BARELY a week goes by without another media story about the growing number of people living with dementia and the challenges we face as a society. Current predictions are that by 2025 there will be over one million people with the condition in the UK.
So what are the implications for the dental team? Whilst the increasing number of people with dementia can bring challenges, there is also an opportunity for the primary care dental team to make a real difference.
Good oral health enables people to enjoy a healthy and varied diet, to smile and interact socially – these are especially relevant for people living with dementia to support adequate nutrition and a good quality of life. Dental pain can be detrimental to all of these aspects, thus mouth care and effective oral disease prevention should be a high priority.
Even experienced special care dentists will agree that the provision of operative dental treatment in the later stages of dementia can be challenging. A thorough oral assessment as soon as possible after diagnosis and careful treatment planning and prevention can significantly reduce the chances of future dental problems and allow patients to make decisions for themselves.
Visiting the dental practice can be bewildering for people with dementia, even in the earlier stages. The appointment and reminder systems, busy waiting rooms, complicated forms and even shiny floors can all present difficulties.
Cheshire and Merseyside are exploring a partnership approach to dental care for this patient group. Each dental practice in the region could have as many as 120 patients with dementia seeking dental care by 2025. Community dental services and hospital-based special care dentistry services have clinicians with additional skills and expertise – but care pathways and shared care arrangements with general dental practitioners are also needed.
To this end a toolkit for the primary dental care team was recently developed and tested in Cheshire and Merseyside as part of a 'dementia friendly dentistry' programme. Subsequent phases of this programme will establish systems to direct those who are newly diagnosed with dementia to local dental practices for early assessment and care planning, and to streamline the dental care pathways between general dental practice, community and hospital services.
DEMENTIA AND ORAL HEALTH
Following a dementia diagnosis, there are many issues to consider around the health and well-being of a patient and their future care – and oral health is an important component. In the early stages of dementia, oral care follows the same principles as for any patient. Preventive strategies should be tailored to the individual risk of oral disease, including caries, periodontal disease, oral cancer and toothwear. Current guidelines may be used to identify appropriate intervals for recall, radiographical examination and fluoride regimen.
Early treatment decisions should take into account the expected disease course and result in a dentition which can be maintained long term. As dementia progresses, risk of plaque-related disease increases and it may become more difficult to achieve a high standard of plaque control, particularly where a third party is relied upon for personal care. Advanced restorative dentistry, for example fixed bridgework and implant retained prosthesis, can present a particular challenge when dementia has progressed and oral hygiene may deteriorate.
A number of other factors may affect diet and nutrition and as a consequence increase the risk of dental caries. These include an increased reliance on convenience foods, changes to taste and appetite, increased snacking and subsequent increase in sugar consumption.
Dietary choices may be made by a patient’s carers, or directed by medical needs. Nutritional supplements may be required in order to increase calorie intake, but these can also be high in sugar. Chewing may become more difficult, fluids may need to be thickened to prevent aspiration, and clearance of food from the mouth may be delayed. These changes, together with a dry mouth due to xerogenic medicine, significantly increase caries risk.
Special care dentists will agree that the provision of operative dental treatment in the later stages of dementia can be challenging
PREVENTIVE DENTAL CARE
Access to dental care can become more problematic as memory deteriorates. Communication of pain can be less specific, and it may become necessary to consider other behavioural changes such as altered demeanour, sleep and eating patterns, alongside objective signs such as swelling or reaction to palpation of soft and hard tissues.
Anxiety and cognitive decline can mean reduced cooperation in dental treatment and it may become necessary to consider intravenous sedation or general anaesthesia in some cases. It is vital to carefully balance the risks of these procedures against the benefits of treatment. Medical comorbidities, such as chronic cardiorespiratory disease, may present increased risks such as aspiration pneumonia or post-operative delirium in the cognitively impaired patient.
Prevention of oral disease remains the foundation of care for people with dementia. The best time to discuss possible future problems associated with dementia is following diagnosis, whilst cognition and the ability to accept care are largely unchanged. Removal of nonfunctional, non-aesthetic, carious and heavily restored teeth may be advised, rather than providing treatment which is unlikely to be maintained in the longer term. The shortened dental arch approach may be considered, with the overall aim of providing a functional, easily maintained dentition with good long-term stability.
Regular preventive planning, including fluoride application, can be provided through a team approach using hygienists and therapists to deliver appropriate care – and this may be vital in establishing a continuing relationship with patients.
A patient living with dementia should be supported to make their own treatment decisions for as long as possible, with information pitched at the right level and pace. Where capacity is shown to be lacking, any action taken must be in the patient’s best interests, taking into account any advanced decisions, previous wishes and beliefs. Those close to the patient should be consulted and the least restrictive options chosen. Onward referral to a more experienced or specialist colleague may be necessary where assessment of capacity is unclear.
CARE PATHWAYS AND CLINICAL NETWORKS
Local structures will vary across the UK but the principle remains of using the right skill mix for patients matched to the complexity of their care. Supporting GDPs to provide care for people with dementia offers the benefit of establishing a familiar contact within the local community. Many dentists will have always provided long-term holistic care for patients with dementia and will continue to do so. These skills and experiences can be shared with healthcare colleagues.
A whole-team approach is recommended, as receptionists and dental nurses have a vital role to play in identifying ways to support patient care and could be the first to spot behaviour changes or difficulties which may indicate progression of dementia. Sometimes simple adjustments and greater general awareness of dementia can greatly benefit the patient/carer experience, and increase their ability to access dental care in the longer term.
Specialist services will always be required for those with complicated cognitive and medical issues, but these should be reserved for the most complex cases. Thorough early assessment, regular review and tailored evidence-based prevention can have a significant impact on maintenance of good oral health in the long term, and can be effectively provided by the primary care dental team.
- Suzanne Burke is a specialty trainee in special care dentistry at Liverpool University Dental Hospital
- Lesley Gough is a consultant in dental public health at Public Health England (North West Centre)
- Andy Kwasnicki is a consultant in special care dentistry, Liverpool University Dental Hospital
Access the full Dementia Friendly Dentistry toolkit