Dental health is vital for our wellbeing. For people with dementia – which is a progressive condition – it is important to establish a dental care regime at, or shortly after, a diagnosis. Having a dental care regime should help to boost oral health and reduce the risk of developing dental problems.
Maintaining oral health is beneficial for an individual’s self-esteem, dignity, and nutrition. Poor oral health can lead to pain and tooth loss, and can affect self-esteem and the ability to eat, laugh and smile.
Here are some of the dental problems that people with dementia may face at different stages of the condition, and types of treatment and prevention, including maintaining good oral health.
The two main types of dental disease are gum disease and tooth decay. Both can cause pain or discomfort and can lead to infection, which can worsen the confusion associated with dementia.
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, which leads to gum disease if it’s 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 manage gum disease.
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, can help to prevent 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 sugars in food and drink.
A healthy diet, good oral hygiene, and using toothpaste or a mouth rinse containing fluoride helps to prevent tooth decay.
An individual with dementia who is having difficulties with eating can be prescribed food supplements. When these supplements are prescribed for someone with natural teeth, it is important to seek advice from a dentist.
Drugs and dental difficulties
People with dementia may be taking medication for a number of conditions. They may also be prescribed antidepressants, or antipsychotics, and sedatives.
A common side effect of these drugs is a dry mouth. A lack of saliva can result in a build-up of plaque and increase the risk of dental decay, gum disease and infection. A dry mouth can cause problems with dentures, such as discomfort and looseness.
Denture fixatives and artificial saliva – a fluid to lubricate the mouth – can help some individuals with denture problems. A dentist will be able to offer advice to ease discomfort and difficulties resulting from a lack of saliva or a dry mouth. Frequently sipping water throughout the day, especially at mealtimes, will also help.
Some antipsychotic medication 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 happens, a dentist may be able to advise on what can help.
If medication is syrup-based there is an increased risk of tooth decay. A doctor may be able to prescribe a sugar-free alternative if asked, and a dentist may be able to apply chlorhexidine and fluoride varnishes to help prevent decay at the necks of the teeth.
Many older people have partial or full dentures. Plaque can easily build up on dentures. If partial dentures are worn, it is important to maintain oral hygiene or the plaque will accumulate and could result in gum disease and tooth decay.
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 kept and taken to a dentist when the new ones are being constructed.
People with dementia should be encouraged to wear their dentures, and offered help with putting them in, for as long as possible. Wearing dentures is an important way of maintaining dignity and self-esteem. If they are not worn it may affect a person’s appearance, ability to speak, and diet.
Denture loss is common when people with dementia are in unfamiliar environments, such as when they spend time in a residential home for respite care. If an individual is without their dentures for any length of time they may forget how to wear them, or may lose their ability to adapt to a new set.
They may also be unable to co-operate with the dentist during the several visits required to make the new dentures. However, sometimes it can help if a carer holds the individual’s hand, or distracts them through talking.
It can be 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 someone 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, people with dementia may reach a stage where they will no longer tolerate dentures in their mouth, even if they have previously worn them without experiencing difficulties.
Caring for teeth on a daily basis
Early stages of dementia
Someone in the early stages of dementia needs to carry out their own mouth care for as long as possible. They may need reminders, or to be supervised. Carers can give them a brush and toothpaste and show them what to do. The individual may find it easier to use an electric toothbrush or one with an adapted handle to improve their grip.
A dentist or dental hygienist may be able to advise individuals and their carers on the best ways of preventing tooth decay and gum disease.
It is vital to establish a daily care routine in the early stages of dementia.
This may include a high-concentration fluoride toothpaste and regular application of fluoride varnish for people with natural teeth.
Later stages of dementia
As dementia progresses, people may lose the ability to clean their teeth, or no longer understand the importance of keeping teeth clean, so carers may need to help them. A dentist or hygienist can provide guidance and support on how to assist in cleaning another person’s teeth.
The Alzheimer’s Society advises that the easiest way is for the person with dementia to sit on a straight-backed 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 dry toothbrush, and a pea-sized amount of toothpaste.
Recognising if someone has dental problems
There may come a time when an individual with dementia is unable to express the fact they are experiencing pain or discomfort in their mouth or teeth. They will need to rely on other people to notice and interpret their behaviour, and to see a dentist if necessary. Signs that someone with dementia is experiencing dental problems may include:
- refusal to eat – particularly hard or cold foods
- previously worn dentures being left out of their mouth
- frequent pulling at the face or mouth
- increasing restlessness, moaning or shouting
- sleep is disturbed
- aggressive behaviour
- refusal to take part in daily activities.
Types of dental treatment
Early stages of dementia
In the early stages of dementia, most kinds of dental care are possible. A dentist will plan treatment, taking into consideration that the individual with dementia will eventually be unable to look after their own teeth.
A dentist can identify key teeth that need to be restored. Crowns, bridges and implants may only be considered if someone can carry out daily brushing for the individual with dementia, should they reach a stage where they are unable to do this. Preventing further gum disease or decay is also important, and the person and their carer should seek advice from a 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 treatment they receive is likely to be focused on preventing 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.
Later stages of dementia
In the later stages of dementia, the individual is likely to have severe problems with thinking, reasoning and memory and will often be physically frail or have complex medical conditions. Treatment at this stage focuses on preventing dental disease, maintaining oral comfort, and providing emergency treatment.
For people with or without dementia, the recommended interval between check-ups is between three months and 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 consider:
- the level of independence, co-operation, thinking abilities, mental state and physical impairment of the person with dementia
- what – if any – dental symptoms or difficulties the person is experiencing
- whether the person is able to give informed consent.
Consenting to treatment
It is important that the person with dementia is given the opportunity to make, or take part in, decisions about dental treatment. A 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 individual 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 ask for a second opinion.
The law states that every individual 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 individual’s best interests.
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. This may involve treatment under sedation or a general anaesthetic.
Dealing with dental treatment
The way dementia progresses varies, as does the ability to cope with dental treatment. Some people are comfortable visiting a dentist, but others may find the experience stressful.
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 others, visiting a dentist can increase their confusion, making treatment difficult or impossible. In these situations the dentist may make a home visit.
It can be helpful for the person with dementia who is visiting a dentist to be accompanied by a family member, friend or carer. The carer can remain in the person’s view while they are having treatment, and offer support by holding the person’s hand.
For further information
Contact the Alzheimer’s Society helpline: 0300 222 1122