Dental care and dementia
Good oral health is important for general health, well-being and quality of life. It brings significant
benefits to self-esteem, dignity, social integration and general nutrition.
Poor oral health can lead to pain and tooth loss, and can negatively impact
self-esteem and the ability to eat, laugh and smile. This factsheet describes
some of the dental problems that people with dementia at different stages may
face and methods for prevention and treatment.
Dental
disease
There are two main types of dental
disease - gum (periodontal) disease and tooth decay (dental caries, more
commonly known as cavities). Both can cause discomfort or pain and can lead to
the development of infection. Both pain and infection can worsen the confusion
associated with dementia.
Gum
disease
Gum disease can cause inflamed and
bleeding gums, gum recession (where the gum tissue is reduced, causing the
roots of the teeth to become exposed), loose teeth and bad breath. It is caused
by the build up of dental plaque. Plaque is a combination of food debris and
bacteria from the mouth - everyone has some of it. Plaque leads to gum disease
if it is not removed by efficient cleaning as it builds up on the surface of
the teeth, particularly where the teeth meet the gum. Good oral hygiene
(keeping the teeth, gums and mouth clean by brushing and flossing) and the use
of a tooth gel or mouth rinse containing chlorhexidine (an antiseptic and
disinfectant agent) can help to control gum disease.
Tooth
decay
Tooth decay is caused by the action
of dental plaque on the teeth when food and drinks containing sugar are consumed. Essentially, the bacteria in
plaque feed on the sugar, producing acid, which in turn attacks the tooth,
causing decay. Dentists recommend restricting the intake of sugar to two to
three times a day, preferably at mealtimes, as it is the number of times we eat
sugar in a day, rather than the total amount of sugar consumed, that is
important in guarding against tooth decay. This includes hidden sugars in
foods, as well as sugar added to food or drinks. A healthy diet, good oral
hygiene, and the use of toothpaste or a mouth rinse containing fluoride will
also help prevent tooth decay.
High-energy food supplements contain
high levels of sucrose - a form of sugar. If they are used on a regular basis,
it is important that the teeth are kept very clean to minimize the risk of
decay. Gum recession increases the chances of tooth decay occurring at the
necks of the teeth (where the crown of the tooth meets the root at the gum)
unless oral hygiene is excellent and dietary sugar is controlled. When food
supplements are prescribed for a person with natural teeth, it is important to
get advice on prevention from the dental team.
Daily
care of teeth
Early
stages of dementia
In the early stages of dementia, the
person will usually still be able to clean their own teeth. They may need to be
reminded to carry out the task, or they may need to be supervised. If they need
help, try giving them the brush and toothpaste and show them what to do. As
manual ability decreases, an electric toothbrush may help maintain
independence. The person with dementia could also try using a toothbrush with
an adapted handle to improve their grip. Your dentist or dental hygienist may
be able to advise you on this as well as the best methods for prevention of
tooth decay and gum disease in the particular circumstances. It is very
important to establish an individual long-term preventive programme in the
early stages of dementia. This may include a high-concentration fluoride
toothpaste and regular application of fluoride varnish for people with natural
teeth. Fluoride can be applied by the dentist, dental therapist or dental
hygienist under the prescription of the dentist.
Later
stages of dementia
As their dementia progresses, the person may lose the ability to clean their teeth, or
lose interest in doing so, and carers may need to take over this task. A
dentist or hygienist can provide guidance and support on how to assist in
cleaning another person's teeth. The technique will vary depending on the
individual concerned. Generally, the easiest way is for the person with
dementia to sit on a dining-style chair with the carer standing behind. The
carer supports the person against their body, cradling their head with one arm.
They can then brush the person's teeth using a damp toothbrush and a little
toothpaste.
Drugs
and dental problems
People with dementia may be
prescribed antidepressants, antipsychotics and sedatives. One of the main
side-effects of these drugs is a dry mouth. Saliva acts as a lubricant and dry
mouth can cause problems with dentures, including discomfort and looseness.
Denture fixatives and artificial saliva can help some people with denture
problems. The dentist will be able to offer advice. Saliva also has a cleansing
effect on the mouth and teeth. Its absence leads to a build up of bacteria and
food debris, gum disease and dental decay, particularly at the neck of the
tooth. Decay in this area weakens the crown of the tooth, and can cause the
crown to break off.
If medication is syrup-based (eg
lactulose), there is an increased danger of tooth decay. The doctor may be able
to prescribe a sugar-free alternative if asked. The dentist may also be able to
apply chlorhexidine and fluoride varnishes to help prevent decay at the necks
of the teeth.
Some antipsychotic drugs
can cause involuntary repetitive tongue and jaw movements, making it difficult
to wear dentures, particularly in the lower jaw. Unfortunately, these movements
may continue after the drug is stopped.
Mouth
checks
People with dementia are not always
able to recognize or express their dental needs, including when they are in
pain. It is important to have regular mouth checks, whether the person has
teeth, dentures or no teeth at all. Regular mouth checks can highlight any
problems so that they can be treated as soon as possible. Cancer of the mouth,
while generally uncommon, is more likely to occur in older people than in any
other age group. It may start as a small painless ulcer and, if diagnosed
early, treatment is relatively simple and has a high success rate.
Dentures can become loose and begin
to damage the mouth if they have been worn for a number of years. As these
changes happen slowly, the individual can adapt to them without realizing that
the mouth is being harmed. In addition, decay at the necks of the teeth is
often painless, and may go unnoticed until the crown of the tooth breaks off.
Need
for assistance with dental care
As dementia progresses, the person
affected may become less able to:
- clean their teeth effectively
- understand that their teeth need to be kept clean
- express the need for dental treatment
- explain dental symptoms, including pain
- take part in the decision-making process about
treatment
- give their informed consent for dental treatment
- feel comfortable with dental treatment.
How
to tell if someone has dental problems
There may come a time when the
person with dementia is unable to say that they are experiencing pain or
discomfort. They will need to rely on other people to notice and interpret
their behavior and to arrange a visit to the dentist. There are several
behavioral changes that may indicate that someone with dementia is experiencing
dental problems. These may include:
- refusal to eat (particularly hard or cold foods)
- frequent pulling at the face or mouth
- leaving previously worn dentures out of the mouth
- increased restlessness, moaning or shouting
- disturbed sleep
- refusal to take part in daily activities
- aggressive behaviour.
If there is no explanation for the
change in behavior, arrangements should be made to identify the cause. This
should include a dental assessment as part of the process.
Planning
treatment
The dentist, together with the
person with dementia and their family or carers, will discuss treatment needs
and agree on the best treatment plan. They should take into consideration:
- the level of independence, co-operation, cognitive and mental state, and
physical impairment of the person with dementia
- what, if any, dental symptoms or problems the person is
experiencing
- whether the individual is able to give informed consent
(see 'Consent to treatment' below).
Once these questions have been
answered, the dentist will be able to decide on the most appropriate treatment.
They may decide to see the person regularly every few months, or they may only
need to be seen once a year.
Consent
to treatment
It is important that the person with
dementia is given the opportunity to make, or take part in, decisions about
dental treatment. Ask the dentist to explain in simple terms what is being done
and why. Short sentences that are phrased in a way where the person can answer
'yes' or 'no' can be effective.
When dental treatment is
irreversible - for example, when teeth are going to be taken out - and where
the individual cannot give informed consent, the family and/or carers will
usually be involved in the decision-making process. The dentist may also seek a
second opinion, from another dentist or a doctor, to make sure that the
proposed dental treatment is in the individual's best interests.
Everyone is presumed to have the
capacity to make decisions unless it is shown otherwise. If this is not clear,
the dentist should carry out an assessment of the person's capacity. If the
individual does not have capacity, family, professionals and other carers can
be involved in the decision-making process on their behalf as long as these
decisions are in the individual's best interests.
People who have capacity can grant a
person lasting power of attorney to take decisions about property, finances,
health and welfare if they should lose capacity in the future. Where an
individual has been granted lasting power of attorney, their wishes should be
respectedPeople without capacity who do not have family or friends to support
them may be appointed an independent mental capacity advocate to represent them
in any decision over serious health care treatment - for example, removal of
some or all their natural teeth, and which may involve treatment under sedation
or a general anesthetic.
Coping
with dental treatment
The progression of dementia varies enormously, as does the ability to cope with dental
treatment. Some people are comfortable with a visit to the dentist, while others
find the whole experience very distressing.
People who have had regular dental
treatment throughout their lives often remember what they are expected to do in
a dental surgery. They may have little difficulty co-operating with simple
procedures until their dementia is advanced. For other people with dementia,
the journey to the surgery, the strange environment and the unfamiliar faces of
the dental team can increase their confusion, making treatment difficult or
impossible.
In these circumstances, the dentist
may be prepared to make a home visit. Alternatively, it can be helpful for the
person with dementia to be accompanied into the dental surgery by someone they
know. The carer could perhaps remain in the person's sight while they are
having treatment and offer reassurance by holding the person's hand. People
with dementia can have good days and bad days: dental care is better postponed
to a good day, if possible, or scheduled to a person's best time of day.
Types
of dental treatment
Early
stages of dementia
In the early stages of dementia,
most types of dental care are still possible. The dentist will plan the
treatment, bearing in mind that the person with dementia will eventually be
unable to look after their own teeth. Key teeth may be identified and restored.
Advanced restorative treatment (such as crowns, bridges and implants) may only
be considered if someone is prepared to carry out daily brushing for the person
with dementia should they reach a stage where they cannot do this for
themselves. Preventing further gum disease or decay is also very important at
this stage. As dementia is a progressive condition, it is important to obtain
preventive advice from the dental team.
Middle
stages of dementia
During this stage of dementia, the
person is often relatively physically healthy but may have lost some cognitive
skills. The focus of dental treatment is likely to change from restoration to
prevention of further dental disease. Some people may find the acceptance of
dental treatment beyond their tolerance and require sedation or general
anaesthesia for their dental treatment. The decision will be based on the
individual's ability to co-operate, dental treatment needs, general health and
social support.
Later
stages of dementia
In the later stages of dementia, the
person is likely to be severely cognitively impaired and often physically frail
or disabled with complex medical conditions. Treatment at this stage focuses on
prevention of dental disease, maintaining oral comfort and provision of
emergency treatment.
Dentures
More people are keeping their
natural teeth into old age. However, a significant number of older people have
partial or full dentures. Plaque can easily build up on dentures. If partial
dentures are worn, it is important that oral hygiene is well maintained or the
increased plaque accumulation will encourage gum disease and tooth decay.
New dentures may be needed when the
person loses all their natural teeth or if they are misplaced. In both
circumstances the person with dementia may have difficulty coping with their
new set of dentures, and will need to be encouraged to persevere.
Dentures need to be replaced when
they become loose. When dentures have been worn successfully in the past, the
replacement dentures are best constructed using the key features of the old
ones - for example, the overall shape and the tongue space. For this reason it
is important not to throw away old dentures, even when they may seem to be of
no use. Instead, take them along to the dentist when the new ones are being
constructed so that the good features can be copied and any poor features can
be improved.
Denture
marking
Marking a person's name on dentures
does not prevent denture loss, but it does mean that when dentures are found
they can, in many cases, be returned. New dentures should be permanently marked
during their manufacture. Existing dentures can be temporarily marked using a
simple technique that will last for 6-12 months. This can be done using a small
piece of new kitchen scourer, a pencil (or alcohol-based pen) and clear nail
varnish. The process takes about ten minutes and can be carried out by a
dentist, a dental hygienist or a carer.
You need to:
- Clean, disinfect and dry the denture.
- Select an area near the back of the mouth on the outer surface
of the denture just large enough to take the person's name and use a new
piece of green scourer to remove the surface polish from this area.
- Print the person's name on the denture using a pencil
or an alcohol-based pen.
- Paint over the name with a thin coat of the varnish and
allow it to dry.
- Apply a second thin coat of varnish and allow it to
dry.
It is important to thoroughly clean,
disinfect and dry the denture before marking it. Dentures should be checked
periodically to ensure the name is still legible, and the marking renewed as
necessary.
Wearing
dentures
The person with dementia should be
encouraged to wear their dentures, and offered help with putting them in, for
as long as possible. Dentures are important for maintaining dignity and self-esteem
- if a person does not wear them it may affect their appearance and make speech
more difficult.
Denture loss is common when people
with dementia are in unfamiliar environments - for example, when they spend
time in a residential home for respite care. Replacing lost dentures can present problems. If the
person is without their dentures for any length of time they may forget how to
wear them, or they may lose their ability to adapt to a new set. The individual
may also be unable to co-operate with the dentist over the several visits
required to make the new dentures. However, sometimes intervention by the carer
(for example, hand-holding or distraction through hand-stroking or talking) may
be all that is needed. If co-operation is limited, a realistic approach may be
to provide an upper denture only, for the sake of appearance.
It can sometimes be difficult and
distressing for relatives and carers when they are told that it will not be
possible to successfully make a set of new or replacement dentures for the
person with dementia. The decision not to provide new or replacement dentures
would only be made after an individual assessment and if it is in the person's
best interests.
Eventually, many people with
dementia reach a stage where they will no longer tolerate dentures in their
mouth even though they have worn them without problems in the past.
