uSing rolE-substitutioN In care hOmes to improve oRal health (SENIOR)

Aim: To undertake a cluster-randomised controlled trial to determine whether Dental Care Professionals (DCPs) can reduce plaque levels (improve oral cleanliness) of dentate older adults in care-homes over a six-months, compared to ‘treatment as usual’ and whether this effect is sustainable.

Background: The oral health of care-home residents is much worse than their community living peers (e.g. caries prevalence is 73% vs 40%) and about half of all care-home residents now retain some of their natural teeth. Poor oral health may also exacerbate a range of medical conditions including pneumonia and delirium, increasing healthcare costs and leading to poorer outcomes.

Despite this high level of need, dental service provision in residential care is poor, with little emphasis on prevention. Access to domiciliary services is difficult and unscheduled care for dental problems (including hospital admissions) is common, complex to deliver and expensive. The World Health Organisation argues that the design of long-term care systems that are fit for ageing populations should take priority and the Royal College of Surgeons of England, Public Health England and the National Institute of Clinical Excellence (NICE NG48) have all called for more high quality research.

The recent report from the Care Quality Commission in June 2019, highlighted the paucity of NHS dental provision in care-homes.

There is increasing evidence that DCPs offer an alternative to using dentists to meet future challenges in dental public health. DCPs are a broad range of professionals, which include Hygiene-Therapists (H-Ts) and Dental Nurses (DNs). Lead applicant PRB has demonstrated that H-Ts can identify and screen for dental caries and periodontal disease and are safe as front-line health care workers.

The feasibility, productivity and effectiveness of using H-Ts has been tested in primary care, but not in a care-home environment. Use of DCPs (H-Ts and DNs) within residential homes has the potential to improve the provision of care, improve access to services and preventive advice. This study complements a number of on-going studies being undertaken by many of the same team, including NIHR PHR 17/3/11 'Improving the Oral Health of Older People in Care-homes: a Feasibility Study (TOPIC)'.

Design: Three work-streams (WSs) are proposed. WS1 will be a two-arm cluster-randomised controlled trial, with a three-month internal pilot. In the intervention arm, DCPs (H-Ts and DNs) will proactively oversee the clinical management of eligible dentate residents.

They will promulgate advice to improve the day-to-day prevention offered to residents by formal carers (DNs), provide preventive care and any simple operative treatment for individual residents (H-Ts), within their Scope of Practice. Dentists will be referred onto when necessary. This will be contrasted with current practice (which is likely to be very heterogeneous).

WS2 will be a parallel process evaluation, using semi-structured interviews with key stakeholders, exploring the intervention’s acceptability and determining the factors that influence the interventions pathway-to-impact. WS3 will be-a cost-effectiveness analysis.

Dissemination: The research team have substantive links with the Chief Dental Officers across the UK, commissioners, Consultants in Dental Public Health and Restorative Dentistry, Platform of Better Oral Health in Europe and national and international academics.