LONDON, England: Meeting the oral care needs of rapidly ageing populations is one of the greatest challenges facing modern dentistry. A new document from National Health Service (NHS) England recognises the urgent need for reform and sets out a framework for maintaining oral health in older adults. Aimed at dental service providers, oral health bodies and clinical teams in general, the framework does not propose new dental services, but sets out a significant change in how oral healthcare for older adults should be planned, commissioned and delivered.
NHS England argues that service planning has often been organised around where care is delivered, rather than around the needs of older people across the ageing life course. The new framework instead asks local systems to consider oral health needs across the ageing population, including those living independently, those receiving care at home and those in residential or nursing care.
A central change is the use of dependency rather than age as the basis for planning. Drawing on the World Health Organization’s healthy ageing model, NHS England distinguishes between functionally independent, frail and functionally dependent older people. These groups are assessed against three levels of care—Level 1 for routine care, Level 2 for care requiring enhanced skills or facilities, and Level 3 for specialist care—according to individual complexity and dependency status. The aim is to ensure that services respond to changes in function, cognition, mobility, communication and care needs rather than treat older adults as a homogeneous group.
The framework reflects major demographic and oral health changes. The document notes that the number of people aged 65 years and over in England has almost doubled over the past 40 years and that the number of people aged 80 years and over is expected to double in the next 40 years to over six million. At the same time, more older adults are retaining their natural dentition. According to the 2021 Adult Oral Health Survey, 52% of adults in England aged 75 years and over reported having 21 or more natural teeth.
These changes have created a different challenge for dental services. Older patients may now present with heavily restored dentition requiring long-term maintenance, and frailty, dementia, multi-morbidity and polypharmacy can increase the risk of caries, periodontal disease, xerostomia and poor oral hygiene. Declining dexterity, sensory impairment, reduced capacity to consent and difficulties attending dental appointments can further complicate care.
The framework therefore places prevention at its centre, emphasising routine plaque control, fluoride-based prevention, support for xerostomia and broader lifestyle advice. It also stresses the importance of oral health training for all carers, including care agency staff supporting older people in their own homes, as well as care home staff and informal carers.
For dental teams, one of the most important messages is that most older adults should continue to receive care in general dental practice wherever this is clinically appropriate. Referral to special care, other specialist or hospital dental services should be based on complexity and specific treatment need, not on age, disability or frailty alone.
The document also highlights the need for more consistent triage. The framework recommends that services use the British Dental Association’s Case Mix tool as a common method for assessing complexity and directing patients to the appropriate level of care. This would help to assign care levels to patients according to factors such as communication, cooperation, medical status, access needs and oral disease risk.
NHS England advises commissioners to include domiciliary dental care in service planning and set clear criteria so that home-based care is reserved for patients who need it. It also suggests that commissioners use wider health and social care data, including information on dementia, frailty and home care provision, to model demand and identify unmet need.
The framework encourages closer integration between dental services, primary care networks, pharmacy, dietetics, social care providers, voluntary organisations and local authorities. It also calls for improved data sharing to support safer and more patient-centred treatment planning.
Changes for the dental workforce
The workforce implications are substantial. NHS England says dental teams need further training in gerodontology and in the management of medically and socially complex older patients. It also calls for dental care professionals to be enabled to work to their full scope of practice in preventive programmes and clinical care delivery.
NHS England acknowledges that more detailed clinical guidance is still needed, particularly on practical clinical decision-making for older patients with complex restorative needs. It says such guidance should be developed with expertise from special care dentistry and restorative dentistry and should support practical, evidence-informed decision-making.
The framework places responsibility on integrated care systems, local authorities and dental commissioners to assess local oral health needs and design appropriate care pathways. It says integrated care boards should work under the clinical leadership of managed clinical networks for special care dentistry to shape local arrangements and develop quality and outcome measures. In areas without such networks, NHS England recommends establishing local expert groups with input from general dental services, special care dental services, and experts in special care dentistry and restorative dentistry.
For the dental profession, the framework signals a move towards earlier intervention, shared care and more flexible pathways for older adults. However, its impact will depend on how local systems commission services, train the workforce and support general dental practice to provide preventive, maintenance-focused care for an increasingly dentate ageing population.
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