Dementia and dental care

Considerations for caregivers and oral health professionals
January 11th, 2018

close-up of elderly woman's hands holding a caneWe’ve heard or witnessed what the Alzheimer’s phenomenon means for patients diagnosed with this or similar forms of dementia that are so detrimental to memory and cognition: The tasks learned earliest in life, and performed practically on autopilot, are often the last to go. Among them, something we can remember repeating time and time again as little children, standing in front of the bathroom sink brushing our teeth.

Yet retaining this memory doesn’t automatically preserve dental health for these patients. For those in its earliest stages, the 5.5 million Americans with Alzheimer’s — the most common form of dementia — might simply forgot to follow up on routine dental appointments, says Dr. Peggy Timothé, assistant professor in public health sciences and director of the dental public health graduate program at Texas A&M College of Dentistry. As the disease progresses, and remembering how to perform even rudimentary tasks becomes a rarity, oral health often takes a turn for the worse. Health issues in general only complicate matters.

“Routine dental services often take a back seat when patients have other serious medical conditions,” Timothé says. “Coordinating care with multiple providers is a challenge for many patients, as well as getting to and from the dentist.” While mobile dental programs are increasing, in most instances they are the exception, not the norm.

So just how are loved ones, caregivers and the dentists who treat these patients to navigate dental health in the face of dementia?

At the dental appointment, for starters, attempt to seek trust and familiarity.

“Try to find a personal life event, experience or an interest to which the individual may respond,” says Dr. David Goydan, dental anesthesiologist and adjunct assistant professor in the college’s Advanced Education in General Dentistry program. “If you have a male patient, for example, with severe memory loss, you could mention sports, you could talk about food, you could ask about the day he got married, or about his wife or his grandchildren. You may find some connection resulting in a smile or a response with relative cognitive clarity. Surprisingly, you may have made his day. In his neurologic condition, access to a pleasant experience may still be intact.”

Goydan, who has decades of experience practicing dental anesthesiology and general dentistry in the nursing care and hospital settings, recommends a behavioral cooperation assessment when deciding if sedation may be necessary for patients with dementia.

“Determine if their behavior borders on being totally noncompliant, combative or docile. That’s a big consideration for dental treatment planning and treatment,” Goydan says. “Depending where the patient falls on this continuum, you can design an anesthetic to achieve patient cooperation within the boundaries of age, physical status and medical safety.”

The same is true for fine-tuning oral hygiene routines at home with caregivers. Patients in the early stages of dementia may simply need to be reminded to brush their teeth, whereas those in moderate stages may forgot how to use a toothbrush or why they need one at all.

“Family members can post pictures on the bathroom mirror or wall that demonstrate how to brush their teeth,” suggests Kathy Muzzin, clinical professor in the college’s Caruth School of Dental Hygiene. “After allowing the patient to brush their teeth, caregivers can provide follow-up care by brushing areas that the patient had difficulty reaching.”

In later phases of the disease, caregivers become responsible for the patient’s oral hygiene. One of the best tools to use at this juncture: a multi-head toothbrush, which cleans all surfaces of teeth at once. In situations in which noise doesn’t frighten the patient, an electric toothbrush is a viable option. Caregivers may need to adjust their expectations during this stage, as patients can become resistant, combative even, regardless of what device is used.

“In these instances,” says Muzzin, “tooth brushing once a day may be a major accomplishment.”

In all cases, she recommends that caregivers establish a set time each day for mouth care.

Sustainability in the routine is key. It’s something Timothé understands all too well, not just from her vantage point as a public health dentist, but from her role as a daughter and a niece. A Parkinson’s and Alzheimer’s diagnosis claimed her father’s life about 10 years ago. These days, the family is rallying to support two of her aunts, both with dementia.

“There are a lot of issues to manage; making sure the medications are taken on schedule as well as personal hygiene issues such as brushing,” says Timothé, with one bit of insight: “No one ever flosses.

“Although I have been the occasional caretaker, as much as I believe in flossing, I’ve taken the big-picture approach that my other family members do and have not added or advocated for a care routine such as flossing that would not be sustainable.”

— Jennifer Fuentes