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

2. 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.

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

4. Why is oral health important?

5. “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

6. 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)

7. 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)

8. 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

9. 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

10. 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

11. Oral health-related quality of life

12. 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.

13. 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

14. 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.

15. 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

16. Discussion/ Group Activity

17. 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.

18. 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.

19. 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.

20. Supporting service users

21. 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,.

22. 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

23. Source: Getting NHS dental treatment in Scotland
Registration
How to register with an NHS dentist:
Contact your local NHS Board or visit 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

24. 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

25. 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

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

27. Source: NHS Scotland Counter Fraud Services

28. 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

29. 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

30. 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

31. 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

32. Summary

33. 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