostly in the South East (such as Loraine Macintyre, Panel 1).

Initiatives dedicated to improving the oral health of older people in residential homes have got off the ground in different parts of Great Britain. Scotland started the process with a Guide for Care Homes, published as part of its Caring for Smiles initiative.3 The Welsh Government followed soon afterwards when in 2014 Gwên am Byth (A Lasting Smile) was born (Panel 2).

While the approach to improving the oral health of the dependent elderly in the UK has been to train those in the frontline of their care, in Australia, by contrast, the Senior Smiles programme4 employs dental hygienists and oral therapists in Residential Aged Care (RACF) Facilities (care homes). Led by Professor Janet Wallace, the programme began in a region of New South Wales after she was awarded a philanthropic grant to deliver a new model of care.

figure 3

In the opinion of Professor Wallace, there's a need for qualified, preventive dental practitioners such as dental hygienists and oral therapists to be within the care home, providing oral health risk assessments, oral health care plans and developing referral pathways for residents, whether to a dentist or dental prosthetists in the local community. She says: 'One of the main problems is that care home staff are mostly unable to identify oral conditions and, as a result, residents often develop serious dental problems that, if identified in the early stage, could have been managed'.

An economic analysis has shown the Senior Smiles programme to be financially beneficial but funding remains a barrier to scaling up the programme across Australia. Unfortunately, she says, there are many barriers: geographic, economic and access to oral health/dental care in the care homes.

Professor Wallace is lobbying for funding. 'We recently had a Royal Commission into Aged Care Quality and Safety in Australia and one of the recommendations from that was that all care homes should retain or employ an oral health practitioner. Funding these positions is the issue; ultimately the funding for this Senior Smiles practitioner should come directly from the care home and should be linked to accreditation, to ensure oral health is provided along with the other daily cares. We continue to lobby to achieve this goal and to highlight that oral health is part of general health care and not simply an add-on luxury.'

In the UK, there are similar challenges. There is a willingness to provide better care but a reluctance to fund it. Pockets of innovation exist but there is no systematic policy. Richard Valle-Jones is a Special Care Dentistry Consultant and Clinical Director at Leeds Community Healthcare NHS Trust. His Masters focused on restorative dentistry in older patients, and he believes more could - and should - be done to raise the bar on gerodontology.

Dr Valle-Jones says: 'Change needs to start in dental schools where dentists of the future should understand the importance of pragmatic conservative dentistry. And it's not just dentists either, the whole team needs to be engaged'.

For some years Dr Valle-Jones worked in Oldham and experienced the benefits of being part of the devolved Greater Manchester Health and Social Care Partnership, which fostered innovation. There was a collaborative approach to training dentists, involving the Greater Manchester Health & Social Care Partnership (GMHSC), Health Education England and Public Health England.

Foundation dentists would be attached to a care home where there was unmet need and carry out dental checks, supported by experienced dental nurses. As Clinical Director of Pennine Care NHS Foundation Trust, Dr Valle-Jones was one of the course organisers: 'The experience gave the foundation dentists a valuable insight into special care dentistry early in their career'.

Another pocket of innovation is developing in the North West of England. Lancashire & South Cumbria Financial Care Trust (LSCFCT) has commissioned Mike Brindle, a clinical dental technician (CDT), to provide a service to care homes in the area. What makes this initiative so outstanding is that it is the first time that the NHS will be employing a CDT in a domiciliary setting.

Mike, who works as a sessional CDT for the NHS, has been lobbying for 12 years for CDTs to be commissioned to work directly with patients in care homes. The CDTs' scope of practice allows them to work directly with edentulous patients and on prescription with semi-dentate patients. However, in the absence of an NHS performer number, they have only been able to work in a private capacity for care home residents.

figure 4

Progress has been achieved through some significant developments. Firstly, the advent of Health Education England's review of the dental workforce (Advancing Dental Care) to which Mike was recruited; as a result of his input, it was agreed that a trial data collection scheme should be established. In order to circumvent the issue of the NHS performer number, he is now working under the aegis of Fylde Coast Medical Services, which is a recognised NHS provider.

Another important turning point has been the development of sophisticated scanning technology which will enable remote examinations, limiting face-to-face contacts and speeding up diagnosis and treatment solutions.

Mike says: 'Projects such as these are expensive to set up, to run and to monitor. However, LSCFCT are an extremely innovative and forward-thinking trust, so sufficient funding was found, and the first patients will be treated in the spring of 2022'.

He adds: 'Over the past 12 years a huge amount of effort has been put in to convincing the relevant authorities of the benefits of bringing CDTs into recognised employment within the NHS structure. One of the biggest hurdles has been demonstrating a CDT's worth as an effective contributor to the dental team effort. This pilot provides a real opportunity to demonstrate and prove the value CDTs can bring to the domiciliary dental care team'.

If the pilot scheme is successful, there is potential for it to be established as a nationwide programme. Ideally, this should be part of a planned overhaul to improve the oral health of care homes everywhere - but more evidence is needed to establish best practice.

What can be done to develop a more systematic approach to the oral care of the elderly? The Seattle Care Pathway5 created in 2014 was ground-breaking. The structured, evidence-based pathway was developed at a workshop in Seattle attended by 100 clinicians from around the world. The pathway takes into account cultural differences relating to both workforce issues and funding systems.

Four dependency categories form the backbone. Ranging from nil to high, each category sets out the actions required, relating to assessment, treatment, prevention and communication.

The advice to the dental community set out in the paper incorporated:

  • The duty of dental professionals to inform policymakers and others about the epidemic of poor oral health among older people

  • Collaboration with other organisations, such as nursing home managers and voluntary organisations

  • Inter professional education

  • Promotion of research in gerodontology to support interventions for this growing population.

The paper also highlights 'elder abuse', stressing that oral health can be an indicator of neglect and dental professionals must be vigilant for signs.

A new trial6 'Improving the oral health of older people in care homes (TOPIC): a protocol for a feasibility study' is underway which should provide the evidence that is needed to develop a systematic approach to the care of the older person in residential facilities.

Mili appreciates the advent of more robust evidence-based processes but stresses that it is still essential for any programme directed at the frail and elderly to be easily adopted: 'There is so much to be done but we have to be realistic in what can be achieved. The key message is that a healthy mouth contributes to a person's overall health and wellbeing. If we can broaden this understanding across healthcare, we really will be putting the mouth back in the body, where it belongs'.