Realising potential: supporting service users to improve oral health Laura Beaton and Fiona Macfarlane

Learning Outcomes By the end of this session you will: Understand why oral health is important for the overall health and wellbeing of homeless service users. Know what you can do to support and empower service users to address their oral health concerns.

Session Outline Introduction Why is oral health important? Discussion/Group activity Case Study Supporting service users Summary

Why is oral health important?

“Poor oral health affects overall general health, nutrition, quality of life, communication, appearance and employability; all of which compound the problems for individuals attempting to escape homelessness.” - Margie Taylor, Chief Dental Officer Foreword, Smile4life: Guide for Trainers

Common Risk Factor Approach It’s not just teeth! Common Risk Factor Approach to oral health Oral health conditions such as dental decay and gum disease share common risk factors – such as smoking and diet – with general health conditions such as heart disease or obesity. Adopting behaviours conducive to good oral health will also have a positive impact on general health. Sheiham and Watt (2000)

Hodgetts et al. (2007); Lester et al. (2002) Health Inequalities People affected by homelessness face: Material hardship Social marginalisation Unmet health needs Difficulty accessing primary care (e.g. GPs, dentists) Shaw et al. (1999) – homeless people were found to be: 34 times more likely to commit suicide than the general population 150 times more likely to be fatally assaulted than the general population Lester and Bradley (2001) – there is a lack of training among GPs in how to deal with homeless patients, worries about time costs, and often negative perceptions about homeless people. Possible to generalise these findings (Lester and Bradley, 2001) to other health professionals such as dentists Hodgetts et al. (2007); Lester et al. (2002)

Oral health inequalities Variable Smile4life homeless population (n=853) General population (Scotland) Dental phobia 20% 11% Methadone prescription 32% 12% Anti-depressant prescription Smoking 85% 23% Regular alcohol consumption (“most days”) 29% Painful aching, discomfort, self-consciousness and embarrassment were all commonly reported oral health impacts. These figures are from Smilel4ife report, and show that homeless populations differ from the general population in many health-related aspects. Source: Smile4life: The oral health of homeless people across Scotland

Oral Health Inequalities From Smile4life report Two thirds registered with a dentist 68% attended only due to pain 21% attended for routine check-ups Access to dental services Confusion over where to access Confusion over eligibility to free or subsidised care Worries about cost of treatment and fines Fear of rejection / refusal from practice Stigma Communication issues Chaotic lifestyle - non completion of treatment There are not just inequalities in terms of health behaviours but also access to dental services. From Smile4life report: Two thirds not registered with a dentist 68% attended due to pain Only 21% attended for routine check-up

Quality of life Oral health significantly impacts upon quality of life, e.g. speaking, eating, appearance, pain. The Smile4life survey found that the most common oral health impacts among a homeless population were: Feeling embarrassed and self-conscious about teeth, mouth or dentures 13% of the 853 participants reported that their lives were less satisfying because of problems with their mouth and teeth “When I was in the town talking to people, I was hiding my mouth, getting embarrassed.” (M, 35) Women experienced a greater number of oral health impacts on their quality of life 25% self conscious very often 23% feeling embarrassed about mouth and teeth very often 31% painful aching occasionally 28% discomfort when eating occasionally 21% interruptions with meals occasionally

Oral health-related quality of life

Self-esteem “Your self-esteem is low, and you’re looking in the mirror and you’re seeing bad teeth, it’s not exactly the best thing for lifting that self- esteem, to give you a bit of confidence... Once I got my teeth sorted, I felt better myself, and it did lift my self-esteem a lot, and boosted my confidence. I wasn’t self-conscious about smiling anymore.” (F, 43) Smiling impacts on how others perceive you. When you smile people are likely to assume that you have positive qualities (Kershaw et al., 2008) This quote from the Smile4life report clearly emphasises the importance of good oral health – it impacts upon how you feel about yourself, and how others see you.

Depression From Smile4life survey, 58% of homeless people suffered from a depressive illness Links exist between depression and oral health 19% of depression could be explained by missing and filled teeth People who were depressed had more decayed teeth Poor oral health -> negative oral health impacts and/or dental anxiety -> depression Additional barrier to accessing dental care Smile4life could be a link into addressing dental anxiety with service users and exploring how to support clients Coles et al., 2011

Quote from health practitioner, about a service user “...very self-conscious of her appearance and feels that if she could get work carried out (on her teeth) she would be able to improve her life” This quote from the Smile4life report is from a health practitioner talking about a homeless service user. It is illustrative of how oral health is crucial to overall health and wellbeing.

Employability Everyone has the potential to experience the increased wellbeing, confidence and esteem that is proven to arise from work / positive engagement with the employability process The journey into work does not necessarily mean paid employment, e.g. internships, volunteering, apprenticeships There needs to be strong engagement with activities to get someone in supported accommodation motivated and raise their self esteem to start the journey out homelessness Improved oral health » Raised self-esteem and confidence » steps towards employment, out of homelessness Journey to work not necessarily gaining or sustaining employment Not all about paid employment – volunteering/ apprenticeships/ Making positive steps to improve oral health outcomes e.g. dental visits to fix/ replace broken /missing teeth can help raise self esteem and confidence of individuals and encourage them to make steps into employment by starting the journey

Discussion/ Group Activity

Case Study – Client X History Female, 24 years old. Unsettled way of life for numerous years. Experimented with drug and alcohol misuse since a young age. Has been homeless on a few occasions, due to a breakdown in family relationships and anti-social behaviour. While having a chaotic lifestyle, she did not see oral health as a priority. Inconsistent dental attendance, due to missed appointments and not being able to afford the charges. Due to the poor condition of her teeth, a previous dentist wanted to just take her teeth out. She felt embarrassed and ashamed about her teeth, and felt that dental staff would judge her. She developed a fear of visiting the dentist, and admitted that her teeth were in a very poor condition, but she did not want to have them completely removed. Since spending a long period of time in temporary B&B accommodation, a permanent tenancy was signed. Housing support involvement started.

Case Study – Client X Support Discussion of Smile4life and agreement to attend dentist with support. Initial contact with local dentist did not give Client X faith, as they were not accepting NHS patients. A dental appointment was made with a practice accepting NHS patients. Client X was extremely nervous, anxious and frightened. It was agreed that a support worker would go into the dentist’s room with her. Client X needed constant support and reassurance while in the reception area, to ensure that she attended her appointment and did not run away. The support worker discussed oral health and reducing smoking and caffeine intake, as well as developing a regular brushing routine.

Case Study – Client X Work completed Outcomes Full scale and polish X-ray of mouth Root canal treatment Temporary teeth Extraction of 6 teeth Outcomes Client X is extremely happy with her temporary teeth, and her confidence has significantly increased. She is now smiling and taking pride in her appearance, and can now speak to people without hiding her mouth. She can now attend the dentist independently, if she knows that she is not having a tooth extracted. Continued support provided. Appointment booked for three months time.

Supporting service users

Supporting Service Users Recognise that ANYONE working in any capacity within homelessness can have a positive influence on health outcomes for service users even if you don’t have health and wellbeing in your job title Create a culture of health and wellbeing to support service users through their journey Include health and wellbeing outcomes in your strategic aims and service design Up-skilling staff – health and wellbeing awareness (e.g. Smile4life for Oral health) Up- skilling service users – health and wellbeing awareness (e.g. Oral hygiene) Recognise and respect the right of service users to engage with the process at a pace right for them offering tailored and flexible support Engaging with service users in a holistic, person centred approach could transform individuals wellbeing Health is determined by many interrelating and overlapping factors (personal, social networks, socio economic, environmental) therefore addressing issues that may not directly be thought of as having an impact on health may indirectly have a positive influence on an individuals health and wellbeing. This therefore is also true on the other hand in terms of addressing, for example, oral health for service users. By raising the issue and supporting service users to access dental services and improve their oral health there are direct influences on appearance, speech, ability to talk, eat etc however the indirect outcomes for improved oral health for the individual may centre around self esteem, confidence, progressing on a journey to employability,.

Supporting service users Potential Concerns Solutions Oral health / health and wellbeing not recognised as part of role Insufficient knowledge / fear of giving the wrong information Worried about raising the issue in case it impacts on the relationship with the service user Insufficient time with service user to be able to help Holistic, person centred approach dealing with the individual needs of the service user Smile4life training will address this Too important an issue not to raise in order to fully support holistic needs of service users Small steps, brief intervention approach over a period of time

Source: Getting NHS dental treatment in Scotland Registration How to register with an NHS dentist: Contact your local NHS Board or visit www.nhs24.com and go to “Find your local services” Contact dentist and ask to be registered as NHS patient. After registration: You must sign a form, registering with your new dentist. The dentist will ask for some information about you, arrange a dental check-up, and offer information about available services. Not all dentists provide NHS treatment, and not all dentists are taking on new NHS patients. Registered for life unless you or dentist request registration to be withdrawn If a person attends another dentist and you don’t inform them of your registration elsewhere your registration will automatically transfer to that dentist A dentist cannot refuse to provide a registered NHS patient with any treatment they need to secure and maintain their oral health under the NHS After each appointment you will be asked to sign a GP17 form, in the right place, indicating if you have to pay for treatment Source: Getting NHS dental treatment in Scotland

Charges An NHS dental examination in Scotland is free of charge for everyone. Following a dental examination, the dentist will advise you on any treatment you require and the likely cost. They must also provide an itemised account, if requested. NHS patients who pay for their treatment pay 80% of the treatment costs (including any x-rays), up to £384 per course of treatment. A dentist can ask for payment in advance. Source: NHS Inform

Charges Actual charges may vary where additional treatments are provided Examinations: Free One small x-ray: £3.20 Scale and polish and simple gum treatment (includes oral hygiene instruction): £10.20 Small filling: £6.92 Large filling: £17.76 Root filling (front tooth): £37.36 Tooth coloured front crown: £67.24 Extraction – single tooth: £6.36 Upper and lower dentures: £140.28 Denture repairs: Free

Source: NHS Scotland Counter Fraud Services Exemptions You must provide evidence that you qualify for these conditions Source: NHS Scotland Counter Fraud Services

Source: NHS Scotland Counter Fraud Services

Part 1 – You and your partner Part 2 – Children and qualifying young people Part 3 – Other people who live with you Part 4 – Property, savings and other money Part 5 – Your income Part 6 – Work Part 7 – Where you live Part 8 – People in full time education Part 9 – Other information Part 10 – Declaration

NHS Patient Rights and Access Under Access in the Charter of Patient Rights and Responsibilities, you have a right to: use NHS services free of charge, where applicable have your needs taken into account expect your Health Board to assess the local community’s health needs treatment in other European Economic Area (EEA) countries request support to access NHS services be registered with a GP practice receive inpatient or day case treatment within 12 weeks of agreeing to it. Source: NHS Inform

NHS Patient Rights and Access Your Health Board must take your needs into account but must also consider the rights of other patients. You must never be refused access because of your: age sex race religion or belief disability sexual orientation gender reassignment marriage or civil partnership pregnancy or maternity. PASS – independent service- free, accessible and confidential advice and support to patients, carers and families provided by CAB Helps understand right responsibilities Info, advice, wish to give to feedback Provide practical help making a complaint, writing letters, phone calls, making a complaint, preparation for meetings Work with NHS to provide feedback Source: NHS Inform

Useful resources HCS1: Are you entitled to help with health costs? HCS2: A quick guide to help with health costs Getting NHS dental treatment in Scotland Citizens Advice Bureau: Patient Advice and Support Service NHS Scotland Counter Fraud Services: Help with the cost of NHS Dental Treatment NHS Inform Scottish Homelessness and Employability Toolkit

Summary

Oral health impacts on quality of life, depression, self esteem, confidence and employability Recognise that ANYONE working in any capacity within homelessness can have a positive influence on health outcomes Smile4life is a programme to improve oral health awareness, knowledge and outcomes for service users by enabling health and social care staff to provide information and support to access dental services Support service users with information, signposting, dental registration and patient rights