Dental care and dementia

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:

1. Clean, disinfect and dry the denture.
2. 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.
3. Print the person's name on the denture using a pencil or an alcohol-based pen.
4. Paint over the name with a thin coat of the varnish and allow it to dry.
5. 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.