Extracting the Evidence
The oral health and dental care needs of older people
Help the Aged
Policy Statement 2008
Summary
Background
The impact of poor oral health on the quality of
life of older people is easy to underestimate. Poor
oral health is associated with malnutrition, and low
self-confidence. It has also been linked to systemic
disease, particularly Type II diabetes and stroke.
Oral health was defined by the Department of
Health in 1994 as the ‘standard of health of the oral
and related tissues which enables an individual to eat,
speak and socialise without active disease, discomfort or
embarrassment and which contributes to general wellbeing’.2 Oral health is integral to general health and
should not be considered in isolation.
Summarising the importance of oral health, the
World Health Organization has said: ‘The craniofacial
complex allows us to speak, smile, kiss, touch,
smell, taste, chew, swallow, and to cry out in pain. It
provides protection against microbial infections and
environmental threats . . . the psychosocial impact of
these diseases often significantly diminishes quality of
life.’1
Maintaining good oral health can be difficult for
a wide range of reasons. The majority of older
people live on their own and many suffer from
decreased mobility, which makes both self-care and
accessing high street dental care more difficult. This
is compounded by area-wide gaps in provision of
NHS dentists where recent reforms have failed to
improve access following years in which the NHS
haemorrhaged dentists to private practice.
One pensioner pulled out two of her own teeth
because she could not find an NHS dentist in her
local area.
In addition, entitlement to free NHS dental
treatment or help towards the cost of the
treatment is based on income.
Residents of care homes face different difficulties,
as provision of domiciliary dentist services is
extremely limited. Residents and staff are often
unaware of the importance of good oral health and
require training and support in this area. It is also
essential that care homes are held to account for
the extent to which they ensure access to dentistry
services for their residents.
For too long, dental care has been considered
separate from general health concerns. Oral
health care must be regarded as an integral part
of any general health checks and plans and more
consideration must be given to the importance of
oral health to older people.
1 http://www.who.int/oral_health/policy/en/
Much of the improvement in recent decades in
adult oral health can be attributed to exposure
to fluorides. Fluoride has been added to most
toothpastes since the 1970s although water
fluoridisation in areas of high levels of tooth
decay has been shown to be more beneficial than
the use of fluoride toothpaste alone in reducing
levels of disease. Currently only 10 per cent of
the UK’s population receive a water supply that is
fluoridated.3
Older people, however, have particular and changing
oral care needs and expectations. Prior to the
creation of the NHS, most people could not afford
dental treatment and had very poor oral health.
Between 1948 and 1958 it was commonplace for
NHS dentists to remove all the teeth of someone
with severe dental problems. Due to advances in
technology and practice and changes in consumer
awareness, this rarely happens now.
Rather than dentures, the majority of older
people will now need restorative dental work
like fillings and crowns that need much greater
care and maintenance than dentures. This will have
a significant impact on the level of dental care
required by older people.
Having had access to modern dental care for most
of their lives, the next generation of older people
will have much higher expectations for their oral
health. In addition to ensuring that their teeth and
gums are healthy and functional, appearance will
also be a major consideration for these people.
Although advances in materials and techniques
mean that restorations and fillings now last longer,
the care needs of older people are increasing.
2 Department of Health. An Oral Health Strategy for England.
London: Department of Health; 1994.
3 Apart from a small area of Scotland which has a naturally
fluoridated water supply, all other areas, whether receiving
naturally or artificially fluoridated water, are in England
(Nuffield Council on Bioethics, Public Health: ethical issues,
2007, page 125).
2
A combination of rising patient expectations,
technological advances and other healthcare
interventions means that the demands placed
on the care system for those of 50+ is likely to
increase. This will have significant cost and resource
implications for NHS dentistry.
Older people are often more vulnerable to oral
health concerns due to dry mouth, a condition
which can be caused by taking some medicines,
diabetes and chemotherapy. Dry mouth can lead to
tooth decay and gingivitis, as saliva helps clean teeth
and prevents decay.
Both the British Dental Association and the World
Health Organization have acknowledged the
importance of oral health for older people.4 In 2003
the World Health Organization’s World Oral Health
Report stated that ‘the interrelationship between oral
health and general health is particularly pronounced
among older people. Poor oral health can increase the
risks to general health and, with compromised chewing
and eating abilities, affect nutritional intake.’5
The Government, too, is clearly aware of the
importance of oral health for older people:
• the National Service Framework for Older
People, which sets out top-line government
policy in relation to the health and care of older
people, cites the need for improved education
about oral health and access to dental services6
• in Choosing Better Oral Health: an oral health plan
for England, the Department of Health noted
that oral diseases can lead to fear and anxiety,
pain and discomfort and aesthetic and selfesteem issues.7
However, much more action is needed to address
some of the oral health-related problems faced by
older people today.
Issues and evidence
Quality of life
Oral health has a direct and hugely significant
impact on the quality of life of older people. Poor
diet and a lack of good oral hygiene can lead to
tooth decay, the removal of teeth and the need to
fit dentures. This can make it difficult to chew and
enjoy nutritious food, reduce self-esteem and selfconfidence, cause problems with communication
and lead to social isolation.
In a project carried out by the World Health
Organization’s Collaborating Centre for Disability,
Culture and Oral Health and the Eastman Dental
Institute for Oral Health Care Sciences, 72 per cent
of elderly people perceived their oral health status
as important to their quality of life in a variety of
physical, social and psychological ways.8
Poor oral health has also been linked to a number
of serious diseases including aspiration pneumonia
and atherosclerotic vascular disease. There is also
a bi-directional relationship with diabetes in which
people with diabetes are at greater risk of both
periodontal disease and caries and diabetic control
is worse in people with periodontal disease.9
Oral health and nutrition
The links between diet and oral health are wellknown. In particular it has been highlighted that
the sustained consumption of sugar leads to tooth
decay. By reducing the frequency of the intake of
sugar, older people can prevent tooth decay and,
in so doing, guard against one aspect of poor oral
health.
4 Oral Healthcare for Older People: 2020 vision. British Dental
Association, May 2003.
5 The World Oral Health Report 2003. World Health
Organization, 2003.
6 National Service Framework for Older People. Department of
Health, May 2001.
7 Choosing Better Oral Health: an oral health plan for England.
Department of Health, November 2005.
8 The importance of oral health to older people’s quality of
life. Gerodontology 16 (1), 59–63, July 1999.
9 Gerodontology. Volume 22, supplement 1, pages 10–11.
December 2005.
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However, the relationship works the other way
round as well. The National Diet and Nutrition
Survey, published in 1998, highlighted the link
between oral health and nutrition: ‘In general, those
people over 65 who had their own teeth had better
vitamin and mineral intakes and better nutritional status
than those who had lost most or all of their teeth.Those
with no natural teeth or few natural teeth ate a more
restricted range of foods, influenced by their perceived
inability to chew. People without their own teeth were
less likely to select foods such as apples, raw carrots,
toast, nuts and oranges.’10
The National Health Survey of 2005 showed that
just under one-third of men and women aged 65
and over consumed five or more portions of fruit
and vegetables per day.11 To eat fruit and vegetables,
older people are likely to need at least 21 natural
teeth or well-fitting dentures.
People with 21 or more teeth are likely to have
full functionality and should not experience any
nutritional impact due to their oral health. The
British Dental Journal reported in 2002 that people
without teeth were significantly more likely to be
underweight than those with 11 or more teeth.12
Difficulties chewing can also lead to obesity. Older
people with fewer than 21 teeth are likely to
choose softer, but unhealthier and less nutritious
foods. This may contribute to the 72 per cent of
men and 68 per cent of women aged 65 and over
who were reported to be either overweight or
obese in the National Health Survey.13
The effectiveness of dentures in solving this
problem is varied. Dentures need to be reassessed
or re-fitted every three to five years. If this does not
occur, the dentures will invariably become loose,
making it difficult to chew properly and discouraging
many older people from eating nutritious foods.
Dental implants offer a more effective means for
tackling this problem. They secure the denture
so it does not move or drop down. Implants are
normally small titanium pegs inserted into the
jaw to keep dentures in place. However, they are
10 The National Diet and Nutrition Survey: people aged 65 and
over. Volume 1. Office for National Statistics, 1998.
11 Health Survey for England 2005: the health of older people.
Volume 1. Department of Health, 2007.
12 BMI and oral health in the elderly. The British Dental
Journal.192: 703–6, June 2002.
13 Health Survey for England 2005: the health of older people.
Volume 2. Department of Health, 2007.
not routinely available under the NHS. The lack of
availability of dental implants and other forms of
dental care can have a large impact on the quality of
life of older people.
Care homes
Oral health tends to be worse among older people
living in residential care.14 It is estimated that
there are currently about 420,000 older people in
residential care in the UK.15 Given the number of
older people in care homes, it is vital that these
homes encourage good oral health.
The Government has noted that older people living
in residential care tend to have a poorer diet.16
Unfortunately, some care homes adopt a ‘one-sizefits-all’ approach to meals, serving food that is easy
to chew or easy to feed to residents who cannot
feed themselves. Care homes should offer a broad
range of foods, with meals that cater for people
with and without teeth or who have dentures.
Dietary and hygiene arrangements are often
standardised in care homes, which overlooks the
fact that residents’ ability to chew food and to
maintain good oral hygiene varies a good deal.
Barriers to good oral health for care home
residents include poor access to dental treatment,
poor oral hygiene and a lack of education on
the part of both staff and residents about the
importance of oral health.17 Care homes, general
dental practitioners and primary care trusts must
work together to develop flexible solutions which
allow local general dental practitioners to provide
the required services to care home residents. This
could be as simple as reminding residents that they
are entitled to NHS dental care, and helping them
to register with a dentist in that area.
With improved access to dental care in care homes,
residents will be considerably less vulnerable to the
effects of poor oral health, particularly malnutrition.
14 Gerodontology. Volume 22, Supplement 1, page 20.
December 2005.
15 Care of the Elderly People UK Market Survey 2007. 20th
edition. Laing and Buisson, 2007.
16 Choosing Better Oral Health: an oral health plan for England.
Department of Health, November 2005.
17 Gerondontology. Volume 22, Supplement 1, page 20.
December 2005.
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Access to dental care
However, up to 1.74 million older people are
currently not receiving their Pension Credit
entitlement. Dental costs may also present a
problem for those older people not receiving
state benefit support and may prevent them
from seeking the required treatment or care.
It is evident that good dental care is essential for
maintaining overall health and well-being in older
age. Access can however be a problem.
Figures to December 2007 show that only 49.3 per
cent of the adult population in England had seen an
NHS dentist during the previous two years.18
The most recent trend data available suggests that
check-up attendance peaks in the 5–64 age range
(69 per cent of people said they went to the dentist
for a regular check-up), after which it falls. Some 36
per cent of people over the age of 75 failed to have
a regular check-up.19
Looking into the patterns of attendance more
closely, it is apparent that there is a link with socioeconomic status, with the lowest rates among those
in households headed by someone who is long-term
unemployed. It is also the case that visits to a dental
professional become less common for those with
psychological or physical illnesses and for those
people with no teeth (edentulous). The Health
Survey for England 2005 stated that ‘29% of those
who had lost the last of their teeth within the previous
ten years had attended a dentist for regular check-ups,
compared with 59% of those who still had some or all
of their own teeth’.20
Lack of availability of an NHS dentist will also
present a barrier, leaving individuals with the
option of paying for a private dentist or not
going at all.
• transport and mobility Assistance is not
available for travel to the dentist, although
distances can be substantial, especially in rural
areas. Older people are often dependent on
public transport to get to a dentist. There is
therefore a need to ensure safe, accessible,
reliable, affordable transport and flexible
alternatives.
In addition, individuals who suffer from ‘poor
understanding, uncontrolled movements, limited
mouth opening, poor posture or limited mobility,
who may experience tiredness during treatment or
have medical problems’ will experience difficulties
in accessing dental care and finding a suitable
environment to meet their needs.21
Hence, the most disadvantaged older people appear
to be facing significant barriers to accessing dental
services. The following outlines some of the main
ones:
• cost In April 2006, the Department of Health
introduced a new payments scheme for NHS
dental care. Patients can now expect to pay
£16.20 for routine care such as examination,
diagnosis and preventative care including X-rays,
scale and polish. More complex procedures,
such as fillings, root canal treatment or
extractions, will cost £44.60, while complex
courses of treatment and procedures such as
the fitting of crowns, dentures or bridges will
cost £198. There will be no charge for repairs to
dentures.
All NHS dental care is free for those individuals
receiving the guarantee part of Pension Credit.
18 NHS dental statistics for England Q3: 31 December 2007.
19 General Household Survey, 2003.
20 Health Survey for England 2005: the health of older people.
Volume 3. Department of Health, March 2007.
21 Valuing People’s Oral Health: a good practice guide for
improving the oral health of disabled children and adults.
Department of Health, November 2007.
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Domiciliary care services do exist, enabling
dental professionals to treat people in their
own homes. However, these services are timeconsuming for dental professionals, require a
specific skill set and are therefore relatively rare.
Salaried dental services, which supply generalist
and specialist care largely for vulnerable groups,
also offer a means of providing vulnerable older
people with access to dental services, but the
provision of such services is sporadic.
• awareness of the importance of oral
health and how to access support The
most disadvantaged older people are less likely
to be aware of the importance of their own oral
health. This is especially true for those people
who are edentulous, although there remains a
pressing need for a professional to check for the
early signs of oral cancer as well as to ensure
denture quality.
Improving levels of education in oral health and
entitlement to services will serve to prevent
major problems in the future. This includes
alerting those who struggle to manage their
everyday dental care as a result of conditions
such as arthritis to appropriate products and
aids, such as toothbrushes with alternative
designs and grips.
Dental reforms
The Health and Social Care Act 2003 heralded
what have been described as the greatest reforms
to NHS dentistry since its inception, with a duty
for every PCT and Local Health Board in Wales
‘to the extent that it considers it necessary to meet all
reasonable requirements, exercise its powers so as to
provide primary dental services within its area, or secure
their provision within its area’.22
The reforms came into effect on 1 April 2006
with the aim of improving access to NHS
dentistry services following dramatic reductions in
registrations over the previous decade as dentists
scaled back their NHS work in favour of more
lucrative private patients.
The extent to which the reforms have delivered
improved access to NHS dental services is however
questionable. Figures suggest that in the 24-month
period up to December 2007 some 0.7 million
fewer people were seen by an NHS dentist than in
the period leading up to the end of the old dental
22 Health and Social Care Act 2003, s170.
contract.23 A recent Health Select Committee
report highlighted a number of issues with the
reforms:24
• the size of PCT contract allocations was based
on historic spend rather than on an analysis
of unmet need. This may be partly addressed
through the Department of Health’s announced
11 per cent increase in funding for dental
services in 2008–9 and a commitment to
allocate on a needs basis. However, the formula
is yet to be determined
• PCTs have weak commissioning skills and fail to
effectively use dental public health specialists to
inform their decisions
• a reduction since 2006 in the number of
complex treatments, including the fitting of
crowns, bridges and dentures. The number of
root canal treatments has decreased by 45
per cent since 2004 with a parallel increase
in the number of tooth extractions. There is
no evidence that more clinically appropriate
simpler treatments were being carried out.
Additional criticisms include:25
• it remains difficult to find information about
dentists who still accept NHS patients in a given
area. NHS Direct can be misleading
• there are no national performance indicators
or access targets, even though access to NHS
dental care is a priority in the 2008–9 NHS
Operating Framework.
The Help the Aged position
Help the Aged is highly concerned that the oral
health of older people is being overlooked by health
professionals, dental health professionals, care home
workers, carers and older people themselves. Oral
health can have a direct impact on the health and
well-being of older people. Poor oral health and
oral inflammation can negatively impact on quality
of life and lead to the avoidance of nutritious foods,
malnutrition, poor communication and a lack of
self-confidence. It has been linked to conditions
such as Type II diabetes and hospital-acquired
pneumonia.
23 NHS Dental Statistics for England Q2: 30 September 2007.
24 Dental Services: fifth report of session 2007–08. House of
Commons Health Committee, June 2008.
25 Gaps to Fill: CAB evidence on the first year of the NHS dentistry
reforms. Citizens Advice, March 2007.
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We need to make certain that older people have
access to high-quality dental care and are equipped
to maintain their own oral health.
In particular, Help the Aged is calling for:
• a review of standards and practices in
relation to older people in care homes
Care homes should provide at least an initial
oral health examination for older people
on entering and regular access to dental
services. Staff should be trained in clinically
recommended methods of oral hygiene, and
cleaning and storing dentures. Although the
national minimum standards of the Commission
for Social Care Inspection (CSCI) note the
importance of dental care for older people,
practice varies significantly and is a huge area of
concern.
The new regulator should carry out a review
of dental care and oral health in care homes.
It is also essential that rigorous standards on
dental care and oral health are included in the
new system of regulation for care homes, which
should incorporate details of monitoring and
benchmarking requirements.
• an assessment of the impact on older
people’s oral health of the reduction in
the number of complex treatments being
carried out
It is essential that older people receive the most
appropriate treatments, complex or otherwise,
to maintain general oral health in addition to
nutrition levels.
• an extension in the treatments available
on the NHS
Where there is a clinical need, dental care such
as implants should be available on the NHS
to older people to better enable them to eat
nutritious foods.
• more flexible dental care to ensure all
older people have access to the required
services
Additional funding should go directly towards
supplying portable dental equipment or mobile
dental surgeries for dentists to use for checkups. Both measures would improve access
to dental care for the most vulnerable older
people – those in care homes or confined to
their own home.
• additional funding allocations to be
based on an analysis of need, including an
assessment of the needs of older people
• targeted public health messages to older
people and carers, alerting them to the
importance of oral health
There needs to be a greater emphasis on
preventing oral health problems, rather than
combating them. Encouraging good oral hygiene
– by using fluoride toothpaste, mouthwash
and floss – will reduce the burden on dentists
and improve quality of life for older people.
Changes in the dietary choices of older people,
particularly the reduction of sugar consumption,
are also central to maintaining good oral health.
Such communication needs to include reference
to the dental care entitlements for older people,
how to find out about services in an area and
what additional support or equipment may be
available.
Where financial allocations have been based
on historical spending rather than need for
dental care, funding is clearly a restraint to
PCTs commissioning additional services. As
the Department of Health develops a formula
for the allocation of additional funding, it must
adhere to its commitment to base this on need
rather than historical spending.
• free dental examinations for over-65s
Over-65s have access to free eye exams and
hearing tests, and dental screening can help
detect conditions which, if left untreated, can
play an equally significant role in an older
person’s health and well-being. In Wales,
entitlement to free dental examinations already
exists for the over-60s. These checks should be
accompanied by an individualised oral health
plan, devised by the dental professional in
consultation with the patient. The plan should
include the frequency of check-ups and any
dietary and lifestyle changes necessary to
maintain oral and general health.
August 2008
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ID7609 08/08 Registered charity no 272786
WE WILL fight to free disadvantaged older people in the UK and overseas from
POVERTY, ISOLATION and NEGLECT
Head Office, 207–221 Pentonville Road, London N1 9UZ
T 020 7278 1114 F 020 7278 1116
E [email protected] www.helptheaged.org.uk
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