Domiciliary Dentistry: How Does it Work?

For the past 6 months, I have been providing domiciliary dentistry (doms) to housebound patients. But how does it work?

Who do I see?

I see patients who are referred into our Community Dental Services (CDS) covering the Boroughs of Hackney and Tower Hamlets. We are referred patients by GPs, community nurses, doctors, nurses, care homes and carers and occasionally other dentists. For patients to receive domiciliary care, this means they cannot get access to our fixed site clinics. This can be due to a number of reasons:

  1. They are housebound and cannot leave their house. This could be due to physical disability, complex medical conditions (e.g. being bedbound due to MS), dementia or mental health issues e.g. agoraphobia
  2. They live in a care home where is it not practical/there is no escort to bring them into clinic. 
  3. They are an in patient in hospital whether this be chronic or an acute admission
  4. They are institutionalised e.g. in a forensic mental health unit 

What treatments do I provide?

Luckily, our doms team are very well established and we can provide many treatments in a home setting - although I'd like to add that the quality of some of the treatment we provide may be compromised compared to what we can provide in a clinic where we have adequate lighting, access and equipment. Some treatments I provide include:
  • Dentures - this is what I spent 70% of my doms days providing
  • Screening/check-ups - this allows me to signpost to a clinic if needed
  • Prevention advice e.g. Oral Health Care Plans, Oral Health Education for carers
  • Hygiene visits 
  • Simple fillings using ART 
  • Extractions - when appropriate cases

What equipment do I take?

If any of you follow me on Instagram (@natb990), you will probably have seen all the equipment I take with me on doms. Since our service uses pool cars which the dentists drive, we have to take the whole shabang of equipment with us, in comparison to services which use public transport where they cannot take oxygen for example. For doms, equipment I take with me includes:

  • Paperwork (notes, forms, lab work, prescription pad etc.)
  • Equipment needed for treatment - we have separate tool boxes for pros, extractions and cons
  • Emergency drug kit
  • Oxygen cyclinder
  • Defibrillator
  • Portable scaler if providing hygiene visit
  • Clinical waste box
  • Dirty instruments box
For example, last week this is what I took with me (thank goodness for the trolley and my nurse to help!)

A light weight day as we only had 3 patients to see!

What problems do I encounter?

When I started going out on doms, there were many situations I encountered which were challenging and I didn't expect beforehand; for example:

  • Manual Handling - what do you do if a patient lives on the 4th floor with no lift and we have all that equipment to carry? I heard lots of stories of other dentists damaging their backs from going out of doms and I realised it was important not only to look after the patients, but to look after myself and my nurse!
  • Positioning - you can really get into some funny positions when treating patients on doms. They may be bed-bound, have stooped postures or be in wheelchairs. I have learnt not to be afraid to ask to re-position a patient e.g. asking them to sit in a high backed chair or moving their hospital bed into a better position. Otherwise my posture will suffer!
  • Environment - having to do a risk assessment of an environment in your head as you enter a person's house is paramount for you and your nurse's safety. Often this can be helped by the team who book patients in for you e.g. asking if they can not smoke for hour before your arrival, to lock any pets away in separate rooms. It is very interesting to see how some people live and indeed it can also be shocking!
  • Infection control - trying to set up your zoning in an environment where often there is clutter everywhere can be a challenge! Especially the patients I see in London who are often living in rather cramped conditions!
  • Consent and capacity - most doms patients are elderly and specifically those I see in care homes, consent and capacity can be an issue. This may fluctuate depending on when you see them or with help from their carers or family but there have been times where I have needed opinions from my colleagues. For example, a patient with advanced Alzheimer's disease where his dentures were lost. His family were pushing to have a new set made for him, but me and my colleague decided it was not in his best interest - his appetite was unaffected and it was highly unlikely he would comply enough to allow treatment!
  • Patient expectations - treatment in a doms setting is different to clinics. It will take me much more time to make a denture than in clinic as I cannot see as many patients on doms, and the treatment I provide again will not be as good as in clinic e.g. only being able to place an ART GIC restoration in a tooth rather than a composite or amalgam. Often managing patient's expectations can be difficult, especially when I suggest that they need to come into clinic. Unfortunately, we no longer have access to a portable x ray machine, so even when I do check ups on doms, I have to emphasise to patients that even if I cannot see any issues visually, there may be undiagnosed issues going on I cannot identify without radiographs; therefore, I always recommend coming into clinic for a full assessment in dentate patients. 

What Guidelines are there?

The BSDH has published guidelines on Domiciliary Care - click here.
Other guidelines you may find useful are the new FGDP guidelines on Dentistry and Dementia - click here.

Overall, I really enjoy Domiciliary Dentistry and the challenges it presents. It's also nice to get out of clinic and I can actually practice my driving skills since I only passed my test last summer! I've still got lots of learn but I'll post up my top tips for doms soon so keep an eye out!

Do you do doms? What challenges do you face? Please leave your comments in the section below.

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