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W323717155 abstract "GerodontologyVolume 23, Issue s1 p. 3-32 Free Access Oral health of people with dementia First published: 14 November 2006 https://doi.org/10.1111/j.1741-2358.2006.00140.xCitations: 10AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Contents 1 Introduction 5 2 Aim 5 3 Guiding principles 5 4 The dementias 5 4.1 The reversible or treatable dementias 6 4.2 The irreversible dementias 6 5 Alzheimer's disease 6 5.1 Aetiology 6 5.2 Onset 6 5.3 Clinical features and symptoms 7 5.4 Diagnosis 7 5.5 Management 7 6 Oral health 8 6.1 Key influential factors 8 6.2 Evidence of oral health problems 8 6.2.1 Oral hygiene 8 6.2.2 Periodontal (gum) disease 8 6.2.3 Dental caries (decay) 8 6.2.4 Medication, saliva and oral mucosa 9 7 Oral health assessment 10 7.1 Types of oral health risk assessment 10 7.2 Undertaking the assessment 11 7.3 Assessment for dental treatment 12 8 Oral health care planning 13 8.1 Expression of oral symptoms 13 8.2 Capacity to consent 14 8.3 Oral health care planning 15 8.4 General principles for oral health care 15 8.5 The role of carers 15 9 Dental treatment 16 9.1 Tolerating oral and/or dental interventions 16 9.2 Treatment planning 17 9.2.1 In the early stage 17 9.2.2 In the moderate stage 17 9.2.3 In the late stage 17 9.3 Denture requirements 17 9.3.1 Denture wearing 18 9.3.2 Denture loss 18 9.3.3 Denture provision 18 9.3.4 Denture marking 19 9.3.5 Denture and mouth hygiene 19 10 Delivery of dental care 19 10.1 Dental attendance 19 10.2 Access to dental services 19 10.3 Delivery of dental services 20 10.4 Professional barriers 20 10.5 Carer barriers 21 11 Autonomy and respect 22 12 Addressing the barriers 22 13 References 22 14 Useful websites 25 15 Appendices 26 Appendix 1. Oral Health Risk Assessment (OHRA) 26 Appendix 2. Joint Assessment Nursing Education Tool (JANET) 27 Appendix 3. Principles of treatment 29 Appendix 4. Assisting the individual with tooth brushing 30 Appendix 5. Denture marking 31 Appendix 6. A checklist for use in commissioning oral health care for older people 32 1 Introduction As more people survive into old age, there is a growing emphasis on older people's general health care (National Service Framework for Older People1) and on improving health in old age (Better Health in Old Age2). The British Dental Association (BDA) policy document ‘Oral Healthcare in Older People: 2020 Vision’3 set the scene for increased challenges in dental service provision for this sector of the population. In 2004, the Chief Dental Officer for England built on this by commissioning a strategic review of how the challenges of the oral health of older people can be met4. To address standards of care for people with dementia, the National Institute for Clinical Excellence is developing a dementia guideline that is due for publication in 2007. As the number of older people increases and the incidence of dementia rises, more dental teams will encounter the oral care problems of people with this disorder. Future trends predict that people will keep their natural teeth for longer and that older cohorts (55 years plus) will be more demanding of dental care than previously5. People with dementia experience the same oral health problems as the general population. However, their oral health can be compromised by the nature of dementia – including the severity of cognitive impairment, social functioning and behavioural aspects; compliance with dental care; ability of individuals and carers to undertake oral hygiene procedures; and the ability of individuals to undertake daily living activities. The experience of the dental team in providing oral care for people with dementia and the extent to which dental professionals understand the nature of dementia, influences the quality of oral health care provided. The capability of carers to recognise and report oral health problems, thereby initiating oral care, is of paramount importance. Education and training, plus the use of oral risk assessment tools, are essential to ensure optimal oral health for this group of people. 2 Aim These guidelines have been developed to assist in the development of local standards for, and the provision of, oral health care for people with dementia who may no longer have, or will reach a stage when they no longer have, the ability to: • Voice their needs for oral health care and treatment • Carry out daily oral hygiene to a level that prevents dental disease • Make informed choice, and • Give valid consent for treatment. 3 Guiding principles The guiding principles set out here are borrowed from the British Society for Disability and Oral Health's guidelines for ‘Principles on Intervention for People Unable to Comply with Routine Dental Care’6. Whilst it is recognised that some people with dementia, particularly in the early stage of the disease process, are able to comply, the ethos of the following principles still applies. • It is assumed that those people providing care share common values, a commitment to adherence to accepted clinical and professional standards, and, above all, operate within the interests of the service user. • All individuals have a right to equal standards of health and care. • All individuals have a right to autonomy, as far as possible, in relation to decisions made about them. • Good oral health has positive benefits for health, dignity and self-esteem, social integration and general nutrition. The impact of poor oral health can be profound. 4 The dementias Dementia is a progressive, neurodegenerative disease that effects the ability to perform daily living activities. It has been described as a variety of syndromes rather than a sign, a symptom or a disease7. There are a number of types of both reversible and irreversible dementia. 4.1 The reversible or treatable dementias These have been described7 as being due to: D drugs e.g. alcohol E emotions and depression M metabolic factors e.g. pernicious anaemia E endocrine conditions e.g. hypo- and hyperthyroidism N nutritional deficiencies e.g. folic acid deficiency T tumours and trauma of the brain I infections e.g. TB, syphilis, human immunodeficiency virus (HIV) A arteriosclerosis of cerebral vessels 4.2 The irreversible dementias According to Ettinger7 and, Ritchie and Lovestone8, these include: • Alzheimer's disease which accounts for 50–60% of diagnosed dementias • Vascular disease/stroke which accounts for 20% of cases and is due to brain tissue damage as a result of hypoxia or infarct • Lewy body disease, frontal lobe dementia and Pick's disease which all lead to the destruction of brain cells • Parkinson's disease which is associated with an increased incidence of dementia • Huntington's disease which involves mental deterioration in its later stage • Diseases such as acquired immunodeficiency syndrome (AIDS) and Creutzfeldt Jakob Disease (CJD) which account for a very small proportion of cases • Brain tumours and other causes of intra-cerebral pressure which can cause symptoms of dementia 5 Alzheimer's disease Most of the dental literature that relates to dementia is specific to Alzheimer's disease (AD). This is probably because AD is one of the most protracted forms of dementia and, thus, oral health is likely to be an issue at some stage during its process. The clinical features, symptoms and the principles that would be used in providing oral health care for people with AD and other types of dementia are similar, although the time scale of the dementia process may be different and in some cases accelerated; for example, CJD related dementia. For these reasons the bulk of this document refers to AD, however, the guidance can be equally well applied to any type of dementia. Alzheimer's disease is the most common cause of dementia and is responsible for just over half of the 720 000 cases in the UK. The female to male ratio is 2:19. The cultural incidence varies. It is low in people of African and Asian origin, and in China, Japan and the Russian Federation vascular dementia is more common than AD8. 5.1 Aetiology The immediate cause is the loss of neurones. Brain cells are destroyed disrupting transmitters that carry messages in the brain, particularly those responsible for storing memories. The aetiology of AD is uncertain, although, a number of risk factors are recognised. They include: • Age– the risk of developing AD increases with age from one in 1000 below the age of 65, to five to 10 in 100 over the age of 65, and one in five by the age of 80 years • Inherited family risk– some families have a strong family link with dementia but many other people inherit a gene which makes the disease slightly more likely • Brain damage– severe head injury with loss of consciousness, or repeated head injury throughout life • Down's syndrome– approximately 60% of people with Down's syndrome (DS) who survive into their 50s develop AD because of their chromosomal defect. In DS, neuropathological changes typical of AD usually develop by the fifth decade of life; and 75% of individuals with DS over the age of 60 show clinical signs and symptoms of AD. Most commonly, these are changes in personality (46%), apathy (36%) and loss of conversational skills (36%). However, a complete medical assessment should be carried out to eliminate any treatable disorders with similar symptoms such as thyroid disease or depression10. • Herpes simplex– the virus is considered to have a possible complicated link with genetic and chemical factors8. 5.2 Onset of Alzheimer's disease Alzheimer's disease may be either early onset type or late onset type8. The latter is more common. Early onset In the UK, approximately 170 000 people below the age of 65 have AD. Onset can be as early as 35 years of age. AD in younger people often progresses more rapidly. A number of rare genetic faults make AD more likely at a young age. People with a strong family history may seek genetic counselling. However, if identified as having inherited the associated faulty gene nothing can currently be done to prevent the development of AD. Late onset A gene is also associated with late onset AD. The apolipoprotein E gene (ApoE) is carried by everyone. However it comes in three forms –ApoE2, ApoE3 and ApoE4. ApoE2 seems to protect against AD, while ApoE4 makes AD more likely. If an individual inherits one ApoE4 gene, there is an increased chance of AD. If an individual inherits ApoE4 from both parents (approximately two in 100 people), there is a much greater chance of developing AD by the age of 80. 5.3 Clinical features and symptoms Clinical features characterising AD are memory loss, language deterioration, impaired visuo-spatial skills, poor judgment, indifferent attitude, but preserved motor function. AD is a progressive disease, appearing first as memory decline and, over several years, destroying cognition, personality and ability to function (see Table 1). Confusion and restlessness may also occur. The type, severity, sequence and progression of mental changes vary widely. Usually, AD is a slow disease, starting with mild memory problems and ending with severe brain damage. Whilst, the course the disease takes varies on an individual basis, the average life expectancy from diagnosis is 8–10 years. The disease can last for as many as 20 years and the commonest cause of death is infection. Table 1. Summary of the stages and characteristics of Alzheimer's disease Stage Clinical phase/clinical characteristics Normal No more than occasional forgetfulness Forgetfulness Subjective forgetfulness; normal physical examination Early confusion Difficulty at work, in speech, when travelling in unfamiliar areas; detectable by family; subtle memory deficit on examination Late confusion Decreased ability to travel, count, remember current events Early dementia Needs assistance in choosing clothes; disorientation as to time or place; decreased recall of names of grandchildren Middle dementia Needs supervision for eating and toileting; may be incontinent; disorientated as to time, place and, possibly, person Late dementia Severe speech loss; incontinence and motor stiffness. Source: Reisberg89 Its onset is insidious, but progressive over time. In the early stages, a person in their familiar home environment may be able to pass off the symptoms as forgetfulness. With time (6 months or more) a pattern of problems emerges and, as AD progresses, the individual may: • Experience short-term memory loss and routinely forget recent events, appointments, names and faces • Have difficulty in understanding what is said • Become confused by routine procedures such as handling money, driving a car or using a washing machine • Become increasingly disorientated in time, place and, eventually, person • Undergo personality changes becoming agitated, irritable and sometimes verbally abusive or becoming apathetic and non-responsive • Experience delusions, illusions and/or hallucinations In the advanced stages of AD people may also adopt unsettling behaviour (such as, getting up in the middle of the night and/or wandering off from home and becoming lost) or inappropriate behaviour (such as, undressing in public). Finally, the personality disintegrates and the person becomes totally dependent on others for daily living activities such as getting up, washing, dressing, feeding, etc. Relatives have described this experience as ‘like living with a stranger’ and ‘a living bereavement’ that is to say the person they knew and loved has died but the body is still there9. 5.4 Diagnosis Diagnosis usually occurs over a period of time and is made on a differential diagnosis of ruling out other types of dementia (both reversible and irreversible), recording symptoms over time and the results of cognitive/memory tests. Confirmation of diagnosis can only be made at postmortem when the specific pathology of senile plaques and neurofibrillary tangles are identified in the brain8, 9. 5.5 Management Modern management is aimed at maintaining quality of life. There is no cure for AD but its management has improved. Drugs, which slow down the rate of mental decline, are being developed. The first of these drugs to be licensed in the UK was donepzil (Aricept) in 1997. Donepezil and galantamine (Reminyl) are cholinesterase inhibitors and act by enhancing cognitive function in patients with AD. Clinical trials have shown the traditional remedy Ginkgo biloba to improve cognitive function in AD and to be well tolerated by patients11. Drugs can be used to help to control the depression, agitation and challenging behaviour associated with AD. Antipsychotics, such as risperidone, (Risperdal) and olanzapine (Zyprexa) and antiepiletics e.g. carbamazepine (Tegretol) may improve behavioural symptoms. However, pharmacologic interventions only appear to be modestly effective and trials to licence the drugs were performed in patients with mild-moderate dementia who had few co-existing conditions8. As yet it is unclear how long these drugs can help for and the newer drugs are not yet widely available. Memory aids and familiar routines are helpful in maintaining as normal a life for as long as possible. As AD progresses the individual will need more support and eventually is likely to need close supervision and, ultimately, nursing care. 6 Oral health General health and comfort are closely linked with oral health in the terminal stages of progressive neurogenic disease (PND). Poor oral health can impact on diet and nutrition, oral and general comfort, cognition, behaviour change, quality of life and life expectancy12-14. Aspiration pneumonia risk is significantly increased by oral factors such as decayed teeth, periodontal disease and the presence of various decay-causing organisms in saliva15. Good oral health can improve the quality of life and prolong it by reducing the likelihood of aspiration pneumonia. It is well recognised that oral health is likely to decline as AD progresses. The impact of the disorder, especially in the latter stages, leads to poor oral hygiene with an increase in periodontal disease, higher levels of decay (both coronal and cervical) and a greater incidence of other dental problems. These include difficulty wearing dentures, the inability to comply with oral care and the inability to carry out oral hygiene procedures16-21. Poor oral care and an increase in oral disease can lead to changes in eating habits that may be because of a non-functional dentition, pain and discomfort or ill fitting dentures; as well as affecting self-esteem because of compromised aesthetics22. 6.1 Key influential factors Factors influencing oral health, the ability to self care, routine access to, and provision of, oral care include: • The severity and stage of the dementia • The individual's level of cognitive impairment and physical disability • Lack of personal perception of oral health care problems • Previous dental history, including oral health care and dental attendance • Ability to receive oral hygiene care from carers and/or the dental team • Impact of medication on the oral cavity, especially xerostomia (dry mouth) • Motivation and behaviour • Capacity to consent to oral health care • Knowledge of, and attitudes towards, oral care of health and social care workers and carers • Lack of information on how to access dental services • Dental team's attitudes to, and awareness of, ageing and dementia • Lack of training and understanding by dental professionals in oral health care and strategic, long-term, treatment planning for people with dementia • Dental personnel unwilling or unable to provide appropriate care • Site of oral care provision, e.g. dental surgery, day centre, at home 6.2 Evidence of oral health problems Because of the difficulty in carrying out longitudinal studies on people with dementia, to date there is very little published research to support the subjective views of the dental professionals that oral health is often affected. 6.2.1 Oral hygiene People with dementia have poorer oral hygiene than the general population, the consequences of which lead to an increase in oral disease17, 18. The loss of cognitive and motor skills as dementia progresses reduces the ability to self-care, including carrying out oral hygiene procedures20, 23. Reliance on carers who may not have the motivation, knowledge, skills or training necessary to carry out oral care (especially if an individual has challenging behaviour) can have an adverse impact on oral hygiene. Chalmers et al.21 found that high carer burden and oral hygiene difficulties had a negative bearing on both oral care and caries increment. Additionally, they reported90, that people with dementia already had a compromised oral health status when admitted to long-term care homes. The high plaque levels on natural teeth were of particular concern. 6.2.2 Periodontal (gum) disease There is clear evidence that gingivitis is more prevalent in people with dementia. This is due to cognitive impairment, motor restlessness and apraxia. Increased periodontal disease is not surprising as adequate plaque control and oral care require both cognitive and motor skills. Although studies by Ship17, 18 found that people with dementia had significantly higher plaque scores, an increased proportion of gingival bleeding sites and more calculus than the matched control group, there was no statistical difference in periodontal health between the control and dementia group. Warren et al.23 and Chalmers et al.21 demonstrated that poor gingival health increased with the severity of dementia. 6.2.3 Dental caries (decay) The majority of studies concerning the prevalence of caries for people with dementia include non-medicated individuals in the early to moderate stage of the disease process. Thus, it is likely that they underestimate the eventual progression of oral disease and impairment of those individuals who are on medication for their illness. In a recent longitudinal study, Chalmers et al.21 compared dentate people with dementia living in the community with a matched control group without dementia and found that both coronal (crown) and cervical (root) caries increments were significantly higher in the group with dementia. The research concluded that sex (male), dementia severity, high carer burden, oral hygiene difficulties, use of neuroleptic medication (causing dry mouth) and previous caries experience were all risk factors for dental decay. Warren et al.23 reported that the more severe the dementia the more likely it was that there would be oral health problems, including an increased prevalence of dental caries. Whilst a number of researchers have described decreased salivary flow rates, poorer oral hygiene and increased caries (both coronal and cervical) as consistently higher in people with dementia than in control groups, they have been unable to demonstrate any clear statistical difference between the groups and the authors made recommendations for further studies18, 19, 24. The results of such research could be attributable to the exclusion of people with advanced AD who are unable to give informed consent; and the challenges of gaining co-operation of, and compliance from, this group of people when they are included. Those individuals least able to co-operate and comply are the people who are most likely to be at risk of increased oral disease. Indeed, all research in this area has concluded that it is the severity of cognitive impairment rather than the diagnosis of dementia that is a factor in the caries experience18, 19, 21, 23, 24. Avlund et al.25 demonstrated that in a Swedish population, aged 80 years and over, both coronal and cervical caries increases as cognitive function decreases. Additionally, people with poor cognitive function have a four times higher risk of not using dental services regularly. Rejnefelt et al.26 point out that people with dementia living in care homes have more oral health problems than individuals without dementia. Whilst, Adam and Preston27 conclude that moderate to severe dementia may have a deleterious effect on the oral health of individuals in care homes. 6.2.4 Medication, saliva and oral mucosa The commonest medications used in AD (see 5.5 Management) have the potential to cause xerostomia (dry mouth) and its complications of plaque accumulation, periodontal disease, denture wearing problems and dental caries. If medications are syrup-based the potential for the development of rampant caries is increased. It is prudent to advise the use of sugar free medications where possible. Frequent dental review and use of chlorhexidene and fluoride help in the prevention and/or control of caries development. As AD progresses the individual is less able to remember, and less able to carry out, daily living activities such as tooth brushing and will need support in this task. Also, the individual becomes less able to express their needs or wishes, and to understand and explain dental symptoms such as pain7. People with dementia may be given a variety of drugs to treat problems such as anxiety, depression, psychosis, insomnia and other systemic illnesses prevalent in the older age group as well as medication that may slow the dementia process. The medications used to help with mood control and to attempt to slow cognitive impairment include anticholinesterases, antidepressants, antipsychotics and anxiolytics. All these drugs can have xerostomic side-effects28. Chalmers et al.21 found that the use of neuroleptic medication increases a person's susceptibility to caries. The drugs used can also cause glossitis (anticholinesterases) and mucositis (antipsychotics), as well as gingival hyperplasia, oral ulceration, erythema multiforme and loss of taste (anticonvulsants)7, 20, 29. Ship et al.17 found that submandibular gland salivary flow rate was significantly reduced in people with early AD although parotid flow rates were the same as for the control group. Adequate salivary flow is a requirement for good oral health. It assists in the prevention of abrasions (especially for those people wearing dentures), and its qualities of buffering and washing help to reduce the potential for caries. There may be increased plaque accumulation and gingival inflammation in people with a dry mouth that can be painful leading to less inclination to brush the gums and, consequently, poorer oral hygiene30, 31. Ship18 found no difference in mucosal pathology (including candidiasis) although the group with dementia tended to have dry and cracked lips. Despite no significant difference in the prevalence of Candida, 50% of people with dementia had denture induced stomatitis. People with dementia may not be able to complain of a dry mouth so it is prudent, where possible, to include an evaluation for xerostomia in the overall oral health risk assessment. The effect of a dry mouth has serious consequences for a cognitively impaired older person who may be unaware of, or unable to, articulate their difficulties17, 18, 30, 31. Paradoxically, despite reduced salivary flow, drooling (or siallorrhea) can be a problem in people with AD. It is defined by Brodsky32 as ‘abnormal spillage of saliva from the mouth on to the lips, chin and clothing’. It tends to occur because of dysphagia (difficulty swallowing) coupled with a head down posture. It can be exacerbated by oral pain and discomfort. According to Kilpatrick et al.33, profuse drooling can cause perioral maceration, skin chapping and infection, antisocial odour, requirement for frequent change of clothing, lowered self-esteem and depression. Management strategies for controlling drooling include behavioural and oral motor techniques to remind or teach the person to swallow; drugs to reduce salivation (which can exacerbate oral health problems even further); and surgery to reduce the amount of saliva or to re-route the saliva to by-pass the oral cavity33. In the later stages of AD, the pharmacological approach may be the most effective. Because of side-effects such as dry mouth, behavioural changes and hot flushes, anticholinergic drugs (such as transdermal scopolamine) tend to be used intermittently; for example, prior to social outings. It is not possible to predict the degree of dry mouth that will be achieved and it is important to monitor this so that one problem (i.e. drooling) is not substituted for others (e.g. dry mouth, caries, difficulty eating). 7 Oral health assessment In a health care setting, assessment is described as the gathering of information and formulation of judgments regarding a person's health, situation, needs and wishes which should guide further health action. An effective oral health assessment identifies risk factors for present and future oral health care and includes negative factors that impact on oral health. It is not a diagnostic tool unless it also includes a comprehensive oral examination as part of a holistic assessment. Where it is intended for use with a specific client group, it should incorporate the known risk factors for oral health for that client group. There is no universal response to risk factors and there will be individual variations. However, some risks will be deemed to be acceptable as an essential component of treatment, e.g. the side-effects of long-term medication or high calorie, sucrose containing, food supplements to maintain nutritional status. An oral health risk assessment is essential for those conditions where impairment or disability impact on oral health. In dementia it is relevant to focus on: • The four Cs ○ Communication ○ Competence ○ Consent ○ Compliance • The oral side-effects of medication • Dietary changes required to maintain nutritional health7 These factors must be viewed in the context of dementia as a progressive degenerative condition with individual variation in the rate of progression of the illness and be related to all aspects of oral health. An assessment of the individual's ability for self-care in oral hygiene and cooperation for treatment is essential at the point of diagnosis and throughout the progression of dementia in order to formulate appropriate oral care plans, preventive strategies and treatment options. Assessment should be repeated at agreed intervals when there are changes in the progression of the illness, in medication and/or diet. However an oral risk assessment is of limited benefit if it is not accompanied by mechanisms to provide the individual and/or carers with appropriate advice and prevention, and to facilitate regular contact with appropriate dental services. Re-assessment is essential prior to considering any form of dental treatment. 7.1 Types of oral health risk assessment According to Griffiths & Boyle34, there are three broad groups of assessment systems. These are based on: • Intra-oral examination • Observation or assessment of the individual's behaviour • Client perception of need An intra-oral assessm" @default.
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W323717155 title "Oral health of people with dementia" @default.
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