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;

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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
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SpecialCareDentistry

 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.
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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 467
SpecialCareDentistry

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 2015
SpecialCareDentistry

into account the patient’s age, frailty and       in the dental setting. The programme is                7th October 2014.
co-morbidities and it may be sensible to          available from barbarasstory@gstt.nhs.uk           10. NHS England. Commissioning for
carry these procedures out in a hospital          or a condensed version can be viewed on                Quality and Innovation (CQUIN): 2014/15
setting. Titration with midazolam should          YouTube.42                                             guidance.
be modified. One suggestion is to half                                                               11. http://www.alzheimers.org.uk/
the dose and double the amount of time                                                                   site/scripts/documents_info.
between each increment compared to the            Conclusion                                             php?documentID=1521. Accessed 7th
usual adult schedule.37 Intranasal sedation                   Everyone in the dental team                October 2014.
with midazolam can help by facilitating           is going to be affected by dementia. We            12. http://www.alzheimers.org.uk/site/
cannulation for an unco-operative patient;        cannot ignore this condition and must                  scripts/documents_info.php?docume
again much lower doses will be needed for         make provision to provide appropriate oral             ntID=535&pageNumber=2. Accessed
the older/frailer patient and the clinician       healthcare, ensuring that our dental clinics           7th October 2014.
must be well practised in cannulating             are dementia friendly environments.                13. Scott KR, Barrett AM. Dementia
patients to allow for safety.38                               We need to plan treatment                  syndromes: evaluation and treatment.
             Where treatment is extensive or      carefully to reduce the risk of dental pain for        Expert Rev Neurother 2007; 7: 407−422.
sedation not suitable, general anaesthesia        this vulnerable group and reduce the need          14. http://www.medicinescomplete.com/
can be used and allows for full co-operation.     for extensive treatment in the later stages of         mc/bnf/current/PHP3236-drugs-for-
There is evidence to suggest that dementia        the disease.                                           dementia.htm?q=dementia&t=sear
can worsen following general anaesthesia.39                                                              ch&ss=text&p=1#_hit. Accessed 7th
It is thought that short quick procedures                                                                October 2014.
are best and thought should be given              References                                         15. Poole SA, Singhraoa SK, Kesavalu L,
to co-morbidities and fitness for general         1.   http://alzheimers.org.uk/                         Curtis MA, Crean SJ. Determining the
anaesthesia.                                           site/scripts/documents_info.                      presence of periodontopathic virulence
             A light sedation with continuous          php?documentID=342. Accessed 7th                  factors in short-term postmortem
infusion propofol could also be considered.            October 2014.                                     Alzheimer’s Disease brain tissue.
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sedative effect compared to midazolam                  pm-announces-new-measures-to-                 16. Bush T. Communicating with patients
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short procedures and, because it is given         3.   World Health Organization.                    17. http://www.nhs.uk/Conditions/
continuously, it can also be used for longer           International Statistical Classification of       dementia-guide/Pages/dementia-
procedures. This may limit the need for                Diseases and Related Health Problems.             and-communication.aspx. Accessed
general anaesthesia in cases where patients            10th Revision Volume 2 Instruction                7th October 2014.
present with high treatment need and are               Manual: 2010 edition.                         18. Frenkel H. Alzheimer’s Disease and oral
anxious. Propofol does cause respiratory          4.   http://www.alzheimers.org.uk/                     care. Dent Update 2004; 31: 273−280.
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   Part-time MSc Dentistry Courses
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472 DentalUpdate                                                                                                                       June 2015
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