Dementia and Dentistry - FGDP Scotland
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SpecialCareDentistry
Julie A Edwards
Liz Ford and Carole Boyle
Dementia and Dentistry
Abstract: Dementia is increasing in prevalence: by 2025 it is estimated that there will be over a million people in the UK with this diagnosis.
The condition is likely to affect us all as healthcare providers, whether in our patients, our relatives or ourselves. This article gives an
overview of dementia: causes, treatment, how it affects people and provides advice on how to manage patients with dementia who require
dental care.
CPD/Clinical Relevance: By identifying the patient with dementia and being aware of the challenges in providing care the clinician can
provide better treatment and reduce the chance of dental problems as the condition progresses.
Dental Update 2015; 42: 464–472
Dementia is one of the biggest health and reasoning in addition to the memory cognitive decline.5 The dental team might
challenges facing the NHS in the UK and disturbance’.3 spot this change in oral health behaviour
is recognized as a global time bomb. It is Currently dementia is before a family recognizes memory loss.
estimated that there will be over a million underdiagnosed: fewer than half the people
people with dementia in the UK by 2025.1 with the disease have a diagnosis. Early
The G8 summit in London December diagnosis means faster treatment, which Diagnosis
2013 made a commitment to ‘significantly can slow down progression of the disease. Diagnosis of dementia
increase the amount spent on dementia It is important to be aware that dementia requires the person to exhibit changes
research, to identify a cure, or a disease is increasingly a chronic condition, with in cognition, function and personality
modifying therapy by 2025 and to develop an most people living in their own homes, and for at least a year.6 Changes in cognitive
international action plan for research’. David not all are elderly. Although most cases are function alone indicate a diagnosis of mild
Cameron announced care quality measures recognized later in life, increasingly younger cognitive impairment (MCI). Fifty percent
to improve the quality of care provided in people, less than 65, are developing the of people diagnosed with MCI will go on
hospitals for people with dementia.2 condition. Dementia is not a natural part of to develop dementia; the other 50% will
The ICD-10 defines dementia ageing.4 not progress, or even improve.7 The term
‘as a disorder with deterioration in both dementia describes a syndrome: a range
memory and thinking which is sufficient to of symptoms, which combine to make an
impair personal activities of daily living. The Impact on the dental team overall clinical picture. There are over 100
impairment of memory is noted to typically Dementia is going to affect different specific conditions which can
affect the registration, storage and retrieval us all: either in the patients we treat, as cause a person to have a dementia.
of new information. The definition requires sufferers ourselves or as carers for our loved The ideal route to diagnosis,
that the patients have deficits in thinking ones. The dental team needs to be aware following NICE Guidance (2014), starts
of the early signs and how to manage with patients presenting to their GP with
those in the middle and late stages of the a 12-month history of memory loss which
disease. Careful treatment planning will be severely affects their day-to-day life. A
Julie A Edwards, Specialist in Special needed: thinking ahead to avoid providing comprehensive history is taken at this point,
Care Dentistry, Liz Ford, Dementia and complex restorative care, which cannot be with the assistance of a carer or relative for
Delirium Clinical Nurse Specialist and maintained in the long term. clarity.8,9 There are several short cognitive
Carole Boyle, Consultant in Special Care There is some work looking at an exams that can be performed by the GP.
Dentistry, Guy’s and St Thomas’ NHS association between cognitive decline and These can be found in ‘Helping you to assess
Foundation Trust, Floor 26, Tower Wing, oral health. Researchers suggest that less cognition’.6 The following bloods should be
Great Maze Pond, Guy’s Hospital, London frequent toothbrushing and subsequent taken to rule out other causes of confusion:
SE1 9RT. plaque accumulation are early indicators of routine haematology and biochemistry;
464 DentalUpdate June 2015SpecialCareDentistry
thyroid function; serum vitamin B12 and all dementia diagnoses.12 People with AD dementia with Lewy-Bodies, often have
folate. Mid-stream urine, chest X-ray, ECG typically present with short-term memory problems with disturbed sleep and
and bloods for HIV and syphilis should loss and word-finding difficulties. As AD hallucinations. Lewy Bodies (LB) are small
be considered if indicated in the clinical progresses people can become more deposits of protein in nerve cells and
history.8 At this point, referral to a specialist confused, forgetting names of people and are named after the physician who first
memory service should be made. They will places, appointments and recent events. described this condition. LBs can also
perform further cognitive testing, screen They may experience mood swings and cause Parkinson’s Disease and presentation
patients for depression, review medication, frustration, and become more withdrawn, depends on which part of the brain is
and possibly perform neuropsychological possibly due to loss of confidence or affected: at the base of the brain they
testing. Brain scanning, MRI for preference, communication problems. Everyday cause motor problems, in the outer layers
is then performed to rule out other causes activities, such as using a phone or TV cognitive symptoms. With time, the
of the cognitive symptoms and to diagnose remote will become more challenging.13 symptoms of LBD and PD become more
the dementia sub-type. Following diagnosis, Anti-cholinergic therapy has similar.13,14
the Memory Clinic will give information and been shown to be effective in early to
refer on to local services as required. moderate AD. Donepizil (Aricept) is the
Fronto-temporal dementia
In reality, the pathway to NICE recommended first drug of choice.
Fronto-temporal dementia (FTD)
diagnosis rarely runs this smoothly. People There is a strict protocol involving a drug
generally affects people slightly younger
in the early stages of dementia may not holiday to prove efficacy, which must be
than the other dementias, with symptoms
realize their deficits, pass them off as adhered to. Rivastigmine and Galantamine
presenting in the sixth decade. As the name
‘old age’, or fear an unwanted diagnosis; are also available, with Memantine for more
suggests, the disease predominantly affects
all of which may mean that they do not moderate disease. There is also anecdotal
the frontal and temporal lobes of the brain,
present to their GP. Often changes are evidence of Memantine being effective in
meaning the predominant early features
noticed by relatives, who then struggle to the treatment of behavioural disturbances
are personality change, and problems
persuade the affected person to seek help. in moderate to advanced dementia. The
with executive function. People with FTD
The Alzheimer’s Society can be a source most frequent side-effects of Donepezil,
can exhibit challenging behaviour, as the
of support and advice for carers in this Rivastigmine and Galantamine are loss of
brain damage can cause them to become
situation. An even greater challenge can appetite, nausea, vomiting and diarrhoea.
dis-inhibited. This may present as short
be accessing people who live alone, with Other side-effects include stomach
temperedness, aggression, mood swings
limited contact with people who would cramps, headaches, dizziness, fatigue and
and sexually inappropriate behaviour. FTD
notice a change. insomnia.14
can be linked to motor neurone disease.13,14
As a dentist you may find
yourself seeing a patient with obvious
Vascular dementia
confusion but no diagnosis of dementia, Early stages
This form of the disease is
or with a carer asking you for advice as to The dental team may be the first
caused by ‘furring’ up of the small blood
what to do as a healthcare professional. to notice the subtle changes that occur in
vessels in the brain (similar to coronary
You should contact his/her GP highlighting the early stages, which are not detectable
artery disease). People with vascular
concerns and requesting a review. to those who see the person every day.
dementia are often diagnosed after a
The current National Dementia CQUIN A previously reliable patient may forget
stroke, or series of Transient Ischaemic
(Commissioning for Quality and Innovation) appointments and either not come or turn
Attacks (TIAs). Here deterioration is often
requires acute hospital trusts to screen up on the wrong day or at the wrong time.
stepwise, and linked to cerebrovascular
all emergency admissions over the age of Another early sign is difficulty in making
changes in the brain. Vascular dementia
75 for memory problems.10 This may be decisions, perhaps about dental treatment.
can be managed with the therapeutic
extended to outpatient and community Oral hygiene may deteriorate as patients
interventions recommended for coronary
services in the future. The national diagnosis cannot remember whether they brushed
artery disease: healthy diet, smoking
rate for dementia is 42%, which means their teeth that day or not. The dental
cessation; conservative alcohol intake;
a staggering 58% of people living with a team might notice that the person cannot
statins; and possibly anticoagulants to
dementia receive no formal diagnosis. It is remember names of family members or
prevent clots.12
estimated that one in three of us will have forgets the conversation he/she had at the
some form of dementia when we die.11 last visit.
Mixed dementia We can all have forgetful
Usually refers to a combination moments but the memory loss associated
Types of dementia (Table 1) of AD and vascular dementia.12 with dementia is more serious and is
Alzheimer’s Disease usually for recent events. Other early
The commonest and most well signs include repetition: asking the same
Lewy-Body dementia
known form of dementia is Alzheimer’s question repeatedly and losing the thread
People with Lewy-Body
Disease (AD), which accounts for 60% of of what is being said. Confusion and
dementia (LBD), also referred to as
difficulty in grasping new ideas can also
June 2015 DentalUpdate 465SpecialCareDentistry
Type of Dementia Causes Signs and Symptoms Treatment
Alzheimer’s Disease (AD)
Accounts for 60% of Typically present with short-term Anti-cholinergic therapy has been
dementia diagnosis. It is memory loss and word-finding shown to be effective in early to
caused by plaques difficulties moderate AD. Donepizil (Aricept)
appearing in the brain is the NICE recommended first
Progressively become more confused drug of choice
with mood swings and frustration,
more withdrawn, loss of confidence
and communication
Everyday activities, such as using a
phone or TV remote will become
more challenging
Vascular Dementia
Caused by congestion of Often diagnosed after a stroke Healthy diet, smoking cessation;
small blood vessels in the conservative alcohol intake;
brain Deterioration is stepwise with signs statins; and anticoagulants to
and symptoms similar to that of AD prevent clots
Mixed Dementia A combination of vascular A combination of vascular dementia Approach will include treatments
dementia and Alzheimer’s and Alzheimer’s Disease for both vascular and AD
Disease
Lewy-Body Dementia Deposits of protein in Disturbed sleep and hallucinations Management of symptoms and
nerve cells support
Fronto-temporal Dementia
Damage to frontal and Younger presentation Multidisciplinary support
temporal lobes of the brain Challenging behaviour
Disinhibition
Short-tempered
Aggressive
Mood swings
Sexually inappropriate
Table 1. Types, signs, symptoms and treatment of dementia.
make communication difficult. person will need reminding to wash and eat Later stages
If the dental team notice and help to carry out these tasks. The dental Now it will be difficult for the
these changes, it is important to speak team might notice confusion and agitation person to come to the dental surgery
to the patient. This will not be an easy in someone who was previously happy due to increasing fragility and mobility
conversation as it may confirm thoughts in the dental setting. He/she might not problems. They progress from difficulty
that the patient has had but is trying to recognize the dental team and repeatedly walking, to using a wheelchair or, in the
ignore. It would be good to involve the ask the same question, forgetting the later stages, being confined to bed. The
family at this stage. They may have noticed answers given. It is important to stay calm disease can cause difficulty in eating and
behavioural changes with their loved one and allow time for the patient to remember swallowing so that the dental team may
becoming less interested in others around without jumping in and answering for him/ be asked to carry out an examination
them and more irritable. It is important to her. The family are likely to notice changes to rule out a dental cause for these
encourage, in a sensitive manner, patients and may tell you that their family member difficulties. Because of this, people can
to seek diagnosis, as early treatment can has started doing risky things at home, like lose weight, making denture-wearing
slow down progression of the disease. leaving the cooker on or wandering off difficult. There is a loss of speech and
at night. Assistance may be required for increasing communication difficulties. At
toileting: it is helpful if toilets are clearly this stage, dental treatment should be
Middle stages signed in the dental practice and include focused on making sure that the patient’s
By this stage alterations in grab rails and toilet paper with distinct mouth is comfortable and that carers are
behaviour are more apparent and the colours. carrying out regular oral healthcare.
466 DentalUpdate June 2015SpecialCareDentistry
Dementia and link with oral language, speaking clearly and slowly, but herself, unless authorized to do so under
disease without making patients feel stupid. Allow a Lasting Power of Attorney or with the
There is no clear evidence that time for patients to process the information authority to make treatment decisions as
dementia and poor oral hygiene are linked, and time to respond. You may need to a Court Appointed Deputy. Therefore, in
therefore any suggestion that good oral rephrase something if patients do not most cases, parents, relatives or members
hygiene prevents dementia is ill-founded. understand in the first instance. Maintain of the healthcare team cannot consent
Periodontal disease adds to systemic eye contact, smile and constantly reassure on behalf of such an adult. Their views
inflammation and is commonly found in the patients. Explain everything, sometimes you should be respected as far as is reasonably
older dentate population. This inflammation may need to repeat your explanation. Listen possible, as these individuals will know
can affect the brain, disrupt neurons and and do not dismiss them, even if what they the opinions of the individual far better
cause poor memory. A small research study say is out of context. Always remember to than the clinician. This is normally done
looked at gingival bacteria markers in brain include them in conversations, even if there in a best interests meeting and decisions
tissue from ten cadavers from people who is no response. Consideration should also to treat must be based on the patient’s
died with Alzheimer’s Disease and ten be given to other communication aids, such best interests and be the least restrictive
without. Markers were found in four people as pictures and signs.17,18 option.21
with Alzheimer’s but none in any of those Prompts have been shown to Judging someone’s capacity
without dementia.15 However, further work aid communication in dementia.16 Some to consent is a two-stage process and the
is required to establish a definitive link. patients will have a ‘This is me’ Document decision should be made by the clinician
created by The Royal College of Nursing proposing the treatment, however, other
with The Alzheimer’s Society. It is a tool for healthcare professionals can help the
The dental management of people with dementia to complete when dentist make this decision. At some stage,
patients with dementia they are first diagnosed. It gives information the diagnosis of dementia will cause
As dementia progresses so do to health and social care professionals the patient to have impairment of brain
the challenges for dental professionals about their needs, interests, preferences, function and this is the first part of the
who provide treatment for these patients. likes and dislikes.19 Clinicians can also decision process. If the clinician does
The challenges are multifactorial and use this information as a basis for their decide that there is brain impairment,
special consideration is needed not only communication by using the information as the second stage is to decide if this
in providing treatment, but also helping prompts. impairment means that the patient is
patients to access services, taking consent, Up-to-date medical histories unable to make a decision in his/her own
communication and treatment planning may need to be obtained from General best interest. This is a time and treatment
for the future. Prevention of disease is Medical Practitioners. Carers and relatives specific decision. Patients with dementia
fundamental to their dental management. should be asked about changes in may have better times of the day where
behaviour, including eating and sleeping, consent can be given and also phases
which can indicate dental pain. where capacity is reduced but may
Communication improve, as the disease fluctuates. Where
Communication is a two-way dental treatment is not urgent, decisions
process between individuals sending and Consent can be delayed to allow for a time when
receiving information, both verbally and Mental function will decline as individuals can consent for themselves.
non- verbally. As dementia progresses, the dementia progresses and, at some stage, Patients may also be able to consent for
ability of the patient to communicate is an individual diagnosed with dementia simple treatments, such as examination
disrupted and, over time, communication will lose the ability to make decisions. He/ and cleaning of their teeth, but may
becomes more and more difficult.16 Simple she will lose the capacity to be able to not have the capacity to make more
tasks for clinicians, such as taking a medical consent for dental treatment. One of the complicated decisions, such as having
or pain history, can become difficult, as biggest challenges for dental practitioners teeth extracted or general anaesthesia.
well as taking consent. Knowing and is judging if that individual has the capacity The two-stage capacity assessment must
understanding the wishes and beliefs of the to give consent.20 Consent guidelines vary be documented with written evidence of
patient may be hard, especially if he/she is from country to country and even within the decisions made and how.21
new to your practice or service. the UK itself, however, the principles are still An advanced decision is an
It is important to understand the same. intervention made by a person when he/
that patients can feel very confused and In England, the Mental she had capacity. Advanced decisions can
distressed in the dental setting, but may Capacity Act 2005 gives clinicians a clear include decisions not to have treatment
not be able to express this. Effective and structured approach in assessing once mental capacity is lost. Clinicians
communication is important to reduce any someone’s mental capacity and provides must always check to see if there is an
anxiety for the patient and the clinician. The a framework for clinicians. The act states advanced decision, a lasting power of
dental team may need to make adjustments that no-one is able to give consent to the attorney or a court appointed deputy
in how they communicate with dementia examination or treatment of an adult who in place. The clinician must look at the
patients.16 Key changes include using simple lacks the capacity to give consent for him/ paperwork that supports this information
June 2015 DentalUpdate 467SpecialCareDentistry
as decisions or power to consent for dental because of self-neglect and a loss of require frequent monitoring so that, if
or medical procedures are not always cognitive and motor skills. Co-operation a tooth does become problematic, it is
included.21 Where individuals do not have for assistance with oral hygiene may also treated quickly.
relatives or friends involved with their care diminish.20 Patients with dementia take Because of possible early
an Independent Mental Capacity Advocate multiple medications, often resulting in a extraction of teeth for dementia patients,
(IMCA) can be accessed to support any dry mouth.27 Collectively, these problems a high number of them may be wearing
decisions that could be life-changing,21 for place these patients at high risk of oral dentures. The chance of losing dentures
example a dental clearance. disease. is increased when living in a care home
People differ at the rate in which and with hospital admissions. As dementia
they deteriorate20 and treatment plans must progresses, replacing lost dentures may
Access to dental care
be designed to suit the severity of disease. not be in the patient’s best interest owing
Patients with dementia find it
However, consideration must also be given to the co-operation required for each
harder to access health services.22 This may
to the future and the reducing ability stage of the denture. It is often a very
be due to a number of reasons, including
to maintain oral hygiene, including the difficult conversation to have with family
difficulties in making appointments,
ability to use interproximal aids. Providing members when deciding not to replace
being reliant on carers to aid attending
complex crown and bridgework or even lost dentures or, indeed, not to carry out
appointments and being physically frailer.
implants, which are going to be difficult to dental treatment, and should be done with
Patients or carers may need
maintain in the later stages of dementia, is sympathy and empathy but focused on the
reminding of appointments and booking
not in the patients’ best interests.28 best interests of the patient. Dentures can
the appointments should be flexible around
People are now living longer and be labelled with the patients name so that
the best times for the patient, for example
keeping their teeth for longer and patients they can easily be reallocated if found by
in the morning is often better. This will
diagnosed with dementia are likely to have care teams. Copy dentures can be made
often in turn improve co-operation and
at least a partial dentition. This means that at the early stages of dementia so that,
communication.23
they are at risk of recession, root caries if they are lost later on, a replacement is
Patients can be more
and tooth surface loss.29 Ideally, preventive already available without the distress of
comfortable and lucid in their own home
treatment should begin at early diagnosis.30 making a new set for a patient with limited
environments24 and screening, examination
Treatment plans should be kept simple: the co-operation.
and simple treatment could be carried
removal of teeth with a poor prognosis,
out on a domiciliary basis. Guidelines in
which are potential sources of pain, should
domiciliary care can be accessed on the Co-operation for treatment
be carried out, along with restoration of
British Society of Disability and Oral Health As dementia progresses so
the dentition. This is easier when there is
(BSDH) website.25 does the individual’s mental function and
capacity to consent and co-operation for
Some patients may be moved ability to co-operate. Many individuals with
treatment.
from their homes into residential care, dementia have anxiety and depression,
Prevention advice should
supported accommodation or nursing reducing co-operation further.20 Some
include prescription fluoride toothpastes,
homes. This makes access to dental care patients will just require more time and
oral hygiene instruction, including
more difficult and further complicated by explanation, using behaviour management
electric toothbrushes and dietary advice.
frequent admittance into hospital. Family techniques such as ‘tell, show, do’ and
Professional fluoride application should be
and care teams may also find it difficult to systematic desensitization. Use of clinical
applied every 6 months.31 As the disease
access dentistry or to take patients to their holding may also help and are the use of
progresses, individuals may move into care
dental appointments. Shared care between physical holds that are light and do not
homes: advice should be given to the care
primary and secondary care settings may make the patient feel restricted.35
teams in the form of oral healthcare plans
be required and patients may need to be In the early stages of dementia,
and can be put in the patient’s room for
seen on a domiciliary basis. Mobile dental where co-operation is good and patients
carers to follow.30
units can be useful for access to care homes are anxious, inhalation sedation is a simple
There is a link between smoking
where multiple patients can be treated.26 technique that may offer anxiolysis. Where
and dementia and also with smoking and
As dementia progresses, patients co-operation is limited and anxiety high,
periodontal disease. Smoking cessation
will become more frail and possibly rely on sedation with intravenous midazolam is
should be given where required.32,33
the use of wheelchairs. Some people may beneficial.
If implants are present, specific
find transferring to the dental chair difficult The physiological changes
advice should be given and the implant
and need referral to a service with transfer and related diseases that can accompany
carefully monitored. It may be advisable
boards, wheelchair tippers or hoists.26 ageing provide simplifications for
to put the implant to sleep and create an
pharmacodynamics of drugs. Changes in
overdenture.34
body composition, tissue drug binding
Treatment planning If patients present with broken
and tissue perfusion may affect the
The progression of dementia down teeth that are symptomless, it
distribution, redistribution and elimination
is accompanied by a gradual inability to might be better not to provide potentially
of drugs.36 Clinicians will need to take
perform self-care, including oral hygiene, distressing treatment. These teeth will
468 DentalUpdate June 2015SpecialCareDentistry
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Part-time MSc Dentistry Courses
Quality assured Dental education and training for the ambitious practitioner
Most dentists have professional and personal commitments that make
full-time study impossible but many still want the structure and quality
assurance that a university can provide. At UCLan we have a range of
part-time clinical MSc degree programmes designed with the busy but
ambitious dental practitioner in mind. Our Programme Directors are:
• Dr Mike Jones • Professor StJohn Crean
Endodontics Oral Surgery
• Dr Fadi Barrak • Dr Nic Hodson
Implant Dentistry Periodontology
• Dr Elizabeth Browne • Dr Malcolm Edwards
Non-Surgical Facial Aesthetics Prosthodontics
Our programmes will deliver the skills and knowledge that will enable
participating practitioners to fit easily into a managed clinical network
by being able to offer additional clinical services. Such skills not only suit
the new model for the delivery of NHS dental care but clearly have value
where patients choose to receive treatment under private contract.
Come along to our advice day on 9 June 2015, 2.30 – 6.30pm,
register now at: pgdentistry.eventbrite.co.uk
Call 01772 895861
Email medent@uclan.ac.uk
Visit www.uclan.ac.uk/med-dent
Setting standards in Primary Care Education
472 DentalUpdate June 2015You can also read
