Therapeutic, Restorative and Preventive Dental Care for Patients with Alzheimer's and Other Dementias

What a Caretaker Needs to Know about

 Caring for a Dementia Patient’s Teeth

   

 Evelyn Smith

M.S. in Library Science, University of North Texas (2012)

While much advice about how to care for the teeth and gums of Alzheimer's and dementia patients is sparse, the sampling of references below  emphasizes preventive and therapeutic care, most particularly stressing attention to the gums since receding gums speed up the development of dental decay because this process exposes the roots of the gums  Snacking also needs to be restricted since patients who are beginning to have difficulty swallowing pocket food in the mouth rather than swallowing it.  This possibility also suggests that a caretaker needs to brush the patient's teeth following a meal.

Regularly checkups may need to be increased from two to four or more times a year as the patients lose the ability to brush and floss as well as to explain that they are  in pain. Eventually, caretakers will also need to find a dentist that specializes in the care of dementia patients and who makes visits to nursing homes or home visits.

Relatives of residents living in nursing homes need not only to talk regularly with the dental hygienist who professionally clean the residents’ teeth, but they also need to make sure that  the attendants who actually brush them daily are doing an adequate job of it.   For example, while a dental hygienist might recommend exchanging a manual toothbrush for an electric toothbrush, a talk with an aide might help a family member discover that the soft bristles of a battery-powered child’s brush might be more effective in late-stage Alzheimer’s than the harder-bristles of an adult electric toothbrush. 

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Addendum: The Yogurt Cure

January 30, 2014

Noticing my mother’s breathe had a sour smell yesterday, I checked; and sure enough, a layer of brown gunk covered her teeth, verifying my suspicions that the aides weren’t regularly brushing them.  I quickly set about to remedy the situation by brushing away this film during a single session with her child's battery-powered toothbrush.  At this point, I  resolved to brush her teeth daily myself instead of relying on the nursing home staff to do so.  However, when I mentioned the problem to her ward’s on-duty nurse, she suggested that I buy a bottle of mouth wash, so an aide could swab Mother's teeth in addition to brushing them--provided that Mother opened her mouth sufficiently to allow the aide to do so without clamping down on the toothbrush.  When picking up the mouth wash at a local pharmacy, the cashier also recommended that a daily serving of non-flavored yogurt be added to Mother’s diet since it contributed to oral hygiene.  Sure enough, PubMed  has published abstracts that suggest that the regular consumption of yogurt without any added flavors or fruit might be beneficial in patients that are incapable or unwilling to properly brush and floss their own teeth.

Caglar, E, Kargul, B, Tanboga, I. (2005, May). Bacteriotherapy and probiotics' role on oral health. Oral Diseases, 11(3):131-7.   [Abstract only].  Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/15888102

“Probiotic approaches” or what researchers also call “whole bacteria replacement therapy” or “bacteriotherapy” has become “an alternative and preventive way to combat infections by using harmless bacteria to displace pathogenic microorganisms”.

Varghese, L., Varughese, J.M.,  &Varghese. N.O. (2013).  Inhibitory effect of yogurt extract on dental enamel demineralisation - an in vitro study. Oral Health & Preventive Dentistry, 11(4), 369=74. doi: 10.3290/j.ohpd.a30604. [Abstract only].  Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24046825

A study of 80 intact, cavity-free human premolars tested four demineralizing solutions that researchers allowed to stay on four groups of premolars for 96 hours.  After this time elapsed, researchers selected selected five teeth from each group for microscopic study.  Results revealed that “probiotic yogurt extract is effective in reducing demineralisation of enamel under experimental conditions.”

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Bibliography of Commercial and Alzheimer’s Association and Society-based Sources

Alzheimer’s care and dental health.  (2011, October 25).  The Dementia Zone.  Alzheimer’s Care Consultants.  Retrieved from

http://blog.alzheimerscareconsultants.com/alzheimers-blog/bid/103056/Alzheimer-s-Care-and-Dental-Health

Dental care should not stop when a neurologist diagnoses patients with dementia, and although dental problems are not a direct cause of dementia, they can cause difficult behavior and speed up mental and physical decline.  Hence, caregivers need to recognize that 1) brushing and flossing are multistep processes that in time will prove too difficult for the patient to accomplish first without supervision and later at all; 2)  caregivers need to set realistic goals for caring for a patient’s teeth, depending upon his or her stage of dementia; 3) caregivers also need to recognize that the only outward sign of a mouth infection might be difficult behavior;  and 4) since patients can no longer  adequately communicate discomfort, regularly checkups at least twice a year are very necessary. Finally, caregivers need to regularly check dentures to see if they are fitting properly as well as cleaning off the plaque that encrusts them.

De Marco, B. (2009, December 10).  Alzheimer’s disease—brushing the teeth with the Oral B.  Retrieved from http://www.alzheimersreadingroom.com/2010/09/alzheimers-and-oral-hygiene.html

De Marco recommends using an [Oral B] electric toothbrush since 1) patients and caretakers can use the same system as the toothbrush heads are interchangeable; 2) an electric toothbrush handle is easier to grasp that a standard manual toothbrush; 3) an electric toothbrush ensures more efficient care for the gums and the space between the teeth, and 4) caring for the teeth with an electric toothbrush might be turned into a game (De Marco, 2009, para. 3-9).

Dental care. (2009). Alzheimer’s Association.  New York City Chapter.  Retrieved from http://www.alznyc.org/caregivers/dental.asp

Since caregivers need to increasingly assume the responsibility for providing dental care for a patient with Alzheimer’s, the New York City Chapter of the Alzheimer’s Association furnishes a detailed guide for doing so (Alzheimer’s Association, 2009, para. 2).  Regular dental checkups thus might need to increase from two to four times a year, so a dentist can take care of problems as soon as they are discovered.   Additionally, caregivers need to find a dentist qualified to work with elderly patients, and if at all possible choose a dentist that offers home care and/or who visits nursing homes.  The dentist also needs a list of all the medications patients are taking [since dentist often put patients to sleep to facilitate cleaning or to fill cavities or extract teeth if  they cannot otherwise cooperate or tolerate the procedures] (Alzheimer’s Association, 2009, para. 3).

Dental care, however, needs to concentrate on prevention which recognizes the relationship between diet and mental health—eliminating sugary foods and between the meal sacks and substituting fruits and vegetables for cookies and candy--and maintaining “good oral hygiene”: 1) brushing at least twice daily for two minutes, making sure that the teeth are adequately brushed after the evening meal and the dispensing of liquid medication; 2) using a fluoride toothpaste;  3) encouraging patients to brush as long as they are able to do so, possibly using a bicycle grip handled toothbrush; 4) postponing brushing teeth  until patients are willing to cooperate  once aides or caretakers take over this task; 5) introducing an electric [or battery-powered] toothbrush to clean the teeth in a way that does not disturb sensitive patients; 6) using mouth rinses that contain no alcohol (Alzheimer’s Association, 2009, para. 4 & 5).

Dental care and dementia. (2013). Alzheimer’s Society.  Retrieved from 
http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=138

Dental pain and infection from periodontal disease and tooth decay can worsen the confusion associated with Alzheimer’s.  Gum disease results in inflamed and bleeding gums while receding gums reduce gum tissue, causing the roots of the teeth to be exposed.  Plaque caused by food debris and bacteria leads to gum disease if sufficient cleaning does not remove it where the teeth met the gums. Thus, the Alzheimer’s Society recommends that patients rinse the mouth with an antiseptic and disinfectant mouth wash (Alzheimer’s Society, 2013, para. 2 & 3).   However, the author fails to address what caretakers should do when dementia patients no longer understand the concept of rinsing.

Since tooth decay and the action of plaque on the teeth occur when the patient eats sugary foods, foods,  caregivers need to restrict such  treats to meals; for example, high-energy food supplements contain high levels of sucrose.  Gum recession also increases the chance of tooth decay (Alzheimer’s Society, 2013, para. 4 & 5).  

During the early stages of dementia, most patients can most probably still clean their own teeth, at first without supervision and only needing an occasional reminder to do so, but as manual dexterity decreases, an electric toothbrush or a manual toothbrush with an adaptive handle may help them maintain independence.  However, during the later stages of dementia, caregivers will need to assume this responsibility (Alzheimer’s Society, 2013, para. 5 & 6).  

Additionally, antidepressants, anti-psychotic, and sedative medications dry the mouth, causing problems with dentures and causing an increase build-up of bacteria and food debris in the mouth since saliva has a cleansing effect on teeth while at the same time the liquid syrup-based medication that the patient may be administered instead of swallowing a capsule or pill aggravates tooth decay (Alzheimer’s Society, 2013, para. 7 & 8).

Accordingly, it is crucial to schedule regular checkups for since caretakers increasingly may have to infer that patients are in pain by observing outward behavior (Alzheimer’s Society, 2013, para. 9 & 12).

During the early stages of dementia, however, advanced restorative treatment is still possible particularly if patients can still brush their teeth themselves. So this is the time to prevent further gum decay [perhaps by accustoming patients to using an electric toothbrush] (Alzheimer’s Society, 2013, para. 22).  In the middle stages of dementia, however, the focus needs to shift from restoration to prevention since some uncooperative patients may need to be sedated (Alzheimer’s Society, 2013, para. 23).  During the final stages of dementia, caregivers will need to concentrate on maintaining “oral comfort” and emergency treatment; Caregivers also need to clean plaque that can build up on dentures and to replace ill-fitting dentures (Alzheimer’s Society, 2013, para. 24-27). 

Dental health care for Alzheimer’s patients. (n. d.).  Delta Dental.  Retrieved from http://www.deltadentalins.com/oral_health/alzheimers.html

Delta Dental recommends that Alzheimer’s patients or their caretakers 1) brush teeth twice daily, noting that an electric toothbrush may be a good choice if the patient can stand the vibrating bristles;  2) floss once daily, using a special pick or stick rather than dental floss if patients clench their teeth; 3) cleanse the mouth and dentures after each meal, clearing the mouth of any remaining food since patients might not be immediately swallowing everything they put in the mouth; 4) visually inspect the teeth and gums monthly, looking for signs of gum diseases; and 5) schedule regular dental appointments (n. d., para. 2). 

Keith, C. (2012, November 8).  Alzheimer’s Disease/Grinding of teeth in Alzheimer’s.  AllExperts.  Retrieved from http://blog.alzheimerscareconsultants.com/alzheimers-blog/bid/103056/Alzheimer-s-Care-and-Dental-Health

Brain damage in late-stage Alzheimer’s may affect the impulses to the brain that stimulate teeth grinding.  Caregivers may thus need to ask a physician to prescribe sedatives or muscle relaxants; however, a baby’s teething ring briefly chilled in the freezer or a large pacify might also help.  Note: Nursing homes, however, may restrict the use of these low-tech, non-medicinal cures to inhibit tooth grinding because dementia patients might choke on parts that possibly might come loose, and these devices might be perceived of as undignified.

Kennard, C. (2006, September 5).  Dental care in dementia.  About.com. Retrieved from

http://alzheimers.about.com/od/treatmentoptions/a/dental.htm

This British study contrasts the early stages of dementia where patients may have to be reminded to brush, and caretakers may need to check if patients are still able to grasp a toothbrush with late-stage dementia where patients are no longer able to care for their own teeth, and caregivers may need to brush them (Kennard, 2006, para. 1 & 2). At this point, checking the  mouth for damaged teeth, swollen gums, tongue-biting and oral cancer becomes particular important as the patients’ inability to describe any dental symptoms worsens (Kennard, 2006, para. 3).  Signs of dental problems include rubbing or touching the mouth or jaw, moaning or shouting, head rolling or nodding, flinching when someone touches the face, refusing cold or cold drinks, restlessness, poor sleep, irritation, and aggression, and if the patient has dentures, refusing to wear them (Kennard, 2006, para. 4).  Caregivers may be reluctant to schedule dental appointments over anxiety that patients will not cooperate or become upset on the way to the dentist’s office (Kennard, 2006, para. 5). 

Pursley, B.  (2010, September 3). Alzheimer's and oral hygiene.  Alzheimer’s Reading Room.  Retrieved from http://www.alzheimersreadingroom.com/2010/09/alzheimers-and-oral-hygiene.html

Pursley, a registered nurse, gives a first-hand account of how she cared for her mother’s teeth and the problems she faced as a caretaker when trying to give her mother the best care possible.  Brushing her mother’s teeth with an electric toothbrush originally wasn’t difficult, although in time her mother bit Pursley’s hands when she tried to floss between her teeth (2010, para. 1).   However, ten years after the mother was first diagnosed with dementia, when Pursley took her mother to the dentist, he found a broken tooth with a slight infection and five teeth with cavities.  After he recommended that all her mother’s teeth be pulled, Pursley contacted a dental hygienist who counseled against this procedure since if a rotten tooth is dead  patients do not experience any pain, and it takes six months for cavities to show up on an x-ray.  Accordingly, Pursley took the advice that she needed to pay attention to her mother’s facial expressions and how she reacted to hot and cold liquids before taking such a drastic step since late-stage dementia patients usually decline after being administered complete anesthesia, and some never wake up after the procedure. 

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Research-based Surveys & Studies on Dental Care for Dementia Patients

Ellefsen, B., Holm-Pedersen, P., Morse, D. E., Schroll, M., Andersen, B. B., and Waldemar, G. (2008, January).  Caries prevalence in older persons with and without dementia.  Journal of the American Geriatrics Society, 56(1), 59-67.  Abstract only.  Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18028345

Dental problems strongly correlate with the severity of dementia. The mean number of coronal and root surfaces with cavities is considerably higher after the diagnosis of dementia while Alzheimer’s patients have a significantly high mean number of root surfaces with caries than subjects who have not been diagnosed with dementia.  

Friedlander, A. H., Norman, D. C., Mahler, M. E., Norman, K. M., & Yagiela, J. A. (2006, September).  Journal of the American Dental Association [JADA]. 137 (9), 1240-1251.  Abstract only.  Retrieved from http://jada.ada.org/content/137/9/1240.abstract

Dental disease in dementia patients will likely be extensive because of diminished saliva flow and the patients’ inability to brush and floss their own teeth.  Caregivers therefore need to learn about the use of saliva substitutes and anti-caries agents.

Gitto, C. A., Moroni, M. J., Terezhalmy, G. T., and Sandu, S. (1985).  The patient with Alzheimer’s disease.  Berlin: Quintessence International. [Abstract Only]/ Retrieved from Europe Pub Med Central, http://europepmc.org/abstract/MED/12066662/reload=0;jsessionid=pSkVVEB0lbA8qMOFEf7M.4

Alzheimer’s hinders the ability to convey symptoms of dental pain or dysfunction while a gradual and increasing loss of memory affects the capacity to tolerate therapeutic interventions.  Therefore, caregivers need to develop timely, preventive, and therapeutic strategies that respond to the patients’ willingness to undergo dental care. 

Jones, J. A., Lavallee, N., Alman, J., Sinclair, C. and Garcia, R. I. (1993), Caries incidence in patients with dementia. Gerontology, 10: 76–82. doi: 10.1111/j.1741-2358.1993.tb00086.x

http://onlinelibrary.wiley.com/doi/10.1111/j.1741-2358.1993.tb00086.x/abstract

A study that followed a group of 23 male veterans with moderate and advanced Alzheimer’s contrasted a control group with dementia patients matched for age, number of teeth, and education whereupon it discovered significant statistical difference in teeth and root decay between those veterans who still could care for their own teeth and those who have lost this ability.

Mancini, M., Grappasonni, I, Scori, S., Amenta, F. (2010, June 7).  Oral health in Alzheimer’s disease: A review.  Current Alzheimer’s Research.  7(4), 368-73.  Abstract only. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20043813

As oral health declines, dental pathologies increase in patients diagnosed with Alzheimer’s because patients loose the intelligence that will allow them to care for their teeth and/or dentures themselves.  Thus, dental interventions increasingly need to concentrate on decreasing pain and oral disease and contributing to oral and nutritional health.  Dental treatments in the early stages of dementia, by way of contrast, should aim at producing a stable condition that will help ensure a high quality of oral health throughout the duration of the disease.

Niessen, L. C. and Jones, J. A. (1987), Professional Dental Care for Patients with Dementia. Gerontology, 6: 67–71. doi: 10.1111/j.1741-2358.1987.tb00391.x.  Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/j.1741-2358.1987.tb00391.x/abstract

With the goals of restoring and maintaining oral health and preventing future oral disease, dental professionals need to develop a special skills set to treat patients with dementia: 1) planning a treatment program with caregivers and 2) developing the rapport to communicate with patients who can no longer adequately respond verbally. Dental function should be restored as quickly as possible and an intensive preventive program should be put in place.

Srisilapanan, P. and Jai-Ua, C. (2013, March).  Oral health status of dementia patients in Chiang Mai Neurological Hospital.  Journal of the Medical Association of Th[ailand—Chotmaihet thangphaet.  56(3), 351-357. Abstract only. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23539941

This Thai study discovered that 52.40 percent of all dementia patients with the average age of 75.5 years still had at least 20 functional teeth while the mean of decayed, missing, or filled teeth was 14.9 percent.  The biggest problem these patients face was periodical disease (64.7 percent).  The severity of the patient’s dementia also correlated with an increase in cavities. 

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Postscript:  A Personal Note

I would personally like to thank Ledet Dental for Mother's dental care, a service that provides dental care for nursing home patients throughout the North Central Texas area, for their five years of faithful dental care when she could no longer make a trip to the dentist's office.  Not only did Ledet Dental provide skilled dental care, but they always kept me well-informed as well.  Moreover, Mother always seemed to enjoy the attention she received during their visits, and until the last few months of her life, she always had a beautiful smile. 
  

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