OBJECTIVE: This paper presents a contextual approach to the assessment of dental health needs based on a life course approach with vulnerability integrated within the assessment of need. BACKGROUND: Life course approaches to needs assessment,health care planning and commissioning of services are gaining popularity as there is a move away from simpler assessments of need based purely on population demographics such as age. The use of an assessment of vulnerability will be essential in the development of care pathways that are based on patient and population need rather than demand. METHODS: As an example of the health needs of a vulnerable population data are presented on an oral health needs assessment within nursing and residential homes in the North West of England. FINDINGS: These data serve to demonstrate the challenges of the disease burden within such a population but also the complexities of commissioning and delivering services to this group of patients. CONCLUSIONS: Care pathways designed to assist such patients should consider not only prevention and treatment modalities but also the means of implementing such therapies in varying settings and utilising the whole dental team.