Dental care

2. Dental disease

There are two main types of dental disease: gum (periodontal) disease and tooth decay (dental caries, more commonly known as cavities). Both of these can cause discomfort or pain and can lead to infection. Both pain and infection can worsen the confusion associated with dementia.

Gum disease

Gum disease can cause inflamed and bleeding gums, gum recession (where the gum tissue is reduced so the roots of the teeth become exposed), loose teeth and bad breath. It is caused by the build-up of dental plaque (a combination of food debris and bacteria). Plaque leads to gum disease if it is not removed by daily efficient brushing and flossing. Using a tooth gel or mouth rinse containing chlorhexidine (an antiseptic and disinfectant agent) can help to control gum disease for a person who is experiencing bad breath and bleeding and inflamed gums.

Tooth decay

Tooth decay is caused by the action of dental plaque on the teeth when food and drinks containing sugar are consumed. Plaque and sugar together produce acid, which attacks the tooth, causing decay. Restricting the intake of sugar to two to three times a day, preferably at mealtimes, is important in guarding against tooth decay. It is the number of times that sugar is eaten during a day, rather than the total amount of sugar consumed, that is important in reducing the risk of decay. This includes hidden sugars in food and drink, as well as sugar added to food or drinks. A healthy diet, good oral hygiene, and the use of toothpaste or a mouth rinse containing fluoride 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 to keep the mouth clean to minimise the risk of decay. Gum recession increases the chances of decay occurring at the necks of teeth (where the crown of the tooth meets the root at the gum) unless oral hygiene is excellent and dietary sugars are controlled. Food supplements may be prescribed to a person with dementia who is having difficulties with eating. When food supplements are prescribed for a person with natural teeth, it is important to get advice on prevention from the dentist.

Drugs and dental problems

People with dementia may be taking medication for a number of conditions. They may also be prescribed antidepressants or - less often - antipsychotics and sedatives. A dry mouth is a common side effect of these drugs. Saliva acts as a lubricant and also cleans the mouth and teeth. Lack of saliva can lead to a build-up of plaque and increase the risk of dental decay, gum disease and infection. A dry mouth can also cause problems with dentures, including discomfort and looseness. Denture fixatives and artificial saliva (a fluid to lubricate the mouth) can help some people with denture problems. The dentist will be able to offer advice to relieve discomfort and problems caused by lack of saliva or a dry mouth. Frequent sips of water throughout the day, especially at mealtimes, will help.

Some antipsychotic drugs can cause involuntary repetitive tongue and jaw movements, making it difficult to wear dentures, particularly in the lower jaw. In some cases, these movements will continue after the drug is stopped. If this occurs, the dentist may be able to advise on what can help, and how best to ensure that the person is comfortable.

If medication is syrup-based (eg lactulose), there is an increased danger of tooth decay. The doctor may be able to prescribe a sugar-free alternative if asked. The dentist may also be able to apply chlorhexidine and fluoride varnishes to help prevent decay at the necks of the teeth.

Dentures

A significant number of older people have partial or full dentures. Plaque can easily build up on dentures. If partial dentures are worn, it is important that oral hygiene is well maintained or the plaque will accumulate and encourage gum disease and tooth decay.

If the person loses all their natural teeth, they may need to start using full dentures. They may have difficulty coping with their new set of dentures, and will need to be encouraged to persevere. This can also be an issue if the person loses their dentures and needs to start using a new set.

Dentures also need to be replaced when they become loose. Replacement dentures are best constructed using the dimensions of the old set. For this reason, the old set should always be retained and taken along to the dentist when the new ones are being constructed.

Wearing dentures

The person with dementia should be encouraged to wear their dentures, and offered help with putting them in, for as long as possible. Dentures are important for maintaining dignity and self-esteem. If a person does not wear them it may affect their appearance, diet and ability to speak.

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 (see 'Denture marking'). 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 person may also be unable to co-operate with the dentist during the several visits required to make the new dentures. However, sometimes intervention by the carer (for example, hand-holding or distraction through 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.

It can sometimes be difficult and distressing for relatives and carers when they are told that it will not be possible to successfully make a set of new or replacement dentures for the person with dementia. The decision not to provide new or replacement dentures would only be made after an individual assessment and if it is in the person's best interests.

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

Denture marking

A person with memory problems associated with dementia may be more likely to lose their dentures. Marking a person's name on dentures means that lost dentures can often be returned. New dentures should be permanently marked during their manufacture. Existing dentures can be temporarily marked using a simple technique that will last for 6-12 months. This can be done using a small piece of new kitchen scourer, a pencil (or a pen that uses safe alcohol-based ink) and clear nail varnish. The process takes about ten minutes and can be carried out by a dentist, a dental hygienist or a carer.

The process is as follows:
  1. Clean, disinfect and dry the denture.
  2. Select an area near the back of the mouth on the outer surface of the denture just large enough to have the person's name on it, and use a new piece of scourer to remove the surface polish from this area.
  3. Print the person's name on the denture using a pencil or a pen that uses safe alcohol-based ink.
  4. Paint over the name with a thin coat of clear nail varnish and allow it to dry.
  5. Apply a second thin coat of varnish and allow it to dry.

It is important to clean, disinfect and dry the denture thoroughly before marking it. Dentures should be checked periodically to ensure the name is still legible, and the marking renewed as necessary.