Oral health among a group of homeless individuals from dental professional's and patient's perspective

Abstract

The homeless are a vulnerable group in society. They are frail, in poor general health and tend to have difficulty expressing expectations and needs. While poor oral health is clearly an added burden for people who struggle daily to survive under miserable living conditions, there are also many barriers to dental care. There are currently approximately 17 800 homeless people in Sweden, of whom 3 900 are in Stockholm. The overall aim was to describe the oral status of a sample of homeless adults, to analyse their perceptions of oral health and the consequences to focus on adequate dental care for the homeless. Both quantitative and qualitative research methods were applied.

In Paper I, the study population comprised 147 homeless individuals. All subjects underwent oral examination, including registration of periodontal status and caries data. The results showed that homeless adults in Stockholm had fewer remaining teeth than the general population. Heavy plaque accumulation will also have an effect on caries progression, expressed in this study as high DMFT (Decayed-Missing- Filled Teeth) values. Loss of teeth is likely to create dental and chewing problems, eventually resulting in increased dental and medical treatment needs.

In Paper II, the perceptions of homeless people concerning their oral health and perceived consequences of dental treatment were analysed. Open, tape-recorded interviews were conducted in conversational style. A phenomenological-hermeneutical method was used to analyse the subjects' stories. All narratives revealed expressions of loss as well as recovery in the informants' life- world. Both aspects highlight the fact that being homeless means loss not only of a permanent residence but also of many values and similarly, oral health was described and interpreted in terms of loss and recovery.

In Paper III sentences related to the homeless individual as a person, the underlying meanings of what the text talked about, were interpreted as codes and subthemes labelled as two themes, "Struggle to retain integrity" and "Need for freedom without responsibility". In sentences related to the homeless individual as a patient in dental care, the underlying meanings of what the text said were likewise interpreted in codes and subthemes labelled as two themes "Meeting the patient where he/she is" and "Future dental care". A common complaint from the homeless patients was disrespect from care providers. There were many ways of facing the dilemma, e.g. to keep a distance, to try to act normal. Ordinary regular dental contact could be seen as one way back to normal life.

In Paper IV 147 subjects were interviewed with a specially designed structured interview covering attitudes to oral health. 93.8% considered that the teeth are important, 86.3% experienced pain or soreness of the teeth.92.5% report ed chewing difficulties due, to pain, 68.4% subjects expressed embarrassment about the appearance of their teeth, 93.8% refrained from dental treatment due to economical reasons, and fear of dental treatment was confirmed by 70.5%, 74% subjects reported dry mouth, 67.4% had no toothbrush. 91.8% did not have a address or at least a poste restante, 92 % were drug abusers, 85% were tobacco smokers. The median number of teeth was 18.O.The median duration of homelessness was 5.0 years, the interval since previous dental treatment varied between 0.5 and50 years. 115% of the individuals had known HIV-infection, 20.4% reported known heart disease.