Alzheimer's Society

Good oral health brings significant benefit for general health, dignity and self-esteem, social integration and general nutrition (Fiske et al 2006). It is important for a person's sense of well-being and quality of life. Poor oral health can lead to pain and tooth loss. Its impact can be profound, affecting self-esteem and the ability to eat, laugh and smile. This factsheet outlines some advice on dental care for people with dementia.

Dental disease

There are two main types of dental disease − gum (periodontal) disease and tooth decay (dental caries). Both can cause discomfort or pain, and can lead to the development of infection. Both pain and infection can exacerbate the confusion associated with dementia.

Gum disease

Gum disease can cause inflamed and bleeding gums, gum recession, loose teeth and bad breath. It is caused by the accumulation of dental plaque. Plaque is a combination of food debris and bacteria from the mouth. Everyone has some dental plaque. It leads to gum disease if it is not removed by efficient cleaning as it builds up on the surface of the teeth, particularly at the margin of the gum.
Good oral hygiene and the use of chlorhexidine tooth gel or mouth rinse can help to control gum disease.

Tooth decay

Tooth decay is caused by the action of dental plaque on the teeth when food and drinks containing sugar are consumed. Essentially, the bacteria in the plaque feed on the sugar, producing acid, which in turn attacks the tooth, causing decay. Dentists recommend restricting the intake of sugar to two-to-three times a day, preferably at mealtimes, as it is the number of times we eat sugar in a day, rather than the total amount of sugar consumed, that is important in guarding against tooth decay. This includes 'hidden' sugars in foods, as well as 'bag sugar' added to food or drinks. A healthy diet, good oral hygiene, and the use of fluoride toothpaste or mouth rinse will also help prevent tooth decay.

High-energy food supplements contain high levels of sucrose − a form of sugar. If they are used on a regular basis, it is important that the teeth are kept very clean to minimise the risk of decay. Gum recession increases the chances of tooth decay occurring at the necks of the teeth unless oral hygiene is excellent and dietary sugar is controlled.

Daily care of teeth

Early stages of dementia

In the early stages of dementia, the individual will still be able to clean their own teeth. They may need to be reminded to carry out the task, or they may need to be supervised. If they need help, try giving them the brush and toothpaste and showing them what to do. As manual dexterity decreases, an electric toothbrush may help maintain independence. The person with dementia could also try using a toothbrush with an adapted handle to improve their grip. Your dentist or dental hygienist should be able to advise you on this.

Later stages of dementia

As the dementia progresses, the individual may lose the ability to clean their teeth, or interest in doing so, and carers may need to take over this task. A dentist or hygienist can provide guidance and support on how to clean another person's teeth. The technique will vary depending on the individual concerned. Generally, the easiest way is for the individual to sit on a dining-style chair with the carer standing behind. The carer supports the person against their body, cradling their head with one arm. They can then brush the person's teeth using a damp toothbrush and a little toothpaste.

Drugs and dental disease

People with dementia are sometimes prescribed antidepressants, antipsychotics and sedatives. One of the side-effects of all these drugs is a dry mouth. Saliva acts as a lubricant, and dry mouth can cause problems with dentures, including discomfort and looseness. Denture fixatives and artificial saliva can help some people with denture problems. Once again, your dentist can provide advice. Saliva not only acts as a lubricant, but also has a cleansing effect on the mouth and teeth. Its absence leads to plaque accumulation, gum disease and dental decay, particularly at the neck of the tooth. Decay in this area undermines the crown of the tooth, and can cause the crown to break off.

If medication is syrup-based there is an increased danger of tooth decay.
Your doctor may be able to prescribe a sugar-free alternative if asked. The dentist may also be able to apply chlorhexidene and fluoride varnishes to help prevent decay at the necks of the teeth. Reduction of sugar in the diet − particularly sugary snacks − also helps to control decay.

Some antipsychotic drugs can cause increased tongue and jaw movements, making it difficult to wear dentures, particularly in the lower jaw. Unfortunately, these jaw tremors may remain after the drug is stopped.

Mouth checks

People with dementia are not always able to recognise or express their dental needs, including when they are in pain. It is important to have regular mouth checks, whether the person has teeth, dentures or no teeth at all. Regular mouth checks can highlight any problems so that they can be treated as soon as possible. Cancer of the mouth is more common in older people than in any other age group. It may start as a small painless ulcer and, if diagnosed early, treatment is relatively simple and has a high success rate.

Dentures can become loose and begin to damage the mouth if they have been worn for a number of years. As these changes happen slowly, the individual can adapt to them without realising that the mouth is being harmed. In addition, root caries (decay at the necks of the teeth) are often painless, and may go unnoticed until the crown of the tooth breaks off.

Need for assistance with dental care

As dementia progresses, the person affected may become less able to:

• clean their teeth effectively
• understand that their teeth need to be kept clean
• express the need for dental treatment
• explain dental symptoms, including pain
• take part in the decision-making process about treatment
• give their informed consent for dental treatment
• feel comfortable with dental treatment.

How to tell if someone has dental problems

There may come a time when the person with dementia is unable to say that they are experiencing pain or discomfort. They will need to rely on other people to interpret their behaviour and to initiate visiting the dentist. There are several behavioural changes that may indicate that someone with dementia is experiencing dental problems. These may include:

• refusal to eat (particularly hard or cold foods)
• frequent pulling at the face or mouth
• leaving previously-worn dentures out of the mouth
• increased restlessness, moaning or shouting
• disturbed sleep
• refusal to take part in daily activities
• aggressive behaviour. 

Planning treatment

The dentist, together with the person with dementia and their family or carers, will discuss treatment needs and agree on the best treatment plan. They should take into consideration:

• the level of independence, co-operation, cognitive state and physical impairment of the person with dementia
• what, if any, symptoms the person is experiencing
• whether the individual is able to give informed consent (see below).

Once these questions have been answered, the dentist will be able to decide on most appropriate treatment. They may decide to see the person regularly every few months, or they may only need to be seen once a year.

Consent to treatment

It is important that the person with dementia is given the opportunity to make, or take part in, decisions about dental treatment. The dentist should explain, in simple terms if necessary, what is being done and why. Choices can be offered and information gathered by keeping sentences short and simple, and in some cases phrasing them so that they only need a 'yes' or 'no' answer.

When dental treatment is irreversible − for example, when teeth are going to be taken out − and where the individual cannot give informed consent, the family and/or carers will usually be involved in the decision-making process. The dentist may also seek a second opinion, from another dentist or a doctor, to make sure that the proposed dental treatment is in the individual's best interests.

The Mental Capacity Act 2005 requires that everyone is presumed to have the capacity to make decisions unless the contrary is shown. If this is not clear, the dentist should carry out an assessment of the person's capacity. If the individual does not have capacity, family, professionals and other carers can take decisions on their behalf as long as these decisions are in the individual's best interests. (See Factsheet 460, Mental Capacity Act 2005.)

People who have capacity can grant someone lasting power of attorney to take decisions about property, finances, health and welfare if they should lose capacity in the future. Where an individual has been granted lasting power of attorney, their wishes should be respected. (See Factsheet 472, Enduring power of attorney and lasting powers of attorney.)

People without capacity who do not have family or friends to support them may be appointed an independent mental capacity advocate to represent them in any decision over serious health care treatment − for example, removal of all their natural teeth.

Coping with dental treatment

The progression of dementia varies enormously, as does the ability to cope with dental treatment. Some people are comfortable with a visit to the dentist, while others find the whole experience very distressing.

People who have had regular dental treatment throughout their lives often remember what they are expected to do in a dental surgery. They may have little difficulty co-operating with simple procedures until their dementia is advanced. For other people with dementia, the journey to the surgery, the strange environment and the unfamiliar faces of the dental team can exacerbate their confusion, making treatment difficult or impossible.

In these circumstances, the dentist may be prepared to make a home visit. Alternatively, it can be helpful for the person with dementia to be accompanied into the dental surgery by someone they know. The carer could perhaps remain in the person's sight while they are having treatment. They may also be able to offer reassurance by holding the person's hand. People with dementia can have good days and bad days: dental care is better postponed to a good day, if possible, or scheduled to a person's best time of day.

Types of dental treatment

Early stages of dementia

In the early stages of dementia, most types of dental care are still possible. The dentist will plan the treatment, bearing in mind that the person with dementia will eventually be unable to look after their own teeth. Key teeth may be identified and restored. Advanced restorative treatment (such as crowns, bridges and implants) may only be considered if someone is prepared to carry out daily tooth brushing on behalf of the individual with dementia should they reach a stage where they can no longer carry out this task themselves. Preventing further gum disease or decay is also very important at this stage.

Middle stages of dementia

During this stage of dementia, the person is often relatively physically healthy but may have lost some cognitive skills. The focus of dental treatment is likely to change from restoration to prevention of further dental disease. Some people may find the acceptance of dental treatment beyond their tolerance and require sedation or general anaesthesia for their dental treatment. The decision will be based on the individual's ability to co-operate, dental treatment needs, general health and social support.

Later stages of dementia

In the later stages of dementia, the person is likely to be severely cognitively impaired and often physically frail or disabled. Treatment at this stage focuses on prevention of oral disease, maintaining oral comfort and provision of emergency treatment.

Dentures

More people are keeping their natural teeth into old age. However, a significant number of older people have partial or full dentures. Dentures act like magnets to plaque. If partial dentures are worn, it is important that oral hygiene is well maintained or the increased plaque accumulation will encourage gum disease and tooth decay.

New dentures may be needed when the person loses all their natural teeth or when existing dentures go missing. In both circumstances the person with dementia may have difficulty coping with their new set of dentures, and will need to be encouraged to persevere.

Dentures need to be replaced when they become loose. When dentures have been worn successfully in the past, the replacement dentures are best constructed using the key features of the old ones − for example, the overall shape and the tongue space. For this reason it is important not to throw away old dentures, even when they may seem to be of no use, but to take them along to the dentist when the new ones are being constructed so that the good features can be copied and any poor features can be improved.

Denture marking

Marking a person's name on dentures does not prevent denture loss, but it does mean that when dentures are found they can often be reunited with their owner. New dentures should be permanently marked during their manufacture. Existing dentures can be temporarily marked using a simple technique that will last for six to 12 months. This can be done using a small new piece of kitchen scourer, a pencil (or alcohol-based pen) and clear nail varnish. The process takes about ten minutes and can be carried out by a dentist, a dental hygienist or a carer.

You need to:

• clean and dry the denture
• select an area near the back of the mouth on the outer surface of the denture just large enough to take the person's name and use a new piece of green scourer to remove the surface polish from this area
• neatly print the person's name on the denture using a pencil or an alcohol-based pen
• paint over the name with a thin coat of the varnish and allow it to dry
• apply a second thin coat of varnish and allow it to dry
• return the denture to its owner.

Dentures should be checked periodically to ensure the name is still legible, and the marking renewed as necessary.

Wearing dentures

Denture loss is common when people with dementia are in unfamiliar environments − for example, when they spend time in a residential home for respite care. Replacing lost dentures can present problems. If the person is without their dentures for any length of time they may forget how to wear them, or they may lose their ability to adapt to a new set. The individual may also be unable to co-operate with the dentist over the several visits required to make the new dentures.

Sometimes intervention by the carer (for example, hand-holding or distraction by encouraging attention through hand-stroking or talking) may be all that is needed. If co-operation is limited, a realistic approach may be to provide an upper denture only, for the sake of appearance.

Eventually, many people with dementia reach a stage where they will no longer tolerate dentures in their mouth even though they have worn them without problems in the past.

Finding a dentist

If the person with dementia already has a regular dentist, they should continue to see the same dentist for routine treatment and preventive advice.

If they do not have a dentist, they will need to find one. The 2006 NHS Dental Contract did away with registration. Dentists are now only obliged to provide a course of treatment once they accept you for care, although many dentists will still re-call their patients for check ups. The latest guidance on check-ups is that the intervals between them should be tailored to the needs of the individual. They no longer need to be every six months, and the dentist will advise whether you need to be seen more or less often than this.

Some dentists will see an individual at home. This can be less stressful and confusing for the person, and may increase co-operation. Similarly, some care homes have a dentist who visits on a regular basis.

If the person's dementia reaches a point where their dentist can no longer manage their treatment needs, they might be referred to the local salaried primary dental care service (otherwise known as the community or personal dental service). This service acts as a safety net for people who are unable to receive care from a general dental practitioner (high street dentist). The dentists are usually experienced in providing dental care for people with disabilities and complex medical conditions. Details of your local salaried dental service are obtainable from your local primary care trust.

Your local Alzheimer's Society branch will always be willing to talk to you and offer advice and information to support your needs.

For more information, Dementia Catalogue, our specialist dementia information resource, is available on the website at alzheimers.org.uk/dementiacatalogue.

Reference

Fiske J, Frenkel H, Griffiths J, Jones V (2006) 'Guidelines for the development of local standards of oral health care for people with dementia', Gerodontology, vol 23, supplement 1, available at: http://www.gerodontology.com/

Factsheet 448

Last updated: June 2008
Last reviewed: June 2008

Written and reviewed by: Dr Janice Fiske MBE, King's College, London