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Is oral hygiene important for those with
dementia – after all we can just pull out all
their teeth?
Mina Borromeo
(Mina.borromeo@monash.edu)
2
3
What is in the literature?
Adapted interventions, staff training
4 Dermot and Sadaghiani, 2014
Link between poor oral health and some of the symptoms seen in dementia sufferers – a recurring, self-perpetuating loop
WHY ARE THE ELDERLY DIFFERENT?
• Dental needs of elderly are uniquely complex due to a lifelong accumulation of physiological, disease derived, traumatic and iatrogenic effects on the oral structures
• Multiple restorations in various states of despair
• Changes to tooth components eg. shrinkage of pulp space, changes in structure of the dentine, missing and drifted teeth, occlusal attrition
• Physical effects of ageing eg. OA, visual changes, progressive loss of neuromuscular coordination, mobility issues
Dental disease doesn’t start in a nursing home!
6
Bad breath
Lots of plaque
Dentures
Broken or sharp teeth
Decay
No teeth at all
Dry mouth
Increased risk of
untreated tooth decay
Dentures
Unhygienic mouth
Unable to clean teeth
Unwilling to clean teeth
What do we often associate with dementia patients (+/- elderly)?
TEMPTATION TO PROVIDE SUBSTANDARD
OR SUBOPTIMAL CARE
CHALLENGING BEHAVIOUR
NEED FOR SPECIAL
FACILITIES
ACCESS
WHY ARE THERE UNMET DENTAL NEEDS IN
DEMENTIA COHORT?
WITHIN AGED CARE FACILITY
TRAINED STAFF
AT THE DENTIST
parking
UNWILLINGNESS TO PROVIDE CARE
appointments
DOM RENUMERATION
FEAR REMGMT
TIME CONSUMING
EXOs,CLEANS,REVIEWS
(-tmt)
FINANCIALCONSTRAINTS
IMPACT OF ORAL HEALTH ON GENERAL HEALTH
90% of older adults have
some degree of treatable
dental disease
Poor oral health:• Can affect dietary intake/nutritional
status – dehydration and malnutrition
• Can compromise other health
conditions often leading to admission to
acute care facilities
• Oral infections and sepsis
• Pain and discomfort
• Systemic illnesses CVD and
aspiration pneumonia
ORAL CARE IS ESSENTIAL
MAINTAINING
SELF ESTEEM
PREVENTING INFECTION
COMFORT
QUALITY OF LIFE
NUTRITION
APPEARANCE
SOCIAL ACCEPTANCE
ORAL
SYSTEMIC
AIMS OF DENTAL TREATMENT
NON DEMENTIA PATIENT
• Improve quality and quantity of life e.g. self esteem/dignity
• Dental care emphasis
→ quality of life
• Optimum oral health care
→ best possible treatment for the patient
DEMENTIA PATIENT
• Improve quality and quantity of life e.g. self esteem/dignity
• Dental care emphasis
→ quality of life
• Optimum oral health care
→ best possible treatment for the patient in the context of their overall (medical) condition
• Optimal treatment plan may not be ideal treatment plan
• Treatment plan must meet goals of providing an oral
environment that is:
Free from infection
Cleanable
Functional
Aesthetic (limitations??)
Lead to best possible quality of life
Longest possible quantity of life
Pain in the dementia patient?
13
Loss of interest in eating
Sensitive to food
Increased grinding (teeth
or dentures)
Refusal to wear dentures
Refusal to clean
teeth/mouth (????)
Pulling/hitting of face
Mood changes:
aggression, somnolence,
screaming, fearful,
restless
How do we know a patient may have pain of dental origin?
Patient can’t directly express/communicate site or source of pain or pain per se
Highly individual and varies from episode to episode
BARRIERS EXIST – IT’S ALL TO HARD
• What can we do about it?
– Oral health is part of overall good health
– Prevention is key wherever possible
– No one size fits all
– Be champions for our patients
IN REALITY
• As cognition declines
– Ability to self care declines (inc oral care)
– Ability to tolerate dentistry may reduce (especially complex care – should it be avoided?)
WHAT CAN WE DO?
• Assess individual needs early (in the home, on admission to facility, early in diagnosis)
• Preventative plan
– Identify key dental help in the area (public/private)
– Regular recall (patient specific – don’t wait for a problem to present itself)
• Treatment plan
– Flexible (related to cognition level)
– Aims – pain free, adequate nutritional intake
• Restraint management where required during review/treatment (consent):– Who provides it – GP?, dentist?
– Anxiolytics, sedatives
– Holding patients where needed (safe environment)
DOMICILARY CARE
• As pt challenges increase –familiar setting, fragility, falls risk, mobility issues
• Can’t physically get to a dentist
4 KEY ISSUES TO CONSIDER
• Aid of the caregiver
• Modification of OH routine
• OH aids
• Type/frequency of professional care
A lot can be done to aid oral care
PRACTICAL TIPS – AGED CARE FACILITY
• Appointment timing – mid morning (favourable re ADLs, cognition status, meds, calmer (?)), avoid around mealtime if possible, length of time (consult versus treatment)
• Family and facility involvement where possible – consent (who/what), paperwork, records, test results, can family member attend for at least initial appointment, etc
IN THE HOME
• As above
• Have medications at the ready for review
• Patient in comfortable location eg armchair
• Lighting, hand washing, examination location
• Power points for equipment
• Quiet, calm environment
• Minimise others around eg neighbour, grandchildren etc
COMMUNICATION STRATEGIES THAT MAY ASSIST WITH INDIVIDUALS WITH DEMENTIA
• Chaining – initiate activity and carer completes
• Bridging – patient holds similar item to what you are using
• Hand-over-hand – place hand over patients hand to guide the activity
• Rescuing – replace caregiver with another who may be having difficulty performing the OH task
• Mirror-mirror – complete task in front of a patient
www.dementia.org.au/files/hel
psheets/
PROBLEMS BETWEEN PEOPLE WITH IMPAIRMENTS AND THE DENTAL TEAM
Fewer dental visits
Longer intervals bw visits
Unwillingness of clinician to provide care
History of extractions
Emergency hospital care rather than planned community care
Treatment with sedation or GA
Recommended