A surgery is the ideal place to give and receive dental care but this isn't always a practical option. People who are housebound or who have special needs rely on dental professionals to come to them instead.
In an ageing population, there are more people with complex medical conditions who struggle to access conventional health and social services. The provision of support and care in their own homes enables these patients to enjoy a better quality of life.
Since 1974, the population of the UK aged 75 and over has grown by 89% and it is predicted that the population of over-85s will increase by 106% between 2012 and 2032. A report by Public Health England makes clear that good oral health is an important consideration for this group: 'Ensuring that people can participate in social life free from embarrassment or pain and continue to enjoy a balanced and nutritious diet, contributes hugely to quality of life and general health.'
'The aim of domiciliary dental provision,' explains Denise Mattin, is 'to deliver the best quality dental care that we can for patients whose circumstances make it impossible, unreasonable or impractical for them to receive care in a fixed clinic.'
As Clinical Director of Solent NHS Trust Dental Services, Denise oversees domiciliary dental care for the service across Hampshire. The service treats almost 3,000 patients each year in their own home or in residential care. While many of these patients are elderly and frail, the service tries to reach everyone in need.
'Domiciliary care may be required because the patient has a long-term, progressive or terminal medical condition or mental illness,' explains Denise, 'and this is the only practicable way for them to receive treatment. For example, we see people with learning difficulties, conditions such as Parkinson's disease, stroke and MS, and sick, young children, some of who are PEG fed.'
Patients are usually referred to Denise's team by their dentist, GP or district nurses although they can also self-refer. 'In determining whether domiciliary care is appropriate we take a number of factors into consideration,' she reveals. 'This includes an assessment of the patient's mobility, such as whether they are housebound or confined to bed. If patients can access a dental surgery with assistance we encourage them to do so because this is always the preferred option.'
Not only is domiciliary dental care more resource intensive than a dental clinic but there are also significant challenges involved in providing safe, high quality care in someone's home.
One issue for the domiciliary service is that the population's oral health needs are becoming increasingly complex as more patients retain their natural teeth and have extensive restorations which require attention. Another oral health concern is that many old or infirm patients are taking multiple medications, many of which can cause dry mouths, making them vulnerable to decay, while some dietary supplements given to care home residents can be highly cariogenic.
These factors mean that preventative care is a priority for dentate patients, according to Denise. But she notes that the range of dental procedures that can be safely carried out is limited by the surroundings, available equipment and the welfare of the patient. 'We can carry out a scale and polish, denture provision and adjustments, provide temporary dressings and simple restorations but it's not feasible to provide advanced restorative treatments such as crown and bridge work or root canal therapy in a domiciliary setting. We have to manage patients' expectations so they understand what we can and can't do for them at home.'
As well as clinical restrictions, there are practical dangers for dentists when they step over the threshold. Denise remembers one eventful visit: 'The patient was bedbound and living in one room. In a single usable socket, there was an extension cable with plugs for the freezer, electric bed, television, cooker and yet another extension cable which was powering the kettle, a fan, a lamp and the fridge. When I moved a cable, there was a bang and a flash as the fuse blew!'
Facilitating patient-centred care in this way highlights the importance of effective cooperation in providing the best outcome for patients.
Delivering safe care
Such are the challenges of delivering dentistry in the home that most provision is managed by the community dental service (CDS), although a diminishing number of dental practices still make home visits. Dentists who are on the performers' list do not need additional qualifications to be a domiciliary dentist, although most CDS organisations provide training in relevant skills such as life support, information governance and safe moving and handling.
In addition, the British Society for Disability and Oral Health (BSDH) and the British Society for Gerodontology (BSG) have produced useful guidance which highlights the importance of effective teamwork, good communication and careful preparation in delivering safe care.
It's a case of 'fail to plan and plan to fail' agrees Denise. 'If we want to provide an efficient service we can't afford to turn up with half the story. It's important that the referral includes all relevant information about the patient's oral health, but we will also contact the patient or their carer before the visit to ask about practicalities such as directions, parking, access and whether the patient is able to communicate or co-operate.'
When it comes to the visit itself, Denise stresses that dentists, hygienists and therapists should be accompanied by a dental nurse. Their support is necessary as there is a heightened risk of medical emergencies in a domiciliary setting because of the health of the patients receiving care, and in a few cases, patient's medical condition can make them agitated or aggressive. She adds: 'Some neighbourhoods can feel quite threatening to work in, so it's good to have company and to have someone to help with all the heavy equipment.'
Despite the surroundings, domiciliary dentists are obliged to consider dento-legal matters. Full contemporaneous notes should be made at each consultation, although these might have to be handwritten and typed up later. To ensure patient confidentiality, records should always be kept in a locked bag and identifiable data on laptops should be protected with passwords and encryption.
Consent can be an issue when patients have dementia, mental disorders or learning difficulties. 'We assume the patient has capacity but we are trained in how to assess this in line with the Mental Capacity Act,' says Denise. 'If we need to make a treatment decision in the patient's best interest, we will talk to the person with power of attorney or their next of kin and try to take into account what we know about the patient.
'For example, if they have had a lot of crown and bridge work and we are told they went to the dentist regularly, it's more likely they would have wanted to go ahead with restorative treatment. If we believe this will benefit the patient and not cause undue distress we can arrange for them to be treated in a suitable clinic and arrange ambulance transport for them.'
Facilitating patient-centred care in this way highlights the importance of effective cooperation in providing the best outcome for patients. Domiciliary dental professionals typically work closely with other members of the multidisciplinary team responsible for the patient's overall care, including social services, district nurses and residential care home staff. This includes sharing information when appropriate and ensuring safeguarding concerns are raised promptly with the right person.
Denise expects dental professionals working in the domiciliary service to be adaptable and willing to go the extra mile for patients. She acknowledges that it can be a demanding environment, but she reflects: 'It's a pleasure to help the patients and I enjoy having conversations with them. In my experience, they are usually really grateful that we have been able to see them in their own home and understand the limitations of what we can do. Most of all, it's incredibly satisfying to be able to make a real difference to someone's health and wellbeing.'
Interview by Susan Field
Take home points
- Follow local procedures for referring patients to the community dental service. Contact the local CDS or special care dental service if you are unsure.
- If possible encourage patients to attend a dental surgery. Discuss with the local CDS whether it is possible to arrange transport.
- Ensure patients' expectations of domiciliary care are realistic.
- Always work with a dental nurse when making a home visit.
- Keep detailed contemporaneous notes of any home visits you make.
- Understand the process for assessing legal capacity and best interests decisions, as set out in the Mental Capacity Act 2005 and its accompanying Code or the Adults With Incapacity (Scotland) Act 2000.
- Review guidelines for the delivery of a domiciliary oral healthcare service for more about preparation, training, equipment and risk assessment.
- Contact the DDU if you need specific dento-legal advice.