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Wednesday, May 2, 2012

Oral Health in Dementia: Dental Professionals and Patients With Dementia

The use of behavior management techniques will greatly assist the practitioner in obtaining cooperation and compliance of the patient with dementia, particularly in the early stages of the condition. Many patients, who are in earlier stages of dementia than Mrs. K, can be managed by:
  • Providing a friendly and caring atmosphere (smiling, approachable demeanor);
  • Offering a reassuring and comforting approach (tone of voice, gentle touching, etc);
  • Making eye contact and facing the patient;
  • Speaking in a calm, deliberate manner;
  • Eliminating/minimizing distractions (noises, quick movements, etc);
  • Allowing the caregiver to be present, if appropriate;
  • Avoiding forcing the patient to comply; consider rescheduling as a "desensitizing" or "familiarizing" opportunity; and
  • Assessing usefulness of psychotropic medications, such as Ativan (lorazepam) or Xanax (alprazolam), to provide mild sedation, in consultation with the patient's primary care provider.

Patient Management and Stage of Dementia

After assessing and assimilating all available patient information, a rational treatment plan can be formulated that allows the provider to perform the most appropriate care for the patient, considering the overall health, cognitive status, and prognosis of the patient.[9]
In the early stages of dementia, the patient may have relatively good cognition and memory and may be compliant in the dental environment. However, as the dementia progresses, a disruption of normal thought processes and lack of concern for general and oral hygiene are typically evident. Oral health can rapidly decline. With an ever-increasing number of us living well into our 80s and beyond, the ADA has recognized this critical issue, and hosted the National Consensus Conference on the Oral Health of Vulnerable Older Adults and Persons with Disabilities in November 2010 to identify strategies to address this concern.[10] The ADA also has resources for the dental practitioner on the management of the oral health needs of older adults.[11]
Stages of dementia. Dementia is often classified as having 3 stages: early, moderate and severe (terminal). Patient management is influenced by the advancement of the disease process (Table 2).
Table 2. Dental Management by Stage of Dementia
Early Stage - MMSE score 21-24
• Most patients are appropriately responsive and cooperative
• Ask questions that can be answered by either "yes" or "no"
• Provide short, simple instructions
• Repeat instructions, if necessary
• Use the "tell, show, do" technique
• Use a mouth prop, if appropriate
• Most dental procedures can be tolerated at this stage
• Short, morning appointments are often better tolerated
• Emphasize to patient and caregiver(s) the importance of excellent oral
  hygiene and regular dental visits in maintaining oral health
• Consider prescribing adjunctive measures (eg, fluoride toothpaste and
  rinses, chlorhexidine gluconate rinse, salivary substitutes, etc)
• This is the appropriate stage for the dentist to develop a rational treatment
  plan, considering the patient's prognosis, and to provide as much
  treatment as possible to establish optimal oral health
Moderate Stage - MMSE score: 10-20
• Increased loss of cognitive abilities results in diminished ability to perform
  activities of daily living and increased dependence on caregiver(s) to do
  so
• Patient may still be in relatively good physical health
• Primary goal of dental management in this stage is oral health
  maintenance and the elimination of pain and infection
• Patient may not be able to identify source of dental pain
• Signs of dental problems in a dementia patient may include:
    -Rubbing of the face
    -Moaning/yelling/crying
    -Flinching when face is touched or when eating
    -Inability to eat/drink hot and/or cold items
    -Increased irritability
    -Not wearing removable dental appliances
• Patient's ability to cooperate when conscious may be lacking and may
  necessitate intravenous sedation or general anesthesia in the appropriate
  facility and with trained personnel[7]
Severe (Terminal) Stage - MMSE score: ≤ 9
• Physical as well as cognitive abilities rapidly deteriorate
• Caregiver is completely responsible for patient's well being, including daily
  oral hygiene and compliance with regularly scheduled dental
  appointments
• Optimal treatment includes prevention of pain and infection
• Any invasive treatment would most likely require intravenous sedation or
  general anesthesia

Management of Mrs. K. At the return visit, with Mrs. K under anesthesia, multiple dental restorations were performed to maintain several reasonably healthy teeth, preserve some masticatory function, and avoid complete edentulism. Most of her teeth, however, required extraction owing to extensive dental decay. Mrs. K. tolerated the procedure without incident and was discharged from the ambulatory care center later that day in the company of her husband. After this treatment, Mrs. K's husband started an oral hygiene and topical fluoride regimen recommended by Mrs. K's dentist to reduce the accumulation of dental plaque and the rate of dental caries. Unfortunately, Mrs. K's neurologic condition continued its rapid deterioration, and she died 8 months following her dental treatment.
In hindsight, perhaps, the method and treatment rendered for Mrs. K was extreme, given that she succumbed so soon afterward. However, such an outcome cannot be predicted, and all parties (Mrs. K's healthcare proxy, her physician, and her dentist) agreed to treat her. Reducing tooth-related pain near the end of life is an important goal. This case points out the unpredictability of dementia and emphasizes the importance of early restorative and preventive care.

The Challenge of Dementia

The patient with dementia presents many challenges for the oral health practitioner. Early intervention and treatment of the patient before the dementia advances to a moderate or severe stage is vital. Proper interdisciplinary consultation, rapport with family and caregivers, practical patient management techniques, rational treatment planning, and timing of the provision of care are necessary to establish the optimal long-term oral health of these patients.

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