Ed i to r ia l

Oral health for older people

In December 2005, a very significant document was

published as a supplement to this journal. It was

entitled ‘Meeting the Challenges of Oral Health for

Older People: A Strategic Review 2005’ and pro-

duced by a group chaired very ably by Dr David

Davis. Itwas commissioned inDecember 2004by the

then Chief Dental Officer for England, Professor

Raman Bedi who felt that there was a need to set out

proposals for meeting the changing needs of older

people. It concludes with 32 clear recommendations

relating to education and training, the responsibil-

ities of the Department of Health, Primary Care

Trusts, Strategic Health Authorities, Care Homes,

and Voluntary and Community Sector Workers.

The underlying principle of the review is that

oral health care should be available to all older

people regardless of their age or circumstances, and

that one of the key issues to be addressed in

reducing the challenges of this group is to ensure

that good oral health is achieved before they

become frail. It also recognises what is now a

worldwide phenomenon in that the population of

older people is increasing, both in absolute terms

with greater numbers and in relative terms in some

countries, with older people forming a larger pro-

portion of the population. Many of these people are

retaining their teeth later in life, some of which are

highly restored, requiring significant levels of

maintenance. The retention of natural teeth, of

course, has benefits for general health with regard

to improved diet, nutrition and quality of life.

However, these benefits can only be maintained if

the health of the teeth is maintained and increased

emphasis will need to be placed on preventive-

orientated care. Unfortunately, there is still a pro-

portion of this older group, although becoming

smaller that will have no natural teeth and they

must not be overlooked or ignored as their prob-

lems are in fact more difficult to solve. It also

reminds us that although many older patients

receive their care in general dental practice, a

proportion will need to be seen in hospital, day

centres care homes or in their own homes on a

domiciliary basis. This is where dentists with an

interest in special care dentistry can play a key role

in providing oral health care for the more vulner-

able older people, particularly those with complex

needs. It is stated that although the dental team

plays an important role, they only form part of the

caregivers and it is essential that they liaise with

other health and social carers. There is the recog-

nition that any resultant improvement in dental

care for older people will only occur, if there is

appropriate education and training. Unfortunately,

most of this experience will not have been gained

from the frail elderly and this may only occur once

dental qualification has been achieved. However,

part of this may be addressed by the use of outreach

attachments, which are now key components of

dental undergraduate curricula at a number of UK

dental schools. One of the outcomes of these

attachments is gaining knowledge and experience

of oral health care of this ‘at-risk’ group and where

possible carrying out dental care commensurate

with their experience and skills. Feedback from

dental undergraduates indicates that these attach-

ments are very rewarding and it also helps them

understand and, perhaps for the first time, appre-

ciate the real problems associated with caring for

this older group. In some instances, this is their first

experience of even visiting a nursing or residential

care home for older adults.

One key area that dentists have been aware of for

many years is the lack of appreciation of oral care in

the medical and nursing professions, almost to the

extent that it is considered a separate entity. Dental

education to all members of the health and social

care team is essential, just in the same way that

medicine, surgery and behavioural science are part

of the dental curriculum. It is very pleasing to

report that at the launch of this strategic review, the

President of the General Dental Council (GDC), Dr

Hew Mathewson stated that the GDC had agreed in

principle to the creation of a specialist list in special

care dentistry – one of the key recommendations of

the report. It will be interesting to see how this

develops and the place of gerodontology in any

training programme for specialists in this area.

The review also lays out guidelines for nursing

standards for oral health in continuing care,

standards for oral health in care homes for older

people, recommendations to develop local stand-

ards for oral health in residential, and continuing

care and also an oral health risk assessment tool.

One of the key outcomes of these guidelines is to

ensure that there is an identified oral care plan for a

resident’s needs, provision of appropriate oral

hygiene and regular oral assessment, which will

maintain and prevent deterioration in oral status.

Steps should also be taken to ensure maintenance

of oral health, enhanced oral comfort, and

prevention of oral disease and handicap. It is

� 2006 The Author

Journal compilation � 2006 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2006; 23: 1–2 1

important that standards are in accord with the

statement of principles of residential care that stress

positive choice, enhanced quality of life and con-

tinuity of care, by establishing links with former

services, retention of dignity and self-care when-

ever possible. However, it is suggested that without

appropriate legislation, oral health care for older

people will slip further down the health care

agenda.

It is interesting to note that a recent report by the

influential House of Lords’ Science and Technology

Select Committee stated that urgent action should

be taken to encourage more frequent oral health

checks, particularly among older people. It also

highlighted the links between healthy eating and

healthy ageing, and voiced profound concern about

the effect of poor oral health on the psychosocial

welfare of older people. It is clear that there are

many aspects of the Strategic Review and Select

Committee Report that are readily applicable in

other countries where there is an increasing popu-

lation of older adults and even where these chan-

ges are at an early stage, decisions should be taken

that will reduce later oral heath problems.

Related to these issues, Gerodontology includes a

review on oral health and morbidity in older adults,

which states that studies throughout the world

have shown that oral micro-organisms appear to

trigger systemic complications, either directly or

indirectly and long-term care facilities and hospitals

should be particularly concerned. There is a clear

evidence from Finland that where urgent dental

treatment caused by periapical periodontitis or

other dental infections is required, the statistical

risk of dying is increased by up to 3.9 times. The

overall implication is that it is absolutely essential

to take proper care of daily oral hygiene of the el-

derly, particularly in long-term care, thus sup-

porting one of the key recommendations of the

Strategic Review. However, there is a need for

novel prevention and treatment strategies for

combating oral infections in elderly populations

and much of this can only be achieved by multi-

centre studies and randomised controlled trials.

However, it must be borne in mind that patients

often need tailor-made strategies because of ongo-

ing changes in their bodily functions and the sim-

ultaneous need to treat systemic diseases.

In addition, the results of studies into the bio-

compatibility of denture relining materials and

patient satisfaction with the quality of their den-

tures for eating are reported. It is interesting to note

that many dental materials elicit a cytotoxic re-

sponse, but this does not necessarily reflect the

long-term risk for adverse effects as the oral mucosa

appears to be more resistant to toxic substances

than a cell culture substrate. Moreover, a model for

the evaluation of denture quality and denture sat-

isfaction can be achieved, which has the potential

for providing a means by which functional

impairment can be investigated more effectively,

the physical causes of such impairment and their

use with other indices of the need for prosthetic

care, such that older patients will receive a more

predictive approach to care.

In Oral Healthcare for Older People: 2020 Vision

[reviewed Gerodontology 2003 (1), 60–62], older

people were described as falling into three groups:

entering old age, the transitional phase and lastly

frail older people. However, it is important to stress

that transition through these phases is not inevit-

able and, if it does occur, is not age-dependent.

Therefore, the key message from all these reviews,

reports and studies is that oral health care should

be available to all older people, regardless of their

age and circumstances, but it must be appropriate

for the situation that they find themselves in to

ensure the best quality of life.

Old age ….is no longer the twilight years but the

dawn of a whole new adventure

Valery McConnell (2005)

James P. Newton

Editor

� 2006 The Author

2 Journal compilation � 2006 The Gerodontology Association and Blackwell Munksgaard Ltd, Gerodontology 2006; 23: 1–2

2 Editorial