Don’t forget the teeth: how can the dental discipline improve the care and well-being of people with dementia?

Early Onset Dementia is also increasingly seen in younger individuals too, further making dementia a mounting national health issue with major influence on oral health (British Dental Association; Powers).

Currently a cure does not exist, and therefore this terminal condition inevitably affects one’s ability to perform everyday activities, such as thorough and regular oral hygiene (eg brushing their teeth), leading to poorer oral health in the absence of well-trained caregivers (British Dental Association; Pynn & Kolic 2014).

Compounding cognitive deterioration, are the adverse oral effects of the drugs often prescribed ubiquitously for the management of dementia symptom progression. They often induce xerostomia (dry mouth), thus disturbing the oral commensal ecological balance to favour pathogenic microbial growth (British Dental Association). It is evident that people with dementia are associated with a certain set of factors that compromise their oral health and increase their susceptibility to oral disease. The dental discipline therefore is fundamentally involved in improving the care and well-being of those with dementia, in terms of maintaining an acceptable quality of life, with medical, oral, social, and behavioural benefits.

This article attempts to deliver an overview of the essential role of dentists and dental auxiliaries (dental assistants, dental hygienists, dental technicians) in the maintenance of oral health in people compromised with dementia.

Medical and general health benefits

Early diagnosis

The dental practitioner may be the first health-care provider to detect the subtle signs and symptoms of early dementia, and so they have a central role in the secondary management of the condition and its subsequent oral alterations (Edwards et al 2015; McNamara et al 2014). Dentists may recognise behaviour that is out of the ordinary, such as a previously reliable patient forgetting appointments, turning up at the wrong day or time, forgetting conversation that occurred in previous appointments, or repeating the same questions (Edwards et al 2015). People with dementia are usually unable to maintain thorough and regular oral hygiene as their health declines. So monitoring a relatively sudden deterioration in oral health may be indicative of early cognitive impairment. An open dialogue with the person’s close friends and family may also provide a context for concerns about the individual’s memory (McNamara et al 2014).

Once cognitive disease is suspected, the dental professional may encourage patients to seek diagnosis, make a prompt referral to the relevant health care provider (eg the local neurologist or psychiatrist), and promote utilisation of the available support services (Powers; Edwards et al 2015).

As dementia is a progressive degenerative condition, recognising it at the earliest point in time means that an effective management care plan can be implemented to slow disease progression, before it leads to further health problems (Alzheimer’s Society). Early diagnosis provides the time needed for the person with dementia and carers to better prepare for the challenges that dementia presents, and, allows the individual to exercise valuable autonomy before their cognitive status becomes questionable, through active participation in discussions about their future short­ term and long-term care (including power of attorney). The value of early diagnosis therefore may also specify implementation of standardised training of dental practitioners to be able to recognise those most at risk of developing dementia (McNamara et al 2014).

Additionally, those who are dependent on others for care are most at risk of mistreatment and neglect. As health professionals with a responsibility of care, the dental team (especially those doing domiciliary visits) must be able to recognise signs and symptoms of elder abuse, and act appropriately in the best interests of the patient and their well-being (Dougall & Fiske 2008).

Diet and nutrition

Positive oral health is a prerequisite for adequate nutrition and decreased risk of adverse health outcomes (such as infection and mortality) (Martin & Preedy 2014; Alzheimer’s Association). Masticatory function in people with dementia is often limited by tooth mobility, tooth loss, pain and discomfort from caries, periodontal disease, and ill-fitting prostheses (Alzheimer’s Society; Martin & Preedy 2014; Alzheimer’s Association). This may be poorly expressed by the patient due to aphasia, but adversely impact the ability to eat and one’s food choices (Pynn & Kolic 2014; Alzheimer’s Society; Martin & Preedy 2014; Alzheimer’s Association).

These factors may additionally be combined with increased difficulty recognising food, difficulty using eating utensils, forgetting to eat, medications with appetite suppressant side effects, and medications with xerostomic side effects (salivary hyposecretion impairs taste perception, food bolus formation, and swallowing) (Pynn & Kolic 2014, Alzheimer’s Association).

A self-perpetuating pathogenic cycle, that decreases masticatory efficacy and increases the risk of malnutrition, is often generated (Martin & Preedy 2014). For instance, severe weight loss may lead to ill-fitting dentures, which further impacts the ability to eat and receive adequate nutrition (Pynn & Kolic 2014; Edwards et al 2015; Alzheimer’s Association). Difficulty consuming wholesome meals may result in consumption of smaller, more frequent meals, and/or increased snacking of carbohydrate­ rich foods and fluids (such as candy or juice) (Pynn & Kolic 2014). These acidic foods/fluids may cause immediate dissolution and erosion of mineralised tooth structure, or favour proliferation of acidogenic and aciduric microorganisms associated with caries, initiating tooth destruction that further reduces masticatory function. Therefore, in re-instating the masticatory capabilities of the patient with dementia, dentists are crucial in the restoration of nutrition and general health (Powers; Edwards et al 2015).

Decreased dietary quantity and quality may be overcome through the arrest of active oral disease, prevention of further disease, and construction of well-fitting prosthetic appliances to generate a functional occlusion. More comprehensive long term nutrition and disease prevention may be achieved through integration of oral health with nutrition services, as well as cooperative educational and research work between dentists and nutritionists (Martin & Preedy 2014).

Minimise sources of micro-organisms that may later involve other parts of the body

Effective plaque disruption via mechanical or chemical debridement by the dentist, dental hygienist, or carer reduces the pathogenic burden within the oral cavity, and lessens the risk of developing peripheral infection, such as aspiration pneumonia. Aspiration pneumonia refers to the acute inflammation of the lung due to aspiration of oropharyngeal bacteria. It remains one of the major causes of hospitalisation and death of people with dementia in nursing homes. Many studies illustrate a correlation between inadequate oral hygiene and the occurrence of pneumonia, attributed to the increased prevalence of organisms with greater virulency, and greater induction of pro-inflammatory cytokines. Elderly patients with no oral care were found to have triple the risk of mortality from pneumonia, as compared to those who had an oral hygiene aide, who supervised or performed regular mechanical hygiene for them (Bassim et al 2008).

The predominant barrier cited for inadequate oral care by carers was lack of understanding of the significance of oral hygiene, and how to perform oral hygiene for others. This provides an opportunity for the dental ethos to better improve awareness of oral disease, and provide appropriate oral health care training for those caring for people with dementia, as an oral hygiene aide may be the most efficient intervention protocol for maintaining oral hygiene. Through cooperation of the dental team with the patient’s carers, the oral bioburden can be reduced, modulating the pathogenesis of pneumonia (to a less virulent and more survivable disease course), and therefore prevent unnecessary hospitalisation and potential death (McNamara et al 2014; Bassim et al 2008).

Managing the side-effects of medications taken for dementia

People with dementia often experience polypharmacy due to other existing chronic co­morbidities, with adverse oral effects often accompanying the medications prescribed almost universally for the management of dementia (including, but not limited to, anticholinergics, antipsychotics, antidepressants and sedatives) (Edwards et al 2015). Xerostomia is observed ubiquitously in people with dementia, and corresponds to increased plaque biofilm development, increased risk of caries and periodontal disease, dysphagia making talking/eating/swallowing difficult, and denture discomfort.

Dental practitioners are then in the position to offer advice to the patient, or caregiver, that may relieve the associated discomfort from a dry mouth, and improve their quality of life. This includes recommendation of frequent sips of water, antimicrobial mouth rinses, use of artificial saliva substitutes, denture fixatives, and regular application of fluoride varnishes may be implemented to resist or arrest caries development (Alzheimer’s Society).

The dental team may also work in conjunction with a speech pathologist/dietician to improve the swallowing capabilities of the patient. Some drugs also stimulate involuntary repetitive tongue and jaw movements (such as tardive dyskinesia and bruxism), making it difficult for patients to wear dentures, and may result in excessive attrition of natural teeth (British Dental Association; Powers; Pynn & Kolic 2014; Alzheimer’s Society).

Specialised prosthetics may be fabricated to overcome these drug-induced orofacial manifestations. Dentists may liaise with the patient’s medical practitioners, and possibly request alternative treatments/medications to optimise the individual’s oral health (eg switching syrup-based medications, which increases the risk of caries, to a sugar-free alternative) (Alzheimer’s Society). Correction of these undesirable secondary effects reduces additional factors that may compromise the everyday living of those with dementia, improving their patient experience.

Oral benefits and carer education

As dementia is heterogeneous in its presentation, intervention requires dental professionals to work within a broader interdisciplinary and multidisciplinary team that shares one focus – the promotion of oral health that extends beyond elimination of oral disease, to generate a comfortable and functional set of dentition, with masticatory, phonetic, and aesthetic capacities, and thus improve patient well-being (Pynn & Kolic 2014; Martin & Preedy 2014). As accurate information may not always be available from the patient, integration and discussion with their carers and other healthcare providers ensures the most holistic care can be provided (Pynn & Kolic 2014).

However, currently investigations reveal people with dementia experience greater levels of plaque and calculus, active caries and periodontal disease, when compared to individuals without dementia (British Dental Association; Dougall & Fiske 2008; Nitschke et al 2015). These clinical outcomes are indicative of poorer oral health, reflecting the substantial deficit in carer knowledge and training in oral care (Dougall & Fiske 2008; Martin & Preedy 2014; Nitschke et al 2015).

As carers represent the primary oral care providers when the condition progresses, their perception of oral health and hygiene must be optimised (British Dental Association). This means the dentist has a vital role in not only establishing a therapeutic relationship and rapport with the patient, but in engaging and educating carers, in order to achieve successful treatment outcomes (Pynn & Kolic 2014; Alzheimer’s Society). By coordinating with the carer (who may be a social worker, nurse, or family member), the patient (if possible), and their general practitioner, there can be formulation of a management plan that is specific and realistic to the patient status, and able to be adapted to a decline in the patient’s health over time (British Dental Association; Pynn & Kolic 2014; Alzheimer’s Society). Cooperation with the patient’s various health care providers generates a supportive, effective environment for the delivery of high-quality patient-centred care.

In early dementia, most dental treatment is possible, allowing for restoration and rehabilitation of the oral cavity. The dentist may establish a daily care routine tailored to those with reduced manual dexterity, possibly involving a high-concentration fluoride toothpaste, an electric tooth brush, and flossettes (McNamara et al 2014; Alzheimer’s Society).

While individuals are encouraged to perform their own oral hygiene for as long as they can, the dentist/hygienist may instruct the carer to remind the patient, supervise the patient, or demonstrate how to clean the mouth and/or prostheses to the patient (Pynn & Kolic 2014; Alzheimer’s Society). There may be management of any sites of acute/chronic pain or pathology, and instillation high-quality but low-maintenance restorations (British Dental Association). The dentist will take into account the eventual cognitive decline of the individual, and consider advanced restorative treatment (including removable dentures, prosthetic crowns, bridges, and implants) if the person has a carer willing to carry out the necessary hygiene in later dementia stages.

Aggressive preventative methods and frequent recalls are employed at all stages to arrest oral disease at the earliest point in time, prevent development of oral complications and emergencies, and ensure maintenance of positive oral health (British Dental Association; Alzheimer’s Society). As the disease progresses, the focus of dental management changes from restorative to prevention of disease and maintenance of oral comfort (Powers; Alzheimer’s Society).

There may be a growing disinterest in dental maintenance and reduced physical ability of the individual to maintain their oral health and communicate dental issues, so the dentist or dental hygienist may provide the carer with guidance on how to appropriately assist in cleaning another person’s mouth (British Dental Association; Alzheimer’s Society). Reduced tolerance to dental procedures outside their normal environment may require at-home visits or referral to local domiciliary services to ensure continuation of oral care (British Dental Association; McNamara et al 2014). Therefore, the dental team serves to continuously contribute to well-being and quality of life throughout the stages of dementia progression.

Social and behavioural benefits

Dentists employ their knowledge and skill set to provide those with dementia a comfortable occlusion that restores the masticatory, aesthetic, and phonetic functions needed for social interaction (Martin & Preedy 2014). Poorly functioning occlusion limits the food choices available to those with dementia, and therefore may diminish the pleasures associated with eating with others. Missing or grossly decayed teeth, and overtly inflamed gingiva, can lead to soft tissue profile changes, and in combination with halitosis, may detract from the physical appearance and negatively affect patient self-perception and self-esteem (Alzheimer’s Society; Martin & Preedy 2014). Tooth loss can also inhibit speech, further fostering social isolation.

These signs may be compounded with dental pain, and may also manifest as behavioural alterations that limit social integration. Dental practitioners in collaboration with carers may be able to recognise and interpret behaviour indicative of pain/discomfort in people with dementia who have difficulty expressing themselves (Alzheimer’s Society). This may include disinterest or avoidance of food, frequent pulling at the face or mouth, shouting, withdrawal from daily activity, and aggression (British Dental Association; Pynn & Kolic 2014; Alzheimer’s Society; Griffin et al 2012). Treating the source of pain in turn may allow discontinuation of altered behaviour such as restoration of nutrition, and re­participation in social activities, necessary for the overall social well-being of the person with dementia.

Thus, implementation of restorative measures, and thorough and regular hygiene practices, contribute to psychological and physical well-being (as it enables the patient to be pain-free, enjoy eating, maintain confidence in their appearance, and talk comfortably), for full participation in society (British Dental Association; Martin & Preedy 2014).

Conclusion

Recognition that the management of people with dementia is modified by a set of conditions specific to cognitive deterioration, ensures that delivery of oral health by the dental discipline refers to not only the absence of oral disease, but the establishment of a comfortable, aesthetic occlusion with masticatory and phonetic function. The dental profession hence has the capacity to contribute to enhanced quality of life with improvement in medical, oral, social and behavioural facets of the patient experience (Pynn & Kolic 2014; Martin & Preedy 2014). Early diagnosis acts as a catalyst for intervention via an interdisciplinary and multidisciplinary team approach to achieve long-term positive oral health outcomes (Pynn & Kolic 2014; McNamara et al 2014; Martin & Preedy 2014).

It is important to note that analysis of existing publications on the dental management of people with dementia was largely limited by their cross-sectional nature, differing data collection methods, population bias, and low response rates (see References 1-10). Nonetheless, and despite the growing prevalence of the condition, many investigations confirm a poor overall standard of dental care that people with dementia receive, thus revealing a substantial knowledge deficit on the importance of, and techniques for, maintaining oral health by carers (Bassim et al 2008; Nitschke et al 2015). This prompts change in the existing oral healthcare system and possibly implementation of standardised education and training for carers by those within the dental community, to better meet the needs of those with dementia (Nitschke et al 2015).

Danica Zhan

Bachelor of Dental Science (Honours), University of Queensland