Is oral hygiene important for those with

dementia – after all we can just pull out all

their teeth?

Mina Borromeo

(Mina.borromeo@monash.edu)

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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!

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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?

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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