Crisis in care homes: the dentists don’t come

The UK population is ageing rapidly: those aged 65+ were 15.8% in 1999, 18.5% in 2019, and projected to be 23.9% by 2039, adding an estimated 7.5 million people aged 65+ over 50 years. The social care system is under long-standing strain, highlighted by COVID-19. Policies enabling people to remain at home longer (e.g., 2009 Personal Care at Home bill) mean people enter care homes later with higher care needs. NHS dental contract changes in 2006 curtailed routine domiciliary dental care by general dental practitioners, limiting access for care home residents. Meanwhile, older adults retain more natural teeth (in 2009, 53% of adults 85+ retained some dentition; mean 14 teeth), increasing risks of caries and other diseases given reduced self-care and vulnerabilities. Institutionalised older people have fewer teeth and higher decay than community-dwelling peers. Gerodontology is emerging but the workforce is insufficiently sized, trained, and experienced to meet complex needs. These factors contribute to reactive dental care and dental neglect in care homes and motivated the NIHR-funded FinCH feasibility trial to explore preventive fluoride interventions and access challenges.

A literature review on access to dental care in UK care homes was conducted using Penchansky and Thomas’s (1981) theory of access (availability, accessibility, affordability, accommodation). Of 473 articles published in the prior five years, 39 addressed oral health of people in care homes and 11 addressed access to professional care. This analysis informed the interview topic guide and provided an initial coding framework that was refined during analysis.

Setting and sampling: Feasibility trial in one outer London borough with high numbers of care homes. Eligible homes cared for adults aged >65 years, had 60–80 beds, and had passed council inspection. A convenience sample of residential and nursing homes was approached; six homes participated. Participants: Care home managers, deputy managers, lead nurse, and carers. Data collection: 11 sessions (interviews and focus groups) across six homes. Sessions included: manager/deputy interviews and carer focus groups (see Table 1 summary in text). Ethical approval: NHS research and social care ethics (IRAS 202190). Written informed consent obtained; procedures aligned with the Declaration of Helsinki. Procedures: A trained interviewer (RP) conducted interviews/focus groups using a literature-informed topic guide of open questions to explore barriers, facilitators, and solutions for personal oral care and dental service access. Audio-recordings were transcribed verbatim under confidentiality. Analysis: A rigorous matrix-based (framework) approach per Spencer et al. was used. JM and RP, with JEG, iteratively read transcripts, adapted the initial framework (from the literature), and coded data in Microsoft Excel, indexing by themes and sub-themes, preserving context and key expressions/quotations. Findings synthesised to describe patterns and participants’ perspectives on policy and planning.

• Themes mapped onto Penchansky and Thomas’s five dimensions of access, plus care-home-specific issues around priorities, barriers/facilitators, and power dynamics.
• Low prioritisation and reactive patterns: Dental care often sought only when problems arise; residents may deprioritise oral health; carers’ beliefs about ageing and oral health can reduce proactive care.
• Dementia/behavioural challenges: Consistent contact with the same domiciliary dental personnel seen as important to facilitate acceptance among residents with dementia.
• Service availability and willingness: Difficulty locating NHS or private dentists willing to provide domiciliary visits; perceived reluctance linked to regulatory/equipment requirements; in absence of dentists, homes turn to GPs for dental issues.
• Preference and limits of domiciliary care: Preference for in-home care due to residents’ needs and access barriers; acknowledgement that in-home services can be limited in scope.
• Access pathways: Burdensome, lengthy referral processes requiring significant staff time; long waits; lack of coordinated, reliable pathways; some residents died without receiving needed dental treatment.
• Physical accessibility: Many clinics not wheelchair-accessible; transport availability limited; need for transfer assistance often unmet.
• Transport and cost barriers: High transport costs; unclear funding responsibility; residents without personal funds particularly disadvantaged.
• Affordability and exemption confusion: Disparities between self-funding and non-self-funding residents; staff uncertainty about dental charges and exemption criteria; lack of access to residents’ pre-care-home benefits data; fear of financial penalties for incorrect forms.
• Consent/capacity and chaperoning: Operational challenges in arranging appropriate chaperones and managing capacity/consent processes.
• Powerlessness: Managers/staff feel responsible but lack power to secure timely action from families/systems.
• Case study: An 87-year-old man with multiple broken teeth and carious roots relied on biscuits due to chewing difficulty; had not seen a dentist since entering the home; multiple transport and scheduling failures over a year; dentures nearly completed via in-home visits but final fitting cancelled; he was hospitalised, contracted COVID-19, and died, illustrating systemic failures.
• Quantitative/contextual details: 11 interview/focus group sessions across 6 care homes; literature scoping identified 473 recent articles, with 39 on oral health in care homes and 11 on access.

Findings reveal a misaligned, reactive dental care system for care home residents, with insufficient service availability, workforce expertise, and coordinated pathways. Mixed funding and policy misalignment between dental payment exemptions and social care financing create stark inequalities, particularly for residents needing specialist transport or lacking personal funds/active family support. High care needs (behavioural, physical, medical) at admission correlate with significant dental needs (disease, non-functional dentition, poor prostheses) affecting nutrition and quality of life, burdening care staff and residents. Aligning dental care with other routinely provided services (e.g., optometry, pharmacy, medical) and establishing routine, ongoing points of contact could support prevention and culture change in oral health. Emerging opportunities such as teledentistry, normalised during the COVID-19 pandemic, could complement face-to-face care to mitigate transport and compliance barriers. Immediate priority is commissioning adequate routine and urgent services, delivered by suitably skilled clinicians (notably community and specialist dental services), with coordinated, well-communicated pathways. Longer-term, increased funding, workforce expansion/upskilling in managing complex patients, and restructuring of general dental services are required.

There is an urgent need to commission sufficient routine and urgent dental services for care home residents and ensure delivery by clinicians skilled in managing complex medical, behavioural, and mobility needs. At a minimum, free routine dental examinations should be provided to all care home residents to facilitate advice, prevention, and pain-free function, aligning dental care with other health services (e.g., eye tests, prescriptions). System reforms should include coordinated pathways, enhanced community/specialist services, workforce development, exploration of teledentistry as an adjunct, and co-development of services with social care partners to ensure sustainable, person-centred, integrated care.

Findings derive from a qualitative component of a feasibility trial conducted in one outer London borough with a convenience sample of six care homes and 11 interview/focus group sessions involving managers and care staff. The setting, sample size, and qualitative design may limit generalisability. COVID-19-related service disruptions contextualise some access challenges reported.