Homelessness, empathetic care and oral health

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  Posted by: Dental Design      28th September 2024

Bringing preventative care, educational resources and treatment to the most vulnerable and hard-to-reach populations is a goal close to the heart of many dental health professionals. Many clinicians do much to serve marginalised communities through outreach services, volunteering, or within their general practices.

A highly vulnerable group, suffering from inconsistent access to services, and very poor oral health, is the homeless community. In a recent study, 90% of homeless participants reported dental problems since they first lost their homes. 70% experienced edentulousness, 60% had oral pain, 56% had gingival bleeding, and nearly half experienced either dental caries, halitosis or sensitive teeth. 28% developed periodontal disease and 24% suffered from a dental abscess.[i]

Homelessness is a dehumanising condition, which can often be associated with shame and blame. Stigma is linked to poorer dental health – not only can it affect the way homeless people are treated by others, it can be internalised, affecting the way they behave and think about themselves. The fear of discrimination significantly affects the likelihood that a person experiencing homelessness will seek treatment for any condition, no matter how serious.[ii]

Many homeless people want to be able to access general dental services, but face practical as well as psychological barriers. High levels of shame, as well as dental anxiety amongst homeless populations is eased when health professionals exercise empathy, listen to them, understand their needs and respect them as human beings.[iii]

To offer excellent care, it is helpful for clinicians to understand some of the causes of homelessness, as well as some challenges homeless people face.

Understanding the scope of the problem

Reasons for homelessness are complex, but in recent years, lack of access to affordable housing is agreed to be the most common cause.[iv] The cost-of-living crisis strongly impacted housing insecurity, as household incomes decreased in real terms, and essentials, like food and fuel vastly increased in price.[v]

According to the Big Issue, in May 2024, there were 112,660 households in England living in temporary accommodation, including 146,800 children.[vi] An estimated 3,898 people slept rough last year – an increase of 27% on the previous year.[vii] In 2023, a total of 317,430 households in England – the highest on record – needed housing support from councils in England.vi

It is estimated that 64% of people experiencing homelessness in that time either lost their homes due to the end of a rental agreement – mainly due to landlords wishing to sell or re-let the property,[viii] or losing support from those formerly willing to accommodate them. 16% of homeless people reportedly fled their homes due to domestic abuse. The remaining 24% includes a host of different reasons,[ix] including leaving care, leaving the criminal justice system, or due to mental or physical ill health.[x]

Mental ill-health can trigger a series of events that can lead to homelessness, and being homeless, or at risk of losing a home, also has a devastating effect on mental health. Rough sleepers are twice as likely to experience depression, anxiety or panic disorder compared to the general population, and 15 times more likely to experience psychosis.[xi] The oral health of homeless people is aggravated by an increase in risky health behaviours and emotional trauma.iii

Advice for clinicians

A sensitive approach to dental care is very important when treating people affected by homelessness. Some advice[xii] from professionals working with homeless people includes:

  • Be aware that many homeless people have experienced trauma – this can impact on dental anxiety[xiii]
  • Remember that homeless people can feel very embarrassed by their situation, as well as problems with their teeth. Use non-judgemental, supportive language to help build trust
  • Be aware that some people experiencing homelessness may have some

cognitive impairments – use simple and accessible language[xiv]

  • Raise awareness of the value of self-care, good nutrition and oral hygiene
  • Encourage regular dental visits
  • Be kind!

If you have a patient who has experienced homelessness, offering them the tools to support them in maintaining optimal oral hygiene with kindness and empathy can help to improve outcomes. Showing patients how to perform regular cleaning with interdental brushes can help in reducing the risk of preventable decay, periodontal disease and tooth loss.

FLEXI interdental brushes used with PREVENT GEL from TANDEX is a great product to reduce the build-up of harmful biofilm, while remineralising and protecting teeth and gingiva. The FLEXI interdental brush range comes in various sizes, as well as an ultra-soft option to help patients with sensitive teeth. FLEXI also comes with a handy, accessible educational tool, that clinicians can use to help explain and demonstrate how interdental cleaning improves oral health.

By making vulnerable people like the homeless feel more comfortable with accessing dental care, and supporting them in developing positive oral health routines, you can make all the difference.

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Author: Jacob Watwood

[i] https://groundswell.org.uk/wp-content/uploads/2017/10/Groundswell-Healthy-Mouths-Report-Final.pdf

[ii] Reilly, J., Ho, I., & Williamson, A. (2022). A systematic review of the effect of stigma on the health of people experiencing homelessness. Health & Social Care in the Community, 30, 2128–2141. https://doi.org/10.1111/hsc.13884

[iii] Yusuf, H., Golkari, A. & Kaddour, S. Oral health of people experiencing homelessness in London: a mixed methods study. BMC Public Health 23, 1701 (2023). https://doi.org/10.1186/s12889-023-16648-x

[iv] Homelessness: Causes of Homelessness and Rough Sleeping. Rapid Evidence Assessment. Alma Economics/gov.uk. PDF (assets.publishing.service.gov.uk). March 2019 Available from: https://assets.publishing.service.gov.uk/media/5cab2a5040f0b6752a407311/Homelessness_-_REA.pdf Accessed July 2024

[v] Cost of living latest insights. Office for National Statistics. February 2024.  Available at: https://www.ons.gov.uk/economy/inflationandpriceindices/articles/costofliving/latestinsights Accessed July 2024.

[vi] https://www.bigissue.com/news/housing/how-many-people-are-homeless-in-the-uk-and-what-can-you-do-about-it/

[vii] https://www.crisis.org.uk/about-us/media-centre/rough-sleeping-rises-by-27-as-the-homelessness-crisis-deepens-across-england/#:~:text=The%20annual%20rough%20sleeping%20snapshot,27%25%20on%20the%20previous%20year.

[viii] Statutory Homelessness January to March (Q1) 2022: England. Official Statistical Release.  Gov.uk. July 2022. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1094516/Statutory_Homelessness_Stats_Release_Jan-Mar_2022.pdf

[ix] Why is homelessness increasing? The Connection at St Martin-in-the-Fields. Available at: https://www.connection-at-stmartins.org.uk/facts-about-homelessness/why-is-homelessness-increasing/. Accessed July 2024.

[x] https://www.local.gov.uk/sites/default/files/documents/22.7%20HEALTH%20AND%20HOMELESSNESS_v08_WEB_0.PDF

[xi] Rough sleepers in homeless hotspots to benefit from NHS mental health support. NHS England. June 2023. Available at:  https://www.england.nhs.uk/2023/06/rough-sleepers-in-homeless-hotspots-to-benefit-from-nhs-mental-health-support/. Accessed July 2024

[xii] https://groundswell.org.uk/wp-content/uploads/2017/10/Groundswell-Healthy-Mouths-Report-Final.pdf

[xiii] https://www.gov.uk/government/publications/working-definition-of-trauma-informed-practice/working-definition-of-trauma-informed-practice

[xiv] Stone B, Dowling S, Cameron A. Cognitive impairment and homelessness: A scoping review. Health Soc Care Community. 2019 Jul;27(4):e125-e142. doi: 10.1111/hsc.12682. Epub 2018 Nov 13. PMID: 30421478; PMCID: PMC6849546.

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