S P E C I A L S PD

C A R E E C
E INATL I SC TA RR YE D E N T I S T RY

Alzheimer’s Disease and Oral Care

HEATHER FRENKEL

serious infections, such as tuberculosis

Abstract: Alzheimer’s disease (AD) is the commonest form of dementia, closely and syphilis, but also relatively minor
associated with age, but also with other causative factors. AD affects half a million
ones. Urinary tract infection can, for
people in the UK, and presents dentists with numerous behavioural and clinical
challenges. The aetiology, diagnosis and medical treatment for persons with AD are example, cause severe confusion in
discussed, together with communication strategies and issues related to families and older people.
care-givers. Realistic dental treatment planning for patients in early, moderate and late
stage AD is considered in conjunction with relevant ethical issues. Dentists have the
potential to improve markedly the quality of life for people with AD. Irreversible Causes of
Dementia
Dent Update 2004; 31: 273–278 About 20% of people with dementia are
Clinical Relevance: As older people form an increasingly large proportion of the diagnosed with vascular dementia. The
population, dentists will be called upon to plan and deliver treatment for many brain may be deprived of oxygen
individuals with impaired cognitive abilities and challenging behaviour. suddenly, as a result of a stroke, or
cumulatively, as a result of repeated
transient ischaemic accidents (multi-
infarct dementia).3
In about 10% of cases, dementia is
caused by a small number of
comparatively rare conditions.3 The
T he term dementia describes the
progressive cognitive impairment
caused by the effects of disease on the
patients and their families.
remaining 70% will be diagnosed with
AD.
brain, and can be severe enough to DIAGNOSING ALZHEIMER’S
interfere with social or occupational DISEASE
function. The most common type of No definitive test is available. A Diagnosis of AD
dementia is Alzheimer’s disease (AD). probable diagnosis of AD is usually AD is a progressive degenerative
In the UK, AD affects 500,000 people. made if there is a progressive decline condition, affecting the structure and
The incidence is closely associated with from an individual’s previous level of chemistry of the brain. Two
increasing age. The 2001 census1 shows cognitive functioning. A detailed malformations within neurones
that people over 60 now outnumber specialist diagnosis will rule out accelerate cell death:4
children under 16. Dentists will therefore conditions presenting similar symptoms
be increasingly likely to encounter older (Table 1). l Amyloid plaques (localized
patients whose cognitive abilities may accumulations of beta-amyloid
have declined. protein);
By understanding how dementia can Reversible or Treatable Causes l Neurofibrillary tangles adjacent to
be managed, the dental team can have a of Dementia the nucleus of nerve cells.
positive impact on the quality of life of The names of the principal conditions
causing reversible dementia may be As neurones are lost, there will be a
arranged into a useful mnemonic (Table deficiency of the neurotransmitter,
Heather Frenkel, BDS, PhD, Senior 1).2 Depression shares many symptoms acetylcholine, together with significant
Community Dentist,Avon Community Dental with early dementia including general atrophy of the cerebral cortex.
Service and Honorary Lecturer in Oral and Dental
apathy and withdrawal from society. A psychologist can assess the
Science, Bristol Dental Hospital and School.
Infectious causes include not only person’s cognitive skills using tests

Dental Update – June 2004 273

 S P E C I A L C A R E
Reversible or Treatable Causes
l Drugs and alcohol
l Emotional illness (e.g. depression)
l Metabolic disorders (e.g. pernicious
anaemia)
l Endocrine disorders (e.g. hypo- or
hyper-thyroidism)
l Nutritional deficiencies, especially of
B vitamins
l Trauma or tumours affecting the brain
l Infections (e.g. tuberculosis, syphilis,
urinary tract infection)
l Arteriosclerosis affecting the cerebral
circulation and the higher centres of the
brain
Table 1. Causes of dementia.
such as the Mini Mental State
Examination,5 which employs simple
tests of memory including attention,
calculation, language and writing skills.
CT or MRI scans provide evidence
about physical changes in the brain.
Biochemical markers may be detected.
However, definitive diagnosis is often
only possible post-mortem when the
physical changes to the brain can be
seen (Figure 1).
AETIOLOGY
There is no clear picture, and it seems
likely that a combination of factors is
responsible:
l Age is a major factor. Dementia
affects 3% of people aged 65–74,
rising to 47% of people over 85.
l Gender – Women are more likely to
develop AD, even allowing for their
longer life expectancy.
l Genetic inheritance – Abnormalities
on chromosome 1, 14 or 21 account
for a small number of cases of early
onset dementia. Down’s syndrome is
also caused by an abnormality of
chromosome 21 and, as these
individuals age, 50% will show the
physical brain changes and
behavioural symptoms of AD.6 In
later onset AD, a gene on
chromosome 19 that controls apolipo-
protein E4 has been implicated.
l Head injury – Severe head injury or
whiplash, or trauma over an extended
period (e.g. boxing) increase the risk.
l Lifestyle – a combination of smoking,
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D E N T I S T RY
Irreversible Causes
l Alzheimer’s disease
l Vascular dementia (including
multi-infarct dementia)
Rarer causes:
l Binswanger’s disease
l Dementia with Lewy bodies
l Parkinson’s disease
l Conditions associated with earlier onset
dementia (e.g. fronto-temporal dementia)
l Huntington’s disease
l Prion diseases (in humans, Creutzfeld-
Jacob disease and new variant CJD)
hypertension and high blood
cholesterol doubles the risk.
There may be environmental factors yet
to be identified, but no correlation has
been proved with previously suspected
causes, such as aluminium or mercury.3,7
PHARMACOLOGICAL
TREATMENTS FOR AD
There is currently no cure for AD, but
some drugs appear to delay its
progression. Drugs that stabilize
acetylcholine levels may help during
early and moderate AD. Donepezil
(Aricept), Rivastigmine (Exelon) and
Galantamine (Reminyl),3 available on
private prescription, have also been
approved by NICE for prescription
under the NHS by consultants. These
drugs cost about £1000 per patient per
year and, from April 2003, all Health
Authorities and Primary Care Trusts are
required to fund them.
In 2002, Memantine (Ebixa) was
launched.3 Memantine slows the
progress of symptoms in moderate to
severe AD. It is an antagonist of
glutamate, a neurotransmitter present at
abnormally high levels in AD. With only
two efficacy studies completed so far, it
is too early to draw any conclusions.
Oestrogen therapy, non-steroidal anti-
inflammatory drugs, and anti-oxidants
such as Vitamin E may improve
cognition.3 The complementary therapy,
Ginkgo biloba, may improve memory
function.8
Not every patient responds to these
therapies, and there is no evidence that
they are suitable for non-Alzheimer’s
dementias.
Symptomatic Medications
People with AD may also require
symptomatic medication for depression,
aggressive behaviour or hallucinations.3
Selective serotonin re-uptake inhibitors
are better tolerated than tricyclic
antidepressants, which can actually
increase confusion. Antipsychotics may
reduce agitation and aggression,
although they may increase confusion
and may cause tardive dyskinesia
(involuntary movements affecting the
mouth) which makes denture wearing
difficult.9 Benzodiazepines and
hypnotics help, respectively, with
anxiety and sleep disturbances.
COMMUNICATING WITH
PEOPLE WITH AD
People with AD are individuals with
their own likes and dislikes, struggling
to make sense of a world they can no
longer fully understand. It is essential to
treat them with respect and dignity,
using good verbal and non-verbal
communication.10
l Engage their attention. Eliminate
distractions such as traffic noise or
other people’s conversations. Make
eye contact. Be relaxed and calm.
Gently holding their hand or putting
your arm around their shoulder may
comfort them.
l Give verbal cues: ‘I’m your dentist,’
Figure 1. Compared to the section of normal
brain (left), the section from an individual with
AD (right) shows marked atrophy of the cerebral
cortex.
Dental Update – June 2004
 S P E C I A L C A R E
Figure 2. High plaque levels in a patient with
AD have led to buccal enamel demineralization
and caries affecting the incisal surfaces of the
anterior teeth.
Figure 3. Oral hygiene neglect frequently
results in thick calculus deposits and gingivitis in
patients with dementia.
rather than the more challenging ‘Do
you remember who I am?’ Use simple
short sentences. Ask questions one
at a time in such a way that they can
answer ‘yes’ or ‘no’. Repeat or
rephrase your words if they don’t
understand.
l Listen carefully to what the person
says. If you have to interpret their
meaning, check that you have
guessed correctly.
l Never speak down to someone with
dementia, or speak across them as if
they were not there. Even if you get
no response, include them in your
conversations.
l Reassure them constantly. Use gentle
humour to form a bond between you.
Once you know them, it may be
appropriate to call them by their first
name, which they will recall long after
they have forgotten their surname.
DENTAL TREATMENT
PLANNING FOR
PROGRESSIVE STAGES OF
AD
When treatment planning, there are five
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D E N T I S T RY
basic questions to ask:11
l Can the individual brush his/her
teeth or dentures?
l Can s/he describe his/her
complaint?
l Can s/he follow simple instructions
(e.g. to sit in the chair)?
l Can s/he tolerate dental instruments
the mouth?
l Is s/he physically aggressive
(biting or lashing out)?
If the person is co-operative for these
criteria, s/he is in early stage AD. If the
answers are mainly ‘sometimes’, s/he
has moderate dementia. And if s/he is
consistently unable to co-operate and is
frequently aggressive, s/he is in late
stage AD.
Early Alzheimer’s Disease
The earliest symptoms include feelings
of not coping, and failing to remember
words or recent events. It becomes
harder to grasp the meaning of what is
being said, or to make decisions.
Unfamiliar people or unfamiliar places
are increasingly upsetting. Often, the
person attributes these symptoms to
stress, bereavement or normal ageing. S/
he denies or minimizes problems, and
conceals the degree of cognitive loss
with a veneer of good manners.10
People with AD experience a higher
incidence of dental disease (Figures 2,
3).12,13 It is therefore important that a
dental assessment be made as soon as
dementia is diagnosed.
l Encourage patients to maintain
independence. They may need
tactful reminding to carry out oral
hygiene. An electric toothbrush or
modified handle may be easier to
grip if manual dexterity is impaired.
Involve and train family or carers
early in supervising or assisting
with oral hygiene.
l Carry out any major treatment in
early stage dementia, when co-
operation is at its best. Explain and
demonstrate procedures before
carrying them out. Plan for the
future when self-care and treatment
tolerance will be compromised.
Eliminate potential sources of future
problems. Mark dentures before
institutionalization becomes
necessary.
l Employ comprehensive prevention
measures. If medication has caused
xerostomia, artificial saliva and/or
denture fixatives may be useful.
Liaise with the patient’s doctor to
ensure that, wherever possible,
sugar-free medication is prescribed.
Educate carers about reducing
sugar in the diet. Prescribe
chlorhexidine or fluoride either as
mouthwash (swabbed around the
teeth if the person cannot rinse), as
a spray or as a professionally-
applied varnish.
l Employ a chaperone to avoid any
confusion about what happened
during the visit. People with AD
sometimes become suspicious that
others wish to harm them or steal
from them.
Moderate Alzheimer’s Disease
As AD progresses, the person forgets
familiar names and faces. S/he repeats
the same phrase over and over again. S/
he finds it increasingly difficult to
manage day-to-day living, paying less
attention to personal hygiene,
confusing day and night, wandering and
getting lost. S/he becomes easily upset,
angry or aggressive, because s/he
cannot comprehend what is happening.
Providing treatment becomes more
challenging for the dentist.10
l Aim to maintain the existing
dentition without new disease
occurring. It is more important now
that family members or care-givers
assist with, or actually perform, daily
oral healthcare, and implement
preventive measures. Carers need
support from the dental team, and
training in brushing another
person’s teeth.
l Treatment visits should be relaxed
and stress free, in the earlier part of
the day before the patient gets tired.
Follow a regular routine. Carry out
treatment in small stages. If s/he is
Dental Update – June 2004

Figure 4. Treating patients with AD in their
familiar home surroundings reduces the agitation
and stress caused by a strange clinical
environment.
tired, unwell or upset, curtail
treatment or postpone it to another
day.
l People with AD respond best in
familiar surroundings with familiar
carers around them. They cope far
better with a domiciliary visit,
therefore, than with a journey in a
strange car to a strange surgery
(Figure 4).
l Use the least traumatic
interventions. Hand scaling may be
less frightening than sonic or
ultrasonic scalers. Warn the patient
that equipment will be noisy.
Consider chemical caries removal
techniques.
l If it is unrealistic to treat every
tooth, save lower teeth in preference
to uppers, because a lower denture
is less likely to be tolerated.
l Many edentulous individuals
manage to chew effectively if they
are provided with an upper denture
with a lowered occlusal plane in the
posterior region, so that the molars
and premolars occlude against the
lower ridge.
Where co-operation is inadequate and
treatment is imperative, e.g. to relieve
pain, consider sedation or even general
anaesthetic. Intravenous sedation or GA
should only be used after consultation
with the patient’s physician. AD does
not inherently contra-indicate GA, but
confusion is usually worse for a period
post-operatively. If the individual
undergoes GA, ensure that the treatment
carried out is radical enough to obviate
the need for another such intervention
in the future.2 Inhalation sedation is
Dental Update – June 2004
S P E C I A L
contra-indicated because individuals
with dementia do not readily accept the
nosepiece and are unlikely to be able to
follow instructions to breathe through
their nose. Oral sedation may be
effective, but can be unpredictable in its
effect.14
Late Alzheimer’s Disease
In the final stages, people with AD
become totally dependent for personal
and nursing care. Memory loss is
comprehensive, although they may have
a sudden flash of lucidity. Gradually, they
lose the ability to speak and become
doubly incontinent. With increasing
frailty and immobility comes the risk of
pressure sores, deep vein thromboses
and chest infections.10 Individuals may
overeat, become anorexic or be unable to
chew effectively. A common cause of
death is aspiration pneumonia, often as a
result of inhaling oral debris. Death
usually comes within 8–10 years of
diagnosis of AD.
l Even in late stage dementia, people
respond to a calm voice and physical
reassurance.
l Carers have to assume complete
responsibility for oral hygiene.
l Dentures often get lost. It may not
be appropriate to replace them.
These patients will have lost the
main incentives for denture wearing
– appearance and enjoyment of food
– and are unlikely to accommodate
to a new denture.
l Patients cannot communicate if they
are in pain. The only indication may
be a sudden change in behaviour:
refusal to eat, constant rubbing of
the mouth or face, greater
restlessness, disturbed sleep or
increased aggression.2
The main aim of treatment in late
dementia is to render the patient free of
pain, discomfort or infection. Everything
else is elective.
FACTORS AFFECTING
TREATMENT PLANNING
Most decisions rely heavily on the
C A R E D E N T I S T RY
clinician’s experience and judgement.
Evidence is gathered by observing the
patient, talking to them, noting their
implied meanings and body language,
consulting family and health
professionals involved in their care.
Ability to Consent
Some patients can take straightforward
decisions about oral healthcare if it is
explained in simple terms. As dementia
progresses, it is unlikely that they will
be capable of any form of consent.
Then, current consent guidelines for
incompetent adults must be followed.
These vary from country to country,
and also between different parts of the
UK.15
As a general rule, decisions must be
made in the best interest of the patient,
involving family or care-givers in
discussions, and taking into account
any opinions that the individual
previously expressed.
Who are you Treating – the
Patient or the Carer?
Family members or care-givers often
request treatment. We should examine
the reasons for their proxy request,
while being sensitive to their needs.
Dementia is like a living bereavement.
Close relatives feel the same grief and
loss. Others deny that anything is
wrong, requesting treatment that they
think would have been desired had
their relative still been well. Even when
doing the best they can, relatives
frequently feel guilty that they cannot
arrest the disease, that they feel
restricted and irritated by their
relative’s behaviour and, when they can
no longer cope, guilty about ‘putting
mother in a home’.
Families often perceive dental
treatment as one way that they can help
to improve their relative’s quality of life.
Sometimes they have difficulty
accepting that it may not improve the
situation, and may need to see that
treatment attempts may be traumatic for
very confused people, or that a simple
base-plate is not tolerated, and
therefore the greater bulk of a denture
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 S P E C I A L C A R E D E N T I S T RY
would also be rejected. It is important
to families to know when nothing more
is realistically possible, and they have
done the best they could.
Generally, empathetic discussion of
the delicate balance between possible
benefit, realistic outcome, and financial
cost, will enable both sides to reach a
pragmatic decision.
WHAT IS REALISTIC CARE?
Nothing is worse than delivering
treatment that the patient neither
understands nor appreciates, and
struggles to avoid. Treatment planning
should be realistic and patient-centred,
aiming to maintain quality of life. When
the many complex issues are evaluated,
there are essentially four choices:14
l Comprehensive routine care,
including aesthetic and
prosthodontic treatments.
l Monitoring and maintaining the
existing dentition by restoring new
cavities and implementing
prevention.
l Emergency care only, relieving pain
and infection, implementing
prevention if possible.
l No dental treatment possible
because of poor general health or
inability to co-operate.
As AD progresses, the person must
be constantly reassessed, and
individualized care plans revised to take
into account physical and cognitive
changes.16
ABSTRACT
TOOTH PROTECTION DURING
BLEACHING
Sealing Evaluation of the Cervical Base in
Intracoronal Bleaching. L.D. Olivera,
C.A.T. Carvalho, E. Hilgert, I.R. Bondioli,
M.A.M. Araújo and M.C. Valera.
Dental Traumatology 2003; 19: 309–313.
The possibility of external cervical
resorption following intracoronal
bleaching was first reported in 1979. These
workers report an in vitro investigation of
the leakage of bleaching agents through
278
Interprofessional Care
A wide variety of health professionals
will be involved in the care of a patient
with AD (Table 2). The treatment
approach should be holistic, and ideally
the dentist should be an integral part of
the healthcare team, involved in
discussions and case conferences.13
Even without that involvement, you may
need to contact one or more of these
health professionals while you are
providing dental treatment.
CONCLUSION
There are many challenges in providing
dental care for people with dementia. The
main challenge is responding to
behavioural changes and decreasing co-
operation while working realistically and
effectively with patients, family and
members of the healthcare team.
However, the dental team also has a
great opportunity to improve the quality
of life significantly for cognitively
impaired individuals and the people who
care for them physically and emotionally.
Doctors may not yet be able to cure
these patients, but dentists can play a
part in caring for them with empathy,
dignity and human kindness.
REFERENCES
1. www.statistics.gov.uk/census2001
2. Ettinger RL. Dental management of patients with
Alzheimer’s disease and other dementias.
Gerodontology 2000; 17: 8–16.
3. www.alzheimer’s.org.uk
4. Kieser JB, Jones G, Borlase G, MacFadyen E.
Dental treatment of patients with neurological
cervical dentine tubules in three groups of
single-rooted anterior human teeth that
had been subjected to a standard root
canal treatment procedure. Group one
received a 3-mm base of resin-modified
glass-ionomer cement placed below the
cemento-enamel junction; in Group 2, a 3-
mm base of glass-ionomer cement was
used; in Group 3, no base was placed. A
further two teeth were used as positive
and negative controls. All groups were
subjected to the same bleaching regime
over an extended period using sodium
perborate and hydrogen peroxide.
Following the research protocol, dye
Interprofessional Care
General Medical Practitioner
Consultant (neurology/geriatrics/psychiatry)
Community psychiatric nurse
District nurses and health visitors
Physiotherapist/chiropodist/OT
Psychologist
Speech and language therapist
DENTIST AND DENTAL TEAM
Table 2. Health professionals involved in care of
persons with AD.
disease. N Z Dent J 1999; 95: 130–134.
5. Cockrell JR, Folstein MF. Mini Mental State
Examination (MMSE). Psychopharmacology 1988;
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6. Tyrell J, Cosgrave M, McCarron M et al. Dementia
in people with Down’s syndrome. Int J Geriatric
Psychiatry 2001; 16: 1168–1174.
7. Saxe SR, Wekstein MW, Kryskio RJ et al.
Alzheimer’s disease, dental amalgam and mercury.
J Am Dent Assoc 1999; 130: 191–199.
8. www.cochrane.org
9. Fabbrini G, Barbanti P, Aurilia C.Tardive dyskinesias
in the elderly. Int J Geriatric Psychiatry 2001; 16:
S19–S23.
10. Henry RG. Neurological disorders in dentistry:
managing patients with Alzheimer’s disease.
J Indiana Dent Assoc 1998; 76: 51–57.
11. Niessen LC, Jones JA, Zocchi M, Gurian B. Dental
care for the patient with Alzheimer’s disease. J Am
Dent Assoc 1985; 110: 207–209.
12. Jones JA, Lavallee N, Alman J, Sinclair C, Garcia R.
Caries incidence in patients with dementia.
Gerodontology 1993; 10: 76–82.
13. Ship JA, Puckett SA. Longitudinal study on oral
health in subjects with Alzheimer’s disease. J Am
Geriatric Soc 1994; 42: 57–63.
14. Henry RG, Wekstein DR. Providing dental care for
patients diagnosed with Alzheimer’s disease.
Dental Clinics N Am 1997; 41: 915–943.
15. www.doh.gov.uk/consent
16. Vigild M. Benefit related assessment of treatment
need among institutionalised elderly people.
Gerodontology 1993; 10: 1–14.
leakage tests showed that, although
leakage of the bleaching agents along the
cervical dentine tubules occurred in all
specimens, it was significantly less in the
teeth with a base, and less leakage
occurred in the group with the resin-
modified glass-ionomer base than the
group with a conventional glass-ionomer
cement.
The authors recommend that a base
should always be placed below the
cemento-enamel junction before intra-
coronal bleaching is carried out.
Peter Carrotte
Glasgow Dental School
Dental Update – June 2004