Alzheimer’s disease is a common type of dementia that leads to a decline in memory, reasoning, cognition, and communication skills, along with behavioral and psychological symptoms such as aggression and depression. Maintaining oral health in patients with Alzheimer’s disease can be challenging, but it is an integral part of overall health management. If oral care is neglected in Alzheimer’s patients, dental diseases can develop, which can be difficult and expensive to treat later on.
The good news is that by establishing a daily oral care routine and ensuring regular dental examinations, it is possible to avoid extensive and complicated dental procedures in dementia patients. However, while this is relatively easier to accomplish in the early stages of Alzheimer’s disease, as the disease progresses to the middle and late stages, oral care can become more and more challenging. Caretakers may need to take over this task when the patient themselves is unable to maintain good oral hygiene.
This article provides guidance on the maintenance of oral health in Alzheimer’s patients – why it is important and what interventions and techniques can be employed to maintain good oral health in such individuals to allow them to enjoy a good quality of life.
Oral Health in Alzheimer’s Patients
Not surprisingly, elderly people with dementia have worse oral health than people without dementia. Studies have shown that dementia patients have more retained roots, dental caries, and causes of orofacial pain. There are also significant differences in terms of decayed, missing, and filled teeth, which tend to occur more frequently in people with dementia, as well as denture utilization, which is found to be considerably lower in people with severe dementia. 1Moreover, patients with Alzheimer’s disease have a higher prevalence of periodontal problems like periodontitis and gingivitis (gum inflammation), gingival bleeding (bleeding from the gums), stomatitis (mouth and lips inflammation), candidiasis (oral thrush – fungal infection), and xerostomia (dry mouth). 2
The higher incidence of dental problems in Alzheimer’s patients can be explained by reduced cognition and manual dexterity, which can complicate oral hygiene in elderly individuals with dementia. Forgetting to brush the teeth or being unable to do it are both factors that lead to poor oral hygiene. Sub-optimal oral hygiene is strongly linked to periodontal disease. Symptoms like xerostomia (dry mouth) can be the result of aging, but may also be a side effect of prescription medications or treatment with radiation therapy for comorbidities in elderly patients. Studies have found that saliva flow is reduced in Alzheimer’s patients, which can lead to greater plaque accumulation, caries, periodontal inflammation, and halitosis (bad breath). 3
There is growing interest in the link between dementia in elderly individuals and tooth loss. Tooth loss is an indicator of poor oral health. Experts believe the relationship is bidirectional in nature. As noted, dementia can lead to poor oral hygiene, and consequently, tooth loss. But the reverse could also be true. Tooth loss can lead to poor chewing function, which in turn can affect nutritional intake and brain functioning, leading to a worsening of dementia. 4 Another plausible mechanism by which dental disease could lead to the development of Alzheimer’s is that microorganisms in the mouth can potentially enter the bloodstream, cross the blood-brain barrier, and cause inflammation and plaque formation in the brain, which causes or worsens Alzheimer’s. It has also been postulated that chronic periodontitis increases the levels of inflammatory markers in the blood which can lead to cerebral inflammation and neurodegeneration.
Complications of Poor Oral Health in Patients with Alzheimer’s Disease
It is clear from the above paragraphs that oral health in Alzheimer’s patients is often less than adequate. It is essential to improve the oral hygiene status of such individuals to prevent serious complications which may require complex medical procedures in the future and result in a poorer quality of life or even death.
However, this can be challenging for multiple reasons. Elderly individuals with Alzheimer’s disease are frequently uncooperative with receiving the necessary dental services. Also, frailty, limited mobility, and compromised dexterity can limit the ability of these individuals to care for themselves. Medical comorbidities can limit their dental treatment options. Moreover, cognition and memory problems can make communication with dentists and caretakers difficult.
Nonetheless, despite these difficulties, a focus on oral care in Alzheimer’s patients is critical to reducing the occurrence of complications. Some of the potential problems that can arise in patients with dementia because of poor oral hygiene are described below.
As noted, dementia patients have more dental caries compared to those without dementia. With advancing age, the oral health of Alzheimer’s patients worsens, increasing the possibility of dental complications. In healthy individuals, oral pain is a strong indicator of dental problems. However, in Alzheimer’s patients, reports of oral pain are fewer than expected. This could be due to reduced perception of pain, memory loss, or communication issues. Whatever the reason, the result is that oral pain, which is the body’s way of signaling a problem, often goes undetected in patients with Alzheimer’s disease. This means that dental problems can reach an advanced stage before they are discovered unless caretakers are vigilant about keeping up with dental appointments.
Xerostomia (dry mouth) is a common symptom in elderly individuals due to the natural aging process. It can also be a side effect of medications. Patients with Alzheimer’s disease are often on multiple medications that can cause xerostomia and reduced saliva flow. Xerostomia is associated with dental caries, periodontal disease, stomatitis, fungal infections, and discomfort with chewing. Besides these complications, dry mouth can also affect the quality of life of Alzheimer’s patients, preventing them from enjoying the joy and comfort of eating.
A loss of interest in dental hygiene or the inability to complete simple tasks like brushing and flossing can lead to the rapid development of dental diseases in Alzheimer’s patients. The resultant poor oral health with tooth loss and dry mouth can impair sensory and masticatory functions (taste sensation and chewing) in such patients with dementia. A lack of adequate sensation and reduced chewing ability can progress to the point that it adversely affects nutrition, potentially leading to malnutrition.
Unsatisfactory oral hygiene in Alzheimer’s patients is a risk factor for aspiration pneumonia (a condition in which food from the mouth or stomach is misdirected into the trachea (windpipe) and lungs, leading to lung infection). 5
Factors Affecting Dental Services in Dementia Patients
There is no single dental treatment plan that will work for all patients with Alzheimer’s disease. Each patient needs to be evaluated individually and factors such as access to care, co-existing medical problems, and financial capabilities need to be taken into consideration when planning dental care. All dentists offer a range of treatments to maintain oral health, but when it comes to caring for Alzheimer’s patients, it is important to look for additional attributes as well.
Informed consent is a process by which healthcare providers ensure that a patient fully understands all the information about a treatment and makes decisions about their healthcare without coercion. Given the nature of Alzheimer’s disease, this can be challenging in patients with dementia. Such individuals may be dependent on family members or caretakers to accomplish informed consent. Dentists who treat Alzheimer’s patients must strike a balance between respecting the patient’s preferences and offering the most appropriate treatment.
Friendly and effective communication is essential to build rapport with a dementia patient and their caregivers. Dentists who have experience in treating Alzheimer’s patients know to look for both verbal and non-verbal cues. They understand the importance of gentle and reassuring communication so that the patient is comfortable while receiving dental care. Also, communication with Alzheimer’s patients should be short and simple. Dentists who routinely care for dementia patients know to give one direction at a time or ask one question at a time. Dentists with training in treating Alzheimer’s patients also know to speak slowly and ask close-ended questions that can be answered with yes or no.
Short wait-times are critical when caring for patients with dementia. Elderly individuals tend to have a low tolerance in general. They also frequently have several other medical conditions being treated with multiple medications, which makes doctors’ appointments difficult. Dental offices that provide care to Alzheimer’s patients should therefore ensure waiting times are minimized and appointments are as short as possible.
Dentists caring for patients with Alzheimer’s disease may need to use techniques like tell-show-do to facilitate the delivery of treatment. Instructions may need to be repeated more than once. Caregivers should be present during the appointment to ensure understanding.
Dental Treatment Planning in Alzheimer’s Patients
When planning oral care and dental treatments for patients with Alzheimer’s disease, dentists need to keep the following factors in mind.
- The patient’s desires and expectations.
- The type and severity of the patient’s dental problems.
- The impact of the dental problems on the patient’s overall health and quality of life.
- The chances of a positive outcome from the dental treatment.
- The availability of alternative, less invasive treatments.
- The patient’s ability to tolerate the stress of the dental treatment.
- The patient’s and caregiver’s ability to maintain oral health after the treatment.
- The patient’s financial resources.
Dentists who are experienced in the care of geriatric patients with dementia can weigh the impact of these issues and decide on the best course of treatment, ranging from extensive care to intermediate care to very limited care. For example, in an elderly patient with a life expectancy of a few years and a painless dental problem, it may be best to do nothing except provide preventive care. It is, therefore, important to choose a dentist who is capable of making these treatment planning decisions for Alzheimer’s patients.
Early-stage Alzheimer’s Disease
In the early stages of Alzheimer’s disease, dental care is largely preventative. For instance, dentists may offer simple restorations or long-lasting treatments that require easy maintenance and that can be easily remedied as the patient’s dementia progresses. Oral healthcare at this stage typically consists of frequent dental examinations and professional cleanings, which can prevent the need for extensive procedures later on when a person with dementia may be less likely to tolerate them.
The patient should be educated about oral hygiene and given dietary advice. Moreover, care should be tailored to the individual patient, depending on dexterity and memory issues. The 5S method for oral hygiene can be encouraged, consisting of:
- sorting and removing unnecessary items from the bathroom counter
- setting up in order of flow the items needed for dental hygiene
- shining to maintain a clean environment
- standardizing the routine to develop good oral hygiene habits
- sustaining the routine by auditing and improving practices.
Intermediate-stage Alzheimer’s Disease
In patients with intermediate-stage Alzheimer’s, resistance, poor cooperation, and other challenging behaviors are common. Such individuals may require dental devices like mouth props for safety during dental treatments in the office. In general, dentists avoid complicated or lengthy dental procedures at this stage and aim to maintain oral health with simple treatments.
Late-stage Alzheimer’s Disease
A healthy oral cavity can contribute greatly to a better quality of life for patients with advanced Alzheimer’s. Caretakers and family members are the primary points of contact in such individuals, and educating them is essential to keep the patient comfortable. Many patients with advanced Alzheimer’s disease are unmanageable, however, and dental treatment often becomes palliative in nature in such individuals. Oral care may be limited to emergency treatments. Sedation and/or general anesthesia may be needed in some patients during dental procedures.
Tips for Caregivers of People with Alzheimer’s
Patients with dementia are frequently unable to communicate their symptoms. Family members and caregivers providing care to patients with Alzheimer’s disease, therefore, need to be vigilant for signs and symptoms of oral health concerns. For example, loss of appetite or painful facial expressions at mealtimes could be a sign of mouth pain or ill-fitting dentures. Caregivers can follow these simple tips when helping an Alzheimer’s patient perform dental hygiene measures:
- Give short, simple instructions. Break up directions into steps.
- Give specific instructions – “Brush your teeth” may be too vague for a patient with dementia. Rather, say “Pick up your toothbrush,” followed by “Put toothpaste on the brush,” etc.
- Consider showing the person what to do. For example, hold the toothbrush and mimic brushing your teeth. You may need to gently guide the person’s hand to their mouth.
- If the person is agitated or uncooperative, don’t force it, instead consider postponing the toothbrushing to later in the day.
- If you need to brush a person’s teeth for them, do it gently, twice a day. The nighttime brushing should be done after the last meal and any liquid medications have been taken. Make sure the person is in a comfortable position while you do the brushing.
- If the patient wears dentures, clean them as directed by the dentist.
- You might need to experiment with different toothbrushes to find one that is comfortable for the patient or has a long handle that aids the caregiver.
- Dentists recommend flossing once a day. If this is too uncomfortable for the patient, consider using a proxabrush, a type of toothbrush that cleans between the teeth.
Finding the Right Dentist for Alzheimer’s Patients
A large number of Alzheimer’s patients have erratic or inconsistent oral self-care due to the nature of their disease. As a result, such individuals need specialized dental care.
Some of the common dental problems that dentists check for in dementia patients include cavities, broken teeth, tooth abscesses, dry mouth, and bad breath. These are all indicators of poor dental hygiene and can be painful for the patient. Moreover, they may require complex and expensive dental procedures if they are not caught and treated early. The aim should be to keep up with regular dental visits for as long as possible to prevent serious complications that may subsequently require complicated dental treatments.
In the advanced stages of Alzheimer’s disease, some dentists may schedule at-home visits or offer ambulatory care if going to a dental office is no longer possible for the patient.
About the author
Dr. Greg Grillo
Dr. Greg Grillo DDS studied at the University of Washington where he received a bachelors degree with Honors and later attended dental school on the same campus. Following school Dr. Greg served in the United States Navy as a dental officer. During this time he received advanced training in specialty areas of dentistry while also treating families of members of the military.
As well as sharing valuable information on dentistry and oral health, Dr. Greg remains a practicing dentist to this day. He works with families in the Okanogan Valley where he lives with his wife and three children.
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