1. Smile4life

2. Unit 1 Overview of Smile4life

3. Smile4life: Unit 1 - Learning Outcome
To have knowledge of the oral health issues and barriers to accessing care as experienced by homeless people

4. Overview of Smile4life What is Smile4life?
A brief oral health promotion intervention enabling homeless people to improve their oral health knowledge/practices, and access to dental services
Implemented by homelessness sector health and social care staff

5. The overall purpose of Smile4life is to enable health and social care staff and support workers to provide evidence based tailored oral health messages to meet the specific and exceptional needs of homeless (roofless and houseless) people in Scotland.
Trainer to highlight categories
Roofless = People living rough, People in emergency accommodation
Houseless = People in accommodation for the homeless, People in women’s shelter, People in accommodation for immigrants, People due to be released from institutions, People receiving longer-term support (due to homelessness)

6. Setting The Scene Barrie Greenan Part of homeless population
Participated in Smile4life survey
Until the opportunity of dental treatment came my way I was resigned to a life of constant pain. When I was homeless I would sleep rough in
bridges suspended over the River Clyde. There was no possibility of dental care, to get access to treatment you need an address or photo ID -
a sleeping bag in a girder didn’t qualify. Back then I was a drug user and alcoholic, to get relief from the pain I would inject heroin into
my gums - methadone only worsened the decay. We (the homeless) would resort to pulling our own teeth or self-medicating with more alcohol
and drugs - a vicious cycle. In the past I would watch people smile and their smile would be returned, but not for me. I was embarrassed to laugh in public and ashamed to smile in front of my daughters. Toothlessness only lowered my self-esteem which never lifted from rock bottom - until now. The social stigma that excluded me from mainstream society has been removed and I can now move forward with confidence. Everyone in society, especially the homeless and vulnerable, should have the opportunity to access dental care - the effects are transformative.
Barrie Greenan

7. In 2005 improving oral health of homeless people was identified as a priority in the action plan for Improving Oral Health and Modernising NHS dental services, as well as the Health and Homelessness Standards.
The 1998 adult dental health survey revealed that the average adult between the age of 35 and 44yrs had lost 8 adult teeth. 41% of Scottish adults reported some dental pain in the past 12 months.
In 2008 Equally Well the ministerial task force report on health inequalities reported that policies and interventions are more likely to be effective in reducing health inequalities if disadvantaged and vulnerable groups are seen as a priority and recommended that a OHI programme be rolled out to support such vulnerable groups
The most recent document Is the oral health improvement strategy for priority groups which came out in May 2012 and has a number of recommendations for the homeless population

8. Smile4life Oral Health Survey
Trainer – give out copy of the survey form to participants and highlight information taken as follows:
Obvious decay experience (DMFT)
Dental Attendance – when last visited dentist, why, previous dental history, perception of dental care/visits
Medical History
Personal information including living status, drug, alcohol and smoking details
Questions to allow assessment of dental anxiety level
Oral health questions relating to the previous 12 months
Questions relating to their emotional state over the previous week

9. The Oral Health of Homeless People Across Scotland (2011) surveyed over 850 homeless people.
The findings confirmed poorer oral health among this group:
98% had tooth decay
52% had extracted teeth
23% felt embarrassed about their teeth
25% felt self-conscious about their teeth.
Trainer notes:
Many homeless people have unhealthy lifestyles and use tobacco, alcohol and/or drugs to manage the situation they find themselves in. An oral health needs assessment of homeless people in Scotland indicated a strong clinical need for oral health care among this population.

10. Barriers
Main barriers to attending a dentist have been identified as:
the organisation and image of dental practices
dental anxiety
costs : financial and time-related
“They wouldn’t give me another appointment unless I paid £30, which I didn’t have, so I just didn’t bother going back to them.” (M, 35)
Homeless people can face barriers to maintaining oral health and accessing dental care.
Homeless people face additional barriers to those above, as the recent Smile4Life report on oral health and homelessness in Scotland has shown.

11. Barriers Activity
In groups discuss the barriers a homeless person may experience with the following:
Managing Oral Health
Drug & Alcohol Addiction
Perception of Need & Expectations of Dental Care
Dental Anxiety
Emergency Dental Treatment
Split participants into groups and give each group a bullet point to discuss – depending on number of participants more than one category may need to be given to the groups.
You will get much more detail back from discussions than below.
Some examples: (from pg 15 – 17 of Smile4life – more quotes in guide))
Managing Oral Health - Can’t practice preventative oral health measures, have no where to go to brush teeth, may have dentures but no where to clean them, Quote from page 15 S4L – ‘I got dentures and then i got attacked in the town, and they were all smashed up. I made an appointment with the dentist again, i had an appointment for the Tuesday and I got the jail on the Sunday.’ (Male 35)
Drug and Alcohol Addiction – Oral care a low priority, poor oral health accepted as the norm
Perception of Need & Expectations of Dental Care – Feel invisible in accessing oral health services or discriminated against when they do attend, attendance dictated by homeless person’s urgency/perception of need, unknown registration state, missed appointments being held against them, never organised an appointment for themselves, only attend when in pain, have dentures so don’t need a dentist.
Dental Anxiety – needle phobias, previous poor experience,
Emergency Dental Treatment – teeth get taken out as no point filling them, extractions can lead to regret later on, quick fix not available and pain will be gone by the time get appointment.

12. Barriers Feedback from groups Managing Oral Health
Drug & Alcohol Addiction
Perception of Need & Expectations of Dental Care
Dental Anxiety
Emergency Dental Treatment
Obtain feedback from each group and discuss

13. Barriers continued
People who are homeless have increased experience of:
dental anxiety
embarrassment and self-consciousness
depression
It is suggested that these psychosocial factors must be considered as additional barriers to accessing dental care

14. Dental anxiety
From Smile4life report: Over 20% of Smile4life survey participants were dentally phobic. “I’ve been scared of needles for a long time, so I never went to the dentist, but my teeth were really bad… (I felt) disgusted.” (F, 32)
As discussed in the activity, dental anxiety is a potential barrier to seeking dental treatment.
This was identified in the Smile4life report, as the quote illustrates.

15. Embarrassment “I was talking to people and covering my mouth” (F, 32)
“When I was in town talking to people, I was hiding my mouth, getting embarrassed… kidding on I’m scratching my nose to hide my mouth. So I phoned up for an appointment.” (M, 35)
As it says on slide 9:
23% of homeless people who took part in Smile4life survey felt embarrassed about their teeth
25% of homeless people who took part in Smile4life survey felt self-conscious about their teeth.
Embarrassment and feeling self-conscious can be a motivator to seek treatment, as the quotes from the Smile4life report illustrate.

16. Depression From Smile4life survey
58% of homeless participants were suffering from a depressive illness
Link between poor oral health and depression
Depression was another factor examined by the Smile4life report.

17. Engagement with services
Only 31% of homeless Smile4life participants were registered with a dentist
Often only attend when in pain
“I don’t even know how to register (with a dentist), I don’t even know how to go about it.” (F, 17)
Homeless people often rarely engage with health services, including dentists.
Quote from Smile4life report is from a homeless girl who didn’t know how to register with a dentist because her parents had always dealt with her appointments.

18. Enablers Activity In groups:
discuss key points that would enable a homeless person to regain some control over their oral health
What can we as individuals or via our place of work do to facilitate this?
Participants in groups to discuss enablers
Examples –
Homeless person is ready to ‘move on’ out of homelessness
Reducing or ending substance misuse
Concerns about appearance of mouth and teeth
Need/want oral health information
Take first steps to resuming regular attendance.
What we can do, - signpost/support them in attending an appointment, remind them when an appointment is in the early stages. Provide oral health information/leaflets/resources, reassure and support through embarrassment, recognise a lack of confidence and help create a picture of a future with good oral health, recognise other issues homeless person has overcome.

19. Enablers Feedback from Groups: Key enabler points
Facilitation - individual and/or workplace

20. Positive lifestyle choices
Rebuilding relationships with family
Seeking help / treatment
From Smile4life report:
“It wasn’t until I started to address a lot of other life issues, that I started even thinking about getting a dentist.” (M, 36)
“Now that I’m not using anymore, it’s time to get my teeth back.” (M, 35)
Use this slide and quotes to reiterate points from enablers activity.

21. Access to Dental Services
One barrier to taking the first step to improving oral health could be dental access and payment.
As part of Smile4life check out what your local health authority Oral Health Team are doing to assist with access to dental services

22. Who gets help with NHS Charges?
There are many exemptions from NHS charges, If you have access to GP17’s pass some round for staff to look at, as having to complete a form can be another barrier.

23. 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)
Illustrative quote from Smile4life report, showing the value of interventions like Smile4life, not just in terms of improving oral health but also overall wellbeing.

24. Smile4life: Unit 1 - Learning Outcome
To have knowledge of the oral health issues and barriers to accessing care as experienced by homeless people
Recap of material covered, reflecting on learning outcome.

25. Questions?

26. Further reading: Smile4Life Equally Well Health and Homeless Standards
Equally Well
Health and Homeless Standards