Dental care and Dementia
Good oral health is
important for general health, well-being and quality of life. It brings
significant benefits to self-esteem, dignity, social integration and general
nutrition. Poor oral health can lead to pain and tooth loss, and can negatively
impact self-esteem and the ability to eat, laugh and smile. This factsheet describes
some of the dental problems that people with dementia at different stages may
face and methods for prevention and treatment
There are two main types of dental disease - gum
(periodontal) disease and tooth decay (dental caries, more commonly known as
cavities). Both can cause discomfort or pain and can lead to the development of
infection. Both pain and infection can worsen the confusion associated with
Gum disease can cause
inflamed and bleeding gums, gum recession (where the gum tissue is reduced,
causing the roots of the teeth to become exposed), loose teeth and bad breath.
It is caused by the build up of dental plaque. Plaque is a combination of food
debris and bacteria from the mouth - everyone has some of it. Plaque leads to
gum disease if it is not removed by efficient cleaning as it builds up on the surface of the teeth, particularly
where the teeth meet the gum. Good oral hygiene (keeping the teeth, gums and
mouth clean by brushing and flossing) and the use of a tooth gel or mouth rinse
containing chlorhexidine (an antiseptic and disinfectant agent) can help to
control gum disease.
Tooth decay is caused by
the action of dental plaque on the teeth when food and drinks containing
sugar are consumed. Essentially, the bacteria in plaque feed on the sugar,
producing acid, which in turn attacks the tooth, causing decay. Dentists
recommend restricting the intake of sugar to two to three times a day,
preferably at mealtimes, as it is the number of times we eat sugar in a day,
rather than the total amount of sugar consumed, that Is important in guarding
against tooth decay. This Includes hidden sugars in foods, as well as sugar
added to food or drinks. A healthy diet, good oral hygiene, and the use of
toothpaste or a mouth rinse containing fluoride will also help prevent tooth
High-energy food supplements contain high levels
of sucrose - a form of sugar. If they are used on a regular basis, It is
important that the teeth are kept very clean to minimise the risk of decay. Gum recession increases the chances of tooth decay
occurring at the necks of the teeth (where the crown of the tooth meets the
root at the gum) unless oral hygiene is excellent and dietary sugar is
controlled. When food $upplements are
prescribed for a person with natural teeth, it is important to get advice on
prevention from the dental team.
Daily care of teeth
Early stages of dementia
In the early stages of
dementia, the person will usually still be able to clean their own teeth. They
may need to be reminded to carry out the task, or they may need to be
supervised. If they need help, try giving them the brush and toothpaste and
show them what to do. As manual ability decreases, an electric toothbrush may
help maintain independence. The person with dementia could also try using a
toothbrush with an adapted handle to
improve their grip. Your dentist or dental hygienist may be able to advise you
on this as well as the best methods for prevention of tooth decay and gum disease in the particuiar
circumstances. Pt is very important to establish an individual long-term
preventive programme in the early stages of dementia. This may include a
high-concentration fluoride toothpaste and regular application of fluoride
varnish for people with natural teeth. Fluoride can be applied by the dentist,
dental therapist or dental hygienist under the prescription of the dentist.
Later stages of dementia
A$ their dementia progresses,
the person may lose the ability to clean their teeth, or lose interest in doing
so, arid carers may need to take over this task. A dentist or hygienist can
provide guidrIce and support on how to assist in cleaning another person's
teeth. The technique will vary depending on the individual concerned.
Generally, the easiest way is for the person with dementia to sit on a
dining-style 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 damp toothbrush and a little toothpaste.
Drugs and dental problems
People with dementia may
be prescribed antidepressants, anti psychotics and sedatives. One of the main
side-effects of these drugs is a dry mouth. Saliva acts as a lubricant and dry
mouth can cause problems with dentures, including discomfort and looseness.
Denture fixatives and artificial saliva can help some people with denture
problems. The dentist will be able to offer advice. Saliva also has a cleansing
effect on the mouth arid teeth. Its absence leads to a build up of bacteria and
food debris, gum disease and dental decay, particularly at the neck of the
tooth. Decay in this eire a weakens the crown of the tooth, and can cause the
crown to break off.
If medication is syrup-based (eg lactulose),
there is an increased danger of tooth decay. The doctor may be able to
prescribe a sugar-free alternative if asked. The dentist may also be able to
apply chlorhexidine and fluoride varnishes to help prevent decay at the necks
of the teeth.
Some antipsychotic drups can
cause involuntary repetitive tongue and jaw movements, making it difficult to wear dentures,
particularly in the lower jaw. Unfortunately, these movements may continue
after the drug is stopped.
Peopre with dementia are not always able to recognise or
express their dental needs, including when they are in pain, It is important to have
regular mouth checks, whether the person has teeth, dentures or no teeth at
all. Regular mouth cheeks can highlight any problems so that they can be
treated as soon as possible. Cancer of the mouth, while generally uncommon, is
more likely to occur in older people than in any other age group. It may start
as a small painless ulcer and, if diagnosed early, treatment is relatively
simple and has a high success rate.
Dentures can become loose and begin to damage
the mouth if they have been worn for a number of years. As these changes happen
slowly, the individual can adapt to them without realising that the mouth is
being harmed. In addition, decay at the necks of the teeth is often painless,
and may go unnoticed until the crown of the tooth breaks off.
Need for assistance with dental care
As dementia progresses, the person affected
may become less able to:
their teeth effectively
-- understand that their teeth need to be kept
- express the need for dental treatment, explain dental
symptoms, including pain, take part in the decision-making process about
treatment or give their informed consent for dental treatment
comfortable with dental treatment.
How to tell if someone has dental problems
There may come a time when the person with
dementia is unable to say that they are experiencing pain or discomfort. They
will need to rely on other people to notice and interpret their behaviour and
to arrange a visit to the dentist. There are several behavioural changes that
may indicate that someone with dementia is experiencing dental problems. These
-- refusal to eat (particularly hard or cold
pulling at the face or mouth
previously worn dentures out of the mouth, increased restlessness, moaning or
shouting, disturbed sleep
to take part in daily activities, aggressive behaviour.
If there is no explanation for the change in behaviour, arrangements
should be made to identify the cause. This should include a dental assessment
as part of the process.
Review needs and agree on the best treatment plan. They should
take into consideration:
--the level of independence,
co-operation, cognitive and mental state, and physical impairment of the person
--what. if any, dental
symptoms or problems the person is experiencing
--whether the individual is
able to give informed consent (see 'Consent to treatment' below).
--Once these questions have been answered, the
dentist will be able to decide on the most appropriate treatment. They may
decide to see the person regularly every few months, or they may only need to
be seen once a year.
Consent to treatment
It is important that the person with dementia
is given the opportunity to make, or take part in, decisions about dental
treatment. Ask the dentist to explain in simple terms what is being clone and
why. Shod sentences that are phrased in a way where the person can answer 'yes
or 'no' can be effective.
When dental treatment is
irreversible - for example, when teeth are going to be taken out - and where
the individual cannot give informed consent, the family andior carers will
usually be involved in the decision-making process. The dentist may also seek a
second opinion, from another dentist or a doctor, to make sure that the
proposed dental treatment is in the individuars best
The Mental Capacity Act
2005 requires that everyone is presumed to have the capacity to make decisions
unless it is shown otherwise. If this is not clear, the dentist should carry
out an assessment of the person's capacity 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
who have capacity can grant a person lasting power of attorney to take
decisions about property, finances, health and welfare if they should lose
capacity in the future. Where an individual is been granted lasting power of
attorney, their wishes should be respected.
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 health care treatment -
for example, removal of some or all their natural teeth, and which may involve
treatment under sedation or a general anaesthetic.
Coping with dental treatment
The progression of
dementia varies enormously, as does the ability to cope with dental
treatment. Some people are comfortable with a visit to the dentist, while
others find the whole experience very distressing.
People who have had regular dental treatment
throughout their lives often remember what they are expected to do in a dental
surgery. They may have little difficulty co-operating with simple procedures
until their dementia is advanced. For other people with dementia, the journey
to the surgery, the strange environment and the unfamiliar faces of the dental
team can increase their confusion, making treatment difficult or impossible.
In these circumstances,
the dentist may be prepared to make a home visit. Alternatively, it can be
helpful for the person with dementia to be accompanied into the dental surgery
by someone they know. The carer could perhaps remain in the person's sight
while they are having treatment and offerreassurance by holding
the person's hand. People with dementia can have good days and bad days! Dental care is better postponed to a good day, if possible, or scheduled to a
person's best time of day.
Types of cientai
Early stages of dementia
In the early stages of dementia, most types of
dental care are still possible. The dentist will plan the treatment, bearing in
mind that the person with dementia will eventually be unable to look after
their own teeth. Key teeth may be identified and restored. Advanced restorative
treatment (such as crowns, bridges and implants) may only be considered if
someone is prepared to carry out daily brushing for the person with dementia
should they reach a stage where they cannot do this for themselves. Preventing
further gum disease or decay is also very important at this stage. As dementia
is a progressive condition, it is important to obtain preventive advice from
the dental team.
Middle stages of dementia
During this stage of
dementia, the person is often relatively physically healthy but may have lost
some cognitive skills. The focus of dental treatment is likely to change from
restoration to prevention of further dental disease. Some people may find the
acceptance of dental treatment beyond their tolerance and 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 person is
likely to be severely cognitively impaired and often physically frail or
disabled with complex medical conditions. Treatment at this stage focuses on
prevention of dental disease, maintaining oral comfort and provision of
More people are keeping their natural teeth
into old age. However, a significant number of older people have partial or full dentures. Plaque can easily build up on dentures. If partial dentures are
worn, it is important that oral hygiene is well maintained or the increased
plaque accumuration will encourage gum disease and tooth decay.
New dentures may be needed when the person
loses all their natural teeth or If they are misplaced. In both circumstances
the person with dementia may have difficulty coping with their new set of
dentures, and will need to be encouraged to persevere.
Dentures need to be
replaced when they become loose. When dentures have been worn successfully in
the past, the replacement dentures are best constructed using the key features
of the old ones - for example, the overall shape and the tongue space. For this
reason it is important not to throw away old dentures, even when they may seem
to be of no use. Instead, take them along to the dentist when the new ones are
being constructed so that the good features can be copied and any poor features
can be improved.
Marking a person's name on dentures does not prevent
denture loss, but it does mean that when dentures are found they can, in many cases, be returned. New dentures should be permanently marked during he manufacture. Existing
dentures can be temporarily marked using a simple technique that wifl last for
6-12 months. This can be done using a small piece of new kitchen scourer, a
pencil (or alcohol-based pen) and clear nail varnish. The process takes about
ten minutes and can be carried out. by a dentist, a dental hygienist or a
You need to:
- Select an area near the back of the mouth on the
outer surface of the denture just large enough to take the person's name and
use a new piece of green scourer to remove the surface polish from this area,
- Paint over the name with a
thin coat of the varnish and allow it to dry,
- It is important to thoroughly clean, disinfect
and dry the denture before marking it. Dentures should be checked periodically
to ensure the name is still legible, and the marking renewed as necessary.
The person with dementia should be encouraged to
wear their dentures, and offered help with putting them in, for as long as
possible. Dentures are important for maintaining dignity and self-esteem - if a
person does riot wear them it may affect their appearance and make speech more
Denture loss is common when
people with dementia are in unfamiliar environments - for example, when they
spend time visiting others outside their home or facility. Replacing lost dentures can present problems. if the person is without
their dentures for any length of time they may forget how to wear them, or they
may lose their ability to adapt to a new set. The individual may also be unable
to co-operate with the dentist over the several visits required to make the new
dentures. However, sometimes intervention by the carer (for example,
hand-holding or distraction through hand-stroking or talking) may be all that
is needed. If co-operation is limited, a realistic. approach may be to provide
an upper denture only, for the sake of appearance.
sometimes be difficult and 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 the person 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, many people with dementia reach a
stage where they will no longer tolerate dentures in their mouth even though
they have worn them without problems in the past.
If the person with dementia already has a
regular dentist, they should continue to see the same dentist for routine
treatment and preventive advice.
check-ups. The latest guidance on check-ups is
that the intervals between them should be tailored to the needs of the
individual. They no longer need to be every six months, and the dentist will
advise whether you need to be seen more or less often than this.
people at home. This can be less stressful and confusing for the person, and
may increase co-operation. Similarly, some care homes have a dentist who visits
on a regular basis.