4. Dental treatment
Types of dental treatment
Early stages of dementia
In the early stages of dementia, most types of dental care are 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. Crowns, bridges and implants may only be considered if someone is prepared to carry out daily brushing for the person with dementia should they reach a stage where they cannot do this for themselves. Preventing further gum disease or decay is also very important at this stage. As dementia is a progressive condition, it is important for the person and their carer to obtain advice on prevention from the dentist.
Middle stages of dementia
During this stage of dementia, the person may be relatively physically healthy but might have lost some thinking abilities. The focus of treatment is likely to be on prevention of further dental disease. Some people may 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. It is during the middle stages that issues around consent to treatment may start to arise (see 'Consent to treatment' below).
Later stages of dementia
In the later stages of dementia, the person is likely to have severe problems with thinking, reasoning and memory and will often be physically frail or disabled with complex medical conditions. Treatment at this stage focuses on prevention of dental disease, maintaining oral comfort, and provision of emergency treatment.
For people with or without dementia, the recommended interval between check-ups at the dentist should be determined specifically for the individual and tailored to meet their needs, based on assessment and risk of dental disease. For adults, the shortest interval that is recommended is three months, and the longest is two years. If treatment becomes necessary for a person with dementia, the dentist (together with the person 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, thinking abilities, mental state and physical impairment of the person with dementia
- what (if any) dental symptoms or problems the person is experiencing
- whether the person is able to give informed consent (see 'Consent to treatment').
Once these questions have been answered, the dentist will be able to decide on the most appropriate treatment. They will also decide how regularly they need to see the person.
Regular mouth checks can highlight any problems so that they can be treated as soon as possible. Cancer of the mouth, while generally uncommon, is more likely to occur 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. Even if a person has no natural teeth or dentures, regular mouth checks are important to screen for mouth cancer.
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 to the person in simple terms what is being done and why. Short sentences that are phrased in a way where the person can answer 'yes' or 'no' can be effective.
When dental treatment is irreversible (for example, when teeth are going to be taken out) and the individual cannot give informed consent, the family and/or carers will usually be involved in the decision-making process. If the treatment is out of the ordinary or there is disagreement about what is in the best interests of the person, the dentist may seek a second opinion.
The law states that every person is able to make their own decisions, unless it can be proven that they are not able to do so. If this is not clear, the dentist should carry out an assessment of the person's capacity (the ability of that person to make their own decisions). If the individual does not have capacity, family, professionals and other carers can be involved in the decision-making process on their behalf, as long as these decisions are in the person's best interests.
A person who has capacity can grant someone Lasting Power of Attorney in England and Wales, or Enduring Power of Attorney in Northern Ireland, meaning they can take decisions about property, finances, health and welfare if the person should lose capacity in the future. Where an individual has been granted Lasting Power of Attorney or Enduring Power of Attorney, their wishes should be respected.
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 healthcare treatment. An example might be removal of some or all of their natural teeth, which may involve treatment under sedation or a general anaesthetic.
Coping with dental treatment
The way dementia progresses varies considerably, as does the ability to cope with dental treatment. Some people are comfortable with a visit to the dentist, while others may find the experience distressing.
People who have had regular dental treatment throughout their lives often cope better at a dental surgery. They may have little difficulty co-operating with simple procedures until their dementia is advanced. For other people with dementia, the unfamiliar experience can increase 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 can remain in the person's sight while they are having treatment and offer reassurance by holding the person's hand.