Degree of cognitive dysfunctions varies – from very mild ‘confusion’ up to total loss of cognitive abilities, including various level of capacity to consent

Up to 60-70 % of all domiciliary dental care patients suffer from some form of dementia, mainly women (2/3): forgetfulness, early confusion, late confusion, early dementia, middle dementia, late dementia.

• edentulous mouth,
• dry mouth,
• patients unable to tolerate new set of dentures
• poor oral hygiene: gross plaque and calculus accumulation
• multiple carious lesions, often root caries or cervical region caries (by CEJ)
• advanced gingivitis and periodontitis, including gingival recessions, bone loss and tooth mobility
• severe tooth wear
• factors indicating oral pain with cognitive impairments: refusal to eat, pulling at the face, increased drooling, leaving previously worn dentures out of the mouth, increased restlessness, self-injurious bahaviour, refusal to co-operate with normal activities.

 

Assessment of ability to co-operate for dental treatment should involve questions (Niessen et al.):

• Can patient brush teeth or clean dentures?
• Can patient verbalize chief complaint?
• Can patient follow simple instructions, eg. sit in chair?
• Can patient hold radiograph in mouth with film holder?
• Is patient assaultive (bites/hits)?

 

Dental Care

• patient needs full capacity assessment and IMCA involvement for any serious, invasive procedure, including sedation and GA
• patient needs to be encouraged to make decision on his/her own
• simple signs of ‘agreement’ with tx plan vitally important
• regular prescription of high fluoride TP 1.1% sodium fluoride (5000 ppm)
• mood and mental capacity can be short term or fluctuating
• often are medically compromised
• medical history check is essential every single appointment
• be realistic in terms of treatment plan
• oral sedation with temazepam night before and 1 hour before appt. works pretty well, following a risk assessment considering age and general well being
• mouth guard for upper arch in case of lower lip biting and chronic ulceration
• patient can be agitated and aggressive due to a late stage of dementia
• oral hygiene extremely important !

 

Long term oral care planning for people with dementia (compliance with BSDH guidelines, Dougall&Fiske):

• preventative approach as early as possible
• relevant information given to carers about oral health maintenance and prevention
• regular dental check-ups and reviews in order to monitor oral health condition and minimize potential interventions
• dental treatment in early stages of the dementia to manage efficiently dental needs
• dentures should be cleaned on regular basis, special denture brush should be advised
• dentures should be marked and named by lab technician
• dentures can be replaced using duplication technique
• ‘open door’ approach and support to minimize stress, fear
• ‘tapping fingers, nails’ technique to diminish tremor, shaking, involuntary movements

 

Be positive and honest, maintain the eye contact all the time.

Body language and face expression can be more important than the other assets and competences.

Verbal communication not always as important as patient’s cognitive function impaired.

Involve other family members in patient’s care and management, eg. by holding hand, giving reassurance, etc.

Build up gradually a trust with a patient

Allow family members to interact during dental visit

Presence of patient’s next of kin, wife, husband, etc. absolutely crucial for a more complex dental tx plan

Even a simple check-up can be a challenge!, chair reclining may not be well tolerable by patient. Being upfront the patient, with maintaining an eye contact and smiling – helps a lot!

Sometimes, kneeing and the use an electric torch are the only options to start off with a basic dental assessment.

Patient can be very reluctant to open her/his mouth, a gentle lip stretching with plastic mirror/fingers/toothbrush are helpful

If initial exam difficult, that is fine, try another time, another day!, assessment of the anterior part of patient mouth first, the posterior quadrants next visit if pt reluctant.

Do not attempt carry out too much and too many procedures at once.

Constant, close cooperation with consultants, specialists, GP’s, geriatritians regarding dental treatment plan, eg. planned extractions in patient prior starting bisphosphonates therapy.

To balance: benefit of osteoporosis therapy (bisphosphonates) and risk of ONJ

Risk assessment on initial domiciliary visit

Be aware of interaction between antifungal miconazole oromucosal gel often prescribed for patients with denture stomatitis (candidiasis) who are on warfarin – increased anticoagulant action of warfarin, risk of internal bleeding.

“Butterfly Scheme” symbol by patient’s bed at the hospital indicating that patient has got dementia problem and needs special care – The Butterfly Scheme provides a system of hospital care for people living with dementia or who simply find that their memory isn’t as reliable as it used to be; memory impairment can make hospitalisation distressing, but it needn’t be.

 

Elderly patient with mild dementia,  has mental capacity to consent. Attended with daughter.

Initially seemed to be fairly cooperative, sat in chair with her daughter assistance. Slightly confused but communication maintained. “Knee break” dental chair (eg. Belmont) very useful as easy access to it and patient feels more comfortable/natural. Has got upper full denture only which was lost in toilet. MH not contributory apart from progressing dementia. Initial capacity assessment. Daughter requested  a new set of dentures for Mum. Examination with difficulties as patient a bit apprehensive.  On brief intraoral examination: healthy soft tissues, oral cancer screening nil, generalized significant bone loss within mandible, well maintained and reasonable retentive upper area. Infection control issue as old upper full denture contaminated. Thorough denture clean in surgery with soap, disinfectant and ultrasonic bath. Chlorhexidine gluconate 2% and NaOCl 2% used for microorganisms eradication. Discussed options with daughter, explained that patient would not be compliant with standard denture work and lower full denture will not be possible. Realistic options: soft-lining or heat cured lining in Lab. Decided to attempt a F/- fit improvement with a soft acrylic lining GC Reline. Next visit: to try upper denture in office lining, if not possible – to try impression for hard lining.

Elderly patient with moderate dementia, fluctuating capacity. Domicilary visit in a care home.

Happy, fairly cooperative and  verbal patient. Short term memory mainly affected, able to communicate but may not understand the complex dental procedures eg. full denture work. Wears upper full denture only, lower one lost, carers do not know where. MH non contributory apart from progressing dementia. Capacity assessment carried out. Care home staff requested  a new set of dentures. Full examination without difficulties.  oe: healthy soft tissues, oral cancer screening nil, generalized mild bone loss maxilla, reasonable retentive. Discussed options with pt and carers, explained that patient would not be compliant with standard denture work, esp. bite registration stage. Realistic option: soft-lining or heat/cold cured lining in lab or copy/replica F/- . Decision about F/- copy denture. Next visit: silicone putty impression of F/- outside patient’s mouth.

Agitated, elderly patient with severe  dementia, lacks mental  capacity.

Non-cooperative, wheelchair bound patient. Looks distressed and repeats saying” I want to go back home’. Able to communicate but very distressed and does not understand why the appointment was arranged. Carers reported that occasionally patient indicates some sort of discomfort inside the mouth and having difficulties with eating . MH revealed advanced dementia, patient on alendronic acid tablets due to osteoporosis. Only limited brief examination with difficulties, patients declined sit in dental chair, relucantly opened mouth and allowed a quick look for several seconds, oe: multiple retained roots. They seem to be asymptomatic, no obvious signs of local odontogenic inflammation. Decided to accept status quo and not to commence any dental intervention. Decision to discuss potential problems with patient’s next of kin via phone. If any problems in the future: pain, acute infection, etc. – to be acting in the best patient’s interest, DGA to be considered. Explained that patient would not be compliant with any routine procedure under LA at the moment.

Frail, compliant elderly patient with moderate dementia, and other complex medical conditions, has mental  capacity.

Cooperative patient, wheelchair bound, able to transfer into a dental chair, fairly independent and alerted. BMI below average, looks frail and distressed, able to communicate but may not understand the complex dental procedures, eg. RCT. Complex MH, multiple severe health conditions, non-progressing dementia, on several medications, including NAOC apixaban. Patient tends to hold breath for a long time. Lives with a family. Referred by a local GDP for the extractions of carious anterior  teeth due to complex medical problems. O2% saturation initially below 90%, oxygen supplied with face mask, panic attack with hyperventilation. According to family member, patient gets this kind of reaction if get distressed. Attempted to calm patient down by holding hands which worked. Unrestorable teeth are asymptomatic, no obviouos signs of local odontogenic inflammation. Managed PA radiograph – no periapical pathology. Decided to accept status quo and not to commence any dental intervention. If any problems in the future: pain, acute infection, etc. ref for xla’s in a safe hospital setting. Reflection: do not attempt placement of facial oxygen mask or nasal oxygen cannula without warning/letting know the patient, explanations what is going to happen next and reassurance. Some of the patient may feel distressed and anxious.