(Alzheimer’s Society) Good oral health is important for health and wellbeing. Because dementia is aprogressive condition (meaning it gets worse over time) it is important to establish a dental care programme at, or soon after, a diagnosis. The programme should help to improve oral health and reduce the risk of developing poor oral and dental health. This factsheet describes some of the dental problems that people with dementia may face at different stages and methods for treatment and prevention, including maintaining good oral health. It also looks at issues around keeping and wearing dentures.
Maintaining oral health brings benefits in terms of self-esteem, dignity, social integration and nutrition. Poor oral health can lead to pain and tooth loss, and can negatively affect self-esteem and the ability to eat, laugh and smile.
There are two main types of dental disease: gum (periodontal) disease and tooth decay (dental caries, more commonly known as cavities). Both of these can cause discomfort or pain and can lead to infection. Both pain and infection can worsen the confusion associated with dementia.
Gum disease can cause inflamed and bleeding gums, gum recession (where the gum tissue is reduced so the roots of the teeth become exposed), loose teeth and bad breath. It is caused by the build-up of dental plaque (a combination of food debris and bacteria). Plaque leads to gum disease if it is not removed by daily efficient brushing and flossing. Using a tooth gel or mouth rinse containing chlorhexidine (an antiseptic and disinfectant agent) can help to control gum disease for a person who is experiencing bad breath and bleeding and inflamed gums.
Tooth decay is caused by the action of dental plaque on the teeth when food and drinks containing sugar are consumed. Plaque and sugar together produce acid, which attacks the tooth, causing decay. Restricting the intake of sugar to two to three times a day, preferably at mealtimes, is important in guarding against tooth decay. It is the number of times that sugar is eaten during a day, rather than the total amount of sugar consumed, that is important in reducing the risk of decay. This includes hidden sugars in food and drink, 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 to keep the mouth clean to minimise the risk of decay. Gum recession increases the chances of decay occurring at the necks of teeth (where the crown of the tooth meets the root at the gum) unless oral hygiene is excellent and dietary sugars are controlled. Food supplements may be prescribed to a person with dementia who is having difficulties with eating. When food supplements are prescribed for a person with natural teeth, it is important to get advice on prevention from the dentist.
Drugs and dental problems
People with dementia may be taking medication for a number of conditions. They may also be prescribed antidepressants or – less often – antipsychotics and sedatives. A dry mouth is a common side effect of these drugs. Saliva acts as a lubricant and also cleans the mouth and teeth. Lack of saliva can lead to a build-up of plaque and increase the risk of dental decay, gum disease and infection. A dry mouth can also cause problems with dentures, including discomfort and looseness. Denture fixatives and artificial saliva (a fluid to lubricate the mouth) can help some people with denture problems. The dentist will be able to offer advice to relieve discomfort and problems caused by lack of saliva or a dry mouth. Frequent sips of water throughout the day, especially at mealtimes, will help.
Some antipsychotic drugs can cause involuntary repetitive tongue and jaw movements, making it difficult to wear dentures, particularly in the lower jaw. In some cases, these movements will continue after the drug is stopped. If this occurs, the dentist may be able to advise on what can help, and how best to ensure that the person is comfortable.
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.
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 plaque will accumulate and encourage gum disease and tooth decay.
If the person loses all their natural teeth, they may need to start using full dentures. They may have difficulty coping with their new set of dentures, and will need to be encouraged to persevere. This can also be an issue if the person loses their dentures and needs to start using a new set.
Dentures also need to be replaced when they become loose. Replacement dentures are best constructed using the dimensions of the old set. For this reason, the old set should always be retained and taken along to the dentist when the new ones are being constructed.
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, diet and ability to speak.
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 (see ‘Denture marking’). 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 person may also be unable to co-operate with the dentist during the several visits required to make the new dentures. However, sometimes intervention by the carer (for example, hand-holding or distraction through 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 if they have worn them without problems in the past.
A person with memory problems associated with dementia may be more likely to lose their dentures. Marking a person’s name on dentures means that lost dentures can often 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 a pen that uses safe alcohol-based ink) and clear nail varnish. The process takes about ten minutes and can be carried out by a dentist, a dental hygienist or a carer.
The process is as follows:
- 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 have the person’s name on it, and use a new piece of scourer to remove the surface polish from this area.
- Print the person’s name on the denture using a pencil or a pen that uses safe alcohol-based ink.
- Paint over the name with a thin coat of clear nail varnish and allow it to dry.
- Apply a second thin coat of varnish and allow it to dry.
It is important to clean, disinfect and dry the denture thoroughly before marking it. Dentures should be checked periodically to ensure the name is still legible, and the marking renewed as necessary.
Daily Care of Teeth
Early stages of dementia
Someone in the early stages of dementia should carry out their own mouth care for as long as possible. They may need to be reminded to do it, or they may need to be supervised. The carer can give them the brush and toothpaste and show them what to do. The person may find it easier to use an electric toothbrush or a toothbrush with an adapted handle to improve their grip.
The dentist or dental hygienist may be able to advise the person and their carer on the best methods for preventing tooth decay and gum disease in the particular circumstances. It is very important to establish a daily care routine 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 every three to four months.
Later stages of dementia
As dementia progresses, the person may lose the ability to clean their teeth, stop understanding that their teeth need to be kept clean, or lose interest in doing so. 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 straight-backed 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 dry toothbrush and a pea-sized amount of toothpaste.
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 in their mouth or teeth. They will need to rely on other people to notice and interpret their behaviour and to arrange a visit to the dentist if necessary. There are several behavioural 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 their 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 behaviour, arrangements should be made to identify the cause. This should include a dental assessment as part of the process.
Types of dental treatment
Early stages of dementia
In the early stages of dementia, most types of dental care are 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. 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 for the person and their carer to obtain advice on prevention from the dentist.
Middle stages of dementia
During this stage of dementia, the person may be relatively physically healthy but might have lost some thinking abilities. The focus of treatment is likely to be on prevention of further dental disease. Some people may 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. It is during the middle stages that issues around consent to treatment may start to arise (see ‘Consent to treatment’ below).
Later stages of dementia
In the later stages of dementia, the person is likely to have severe problems with thinking, reasoning and memory and will often be 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.
For people with or without dementia, the recommended interval between check-ups at the dentist should be determined specifically for the individual and tailored to meet their needs, based on assessment and risk of dental disease. For adults, the shortest interval that is recommended is three months, and the longest is two years. If treatment becomes necessary for a person with dementia, the dentist (together with the person 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, thinking abilities, mental state, and physical impairment of the person with dementia
- what (if any) dental symptoms or problems the person is experiencing
- whether the person is able to give informed consent (see ‘Consent to treatment’).
Once these questions have been answered, the dentist will be able to decide on the most appropriate treatment. They will also decide how regularly they need to see the person.
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. Even if a person has no natural teeth or dentures, regular mouth checks are important to screen for mouth cancer.
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. The dentist should explain to the person 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 the individual cannot give informed consent, the family and/or carers will usually be involved in the decision-making process. If the treatment is out of the ordinary or there is disagreement about what is in the best interests of the person, the dentist may seek a second opinion.
The law states that every person is able to make their own decisions, unless it can be proven that they are not able to do so. If this is not clear, the dentist should carry out an assessment of the person’s capacity (the ability of that person to make their own decisions). 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 person’s best interests. For more information see factsheet 460,Mental Capacity Act 2005.
A person who has capacity can grant someone Lasting Power of Attorney in England and Wales, or Enduring Power of Attorney in Northern Ireland, meaning they can take decisions about property, finances, health and welfare if the person should lose capacity in the future. Where an individual has been granted Lasting Power of Attorneyor Enduring Power of Attorney, their wishes should be respected. For more information, see factsheet 472, Lasting Power of Attorney or, in Northern Ireland, factsheet NI472,Lasting Power of Attorney and controllership.
People 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 healthcare treatment. An example might be removal of some or all of their natural teeth, which may involve treatment under sedation or a general anaesthetic.
Coping with dental treatment
The way dementia progresses varies considerably, as does the ability to cope with dental treatment. Some people are comfortable with a visit to the dentist, while others may find the experience distressing.
People who have had regular dental treatment throughout their lives often cope better at a dental surgery. They may have little difficulty co-operating with simple procedures until their dementia is advanced. For other people with dementia, the unfamiliar experience 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 can remain in the person’s sight while they are having treatment and offer reassurance by holding the person’s hand.
Finding a dentist
If the person with dementia already has a regular dentist, they should continue to see the same dentist for routine treatment and preventive advice. If the person goes into residential care, it is important that they continue to have access to a dental service; ideally this would be the person’s regular dentist.
If they do not have a dentist, they will need to find one that is accepting new patients. It is no longer necessary to be registered with a dentist to receive treatment, but dentists will usually keep lists of their regular patients. If someone asks for an appointment, the dental practice will try to offer one as soon as possible at a convenient time within the hours the practice has set aside for patients.
Although some dental practices will contact their patients to arrange check-ups, many dental practices do not send out reminders, so it is important that a person with dementia has someone to remind them to make an appointment. It is recommended that a person diagnosed with dementia who has their own natural teeth is seen by a dentist every six months. Some dentists will see people at home. This can be less stressful and confusing for the person, and may increase co-operation.
Dental Care in Care Homes
Care homes have a duty to ensure that their residents’ healthcare needs are met. This includes dental care. The care home manager should be able to supply information about their arrangements for dental care. They may have a local dentist who visits the home to provide regular check-ups, or they may have visits from a local community dental care service.