DENTAL SERVICES FOR HOMELESS PEOPLE

Bringing a smile to the streets

Two locations in Dublin city centre since 2003

Cornmarket Dental Clinic – Appointment service

Merchant’s Quay Project (needle exchange and rehab centre) – Drop-in service

Merchant’s Quay clinic closed since Jan ‘09 - moving premises. Many clients don’t make it ‘up the hill’ to Cornmarket, or can’t keep appointment-miss the drop-in service. Indicitive of importance of multiple centres.

What is special care dentistry?

Special care dentistry is a branch of dentistry that provides care for people with ‘special needs’. This is a large group of the population in Ireland, some 365,000 people, who have one or more of the following:

A learning disability (e.g. Down syndrome, autism spectrum disorder)

Physical impairment (e.g. cerebral palsy, muscular dystrophy, spina bifida)

A chronic medical condition (e.g. cancer, congenital heart disease, epilepsy, clotting disorder, multiple sclerosis, Parkinson’s disease)

Mental illness People who are socially excluded

(e.g. people from the travelling community, homeless people, people who misuse substances).

Why are homeless people considered a special needs group?

Chaotic lives Addiction issues Move frequently from place to place Barriers to attendance of General dental practice Staff attitudes Fear Self esteem- teeth too bad already Medical Card possession• Where to get Information on health services? Expectations- Emergency Treatment/ Full course Missing dental appointments Fees for treatment Chronic physical and psychiatric health issues- Infectious

diseases

Homelessness

Not all homeless people fall into our preconceived ideas of Homelessness

Of more than 5000 Homeless people in Ireland, only 300 are rough sleepers. (Homeless Agency’s annual Winter Rough Sleeper Count and the Dublin Simon Community’s Health Audit) .

Number of rough sleepers is falling. Enough beds to cater for the population but sometimes not suitable/By choice.

And, the remainder? The population is wide and diverse.

Case Studies

Shenagh – 46,married in a middle class environmant, 2 children, physically abused by husband, alcoholic, staying in Focus sponsored alcohol rehab trans housing. Works in adult literacy center. Dental work P/-, ant. restorations

John – 38,HIV+,partner died of HIV,drug user,1child,staying in church sponsored rehab scheme. Now preaching. Dental work F/P

Natasha – 26,HIV+,Prostitute,Drug user,at risk of losing leg due to ulcers,offered a place to study in TCD. Dental F/P

Case studies

Maggie – 24, From travelling community. Has been in many abusive relationships. Disowned when turned to drugs. Nowhere to turn. Keyworker from Focus has taken her under her wing. Very interested in her appearance but erratic attender. Fillings/Ext

Kevin – 52, unmarried man bottom of housing priority list. Staying in hostel to increase chances of housing. Skilled labourer, tells me he has a bigger disposable income than I do – I’m sure he’s right! F/P

Homeless people cannot be stereotyped

One thing in common – Their dentition has a positive effect on their self-esteem and rehabilitation.

Homelessness

The list is endless; all of these people have stories. They start off life often just like you or I and something happens that they find themselves on the streets.

A person is considered homeless if they "are sleeping on the streets or in other places not intended for night time accommodation or not providing safe protection from the elements or those whose usual night time residence is a public or private shelter, emergency lodging, Bed and Breakfast or such, providing protection from the elements but lacking the other characteristics of a home or intended only for a short stay”. Eastern Health Board 1999

Homelessness

There are 5581 registered homeless in Ireland.

The Simon Community have recently warned that this is a gross under-estimation. (March 2009)

Over 4000 homeless adults registered in Greater Dublin area and 1000 dependant children.

Of those, approx.10% sleep rough. Accommodation; Emergency

hostels, long term hostels, B&B accommodation, the Night Bus, refuge, some may stay with friends and family.

Homelessness and drug misuse

Whilst drug use is not the primary reason for people becoming homeless; it is a key reason for them remaining homeless. The primary reason for becoming homeless was family conflict;

Other reasons for remaining homeless include access to housing, money problems, family conflict and continuing alcohol use;

Cannabis is the most commonly used illicit drug followed by heroin

Alcohol remains the primary drug of choice among the homeless population (70%);

Methadone and Benzodiapines popular both prescribed and black-market.

Drug Use

Over half (52%) of the homeless population are currently drug users;

36% are problematic drug users;

19% are currently injecting drugs, of these 1-in-2 injected in public spaces;

1-in-4 of current homeless drug users in Dublin use 5 or more different drugs;

30% has been diagnosed with a psychiatric illness;

Profile of Homeless Person in a Study undertaken in 2005

Gender: 69% male; 31% female. Age: The average age of males 29

years and females 24 years. Education: 25% had only primary

education; 50% reached lower second level; 15% reached upper secondary; 6% reached third level and 4% other education such as FAS training and apprenticeships.

Employment: 66% were unemployed; 24% unable to work; 10% either working, retired, on training course or raising children. 55% of Simon clients in recent study receiving disability benefits.

Prison: 55% have been in prison. Other: 15% suffer from other serious

problems, the most common are the effects of violence and social isolation

Health of Homeless people

More likely to suffer from chronic ill health- arthritis, heart disease, TB, Hep C, skin problems, injuries, eye and ear complaints, bone and joint problems.

Homeless people die younger, average age between 42 and 53 years (Crisis UK 2003)

30% experience mental health problems

68% have attempted suicide. (Cleary and Prizeman 1998)

98% have unmet dental needs.

Dental Problems experienced by Homeless Population (O’Neill 2000)

Gross Caries – 4 times more teeth requiring extraction, twice as many teeth requiring fillings than general population.

Periodontal status – poor Only 1% of population have no treatment need. 54% require S&P. 45% require complex periodontal treatment, of that 27% had shallow pocketing, 6% had deep pocketing and 12% had loss of attachment >9mm requiring extraction.

Oral Mucosal lesions – due to denture wearing, ANUG, leukoplakia (white patches)

Trauma to incisors – 45% of the population Mainly untreated

Dental Problems experienced by Homeless People

Dental problems experienced by drug users

Neglect during drug use High sugar cravings Xerostomic effects of opiates (heroin)- Dry mouth is an

increased risk factor for decay. Analgesic effect of heroin masks symptoms of tooth decay.

Pain is experienced once the person commences methadone with its reduced analgesic effect.

Roots and abscesses are a common complaint. Severe attrition (tooth wear) due to grinding Dental pain can lead to a drug relapse. Lack of self-esteem, believing they don’t deserve to have a

good appearance.

Effects of drugs on Dentition

Aim of service

The aim of the service is to provide pain relief and to improve aesthetics. This significantly improves self-esteem.

Antibiotics are provided from our store. Extractions are often required for pain relief. Not usually committed enough to have multiple visits for root canal

treatment and crowns. Anterior composite restorations and partial dentures provide good

aesthetics without exorbitant cost and in a short space of time. Regular visits are encouraged for scaling and it is good to say we

have many re-attenders for maintenance treatment. We have a store of Corsodyl rinse to give to patients. The outreach program involves going to hostels, day centres to

connect with the clients and give O.H.I, make appointments, discuss their concerns. Possibly the most important function of the service!

To assist patients in applying for a Medical Card.

Number of procedures carried out2008*,2007,2006,2005* week 9 2008 to week9 2009

Appointments

946

Emergencies

301

Fillings

769

Extractions

207

Dentures

198

Root Canal

10

739 329 479 214 40 4

917 332 577 324 45 45

755 309 465 427 81 15

Challenges to the Service

Creating a bottleneck service with many new patients entering and nowhere for the rehabilitated patients to go for continuing treatment.

Patients not applying for Medical Card. The chaotic nature of the lives of our patients means they appear sporadically.

Courses of treatment are often started multiple times for the same patient. Lost dentures! John lost his 2 day old denture down the toilet! Inter-disciplinary sharing of information is slow and tedious. There is a good

relationship within the multi-disciplinary team for the Homeless population “Safety Net” (G.P, nurse, dentist, social worker, psychiatrist, key worker) but an essential computer network has never materialised. Basic medical history and medication lists would make life much easier if available at the push of a button.

Changing staff in the day centres and hostels. Keeping up to date with new staff to maintain links with the centres. Centres with interested staff refer the most patients.

Interestingly the DNA rate of approx. 20% is similar to that of many General Dental Practices. (Lee,Earnest,Chen 2005; Blankenstein 2003)

Challenges to the Service

The number of foreign nationals seeking treatment is increasing. Many are ineligible for treatment and with no money, have nowhere else to turn. EHIC entitles to emergency treatment, most don’t possess one.

According to the Department of Social and Family Affairs’s “habitual residency clause” rule, a person has to be resident in the State for two years before being entitled to any welfare payment, (or to register Homeless)

Embargo on recruitment has effected the service with no replacement for maternity leave.

Many dentists both in Private practice and HSE are reluctant to take on Homeless patients.

Unsure if the Merchant’s Quay clinic will re-open.

Rewards

Appreciative patients Patients empowered by new found confidence, both by having new

teeth and by experiencing a positive relationship with a health care team.

To hear the changing life stories of the patients as they are rehabilitated.

The non-judgement of patients when they relapse into addiction, street sleeping or simply fail to attend to complete treatment.

Delight to see them re-attend. That they feel they can take up where they left off 6 months earlier.

To change a person’s attitude to the dentist, alleviate their fear. No fissure sealants!