Improving Oral Health For Patients With Alzheimer’s Disease Or Related Disorders (ADRD)

In their 2016 report, the Alzheimer’s Association found that a staggering 5.4 million Americans are currently suffering from Alzheimer’s disease or related disorders (ADRD). This number is projected to skyrocket to 16 million by 2050, the most pressing epidemic for our aging population.

While it’s alarming that someone develops Alzheimer’s every minute in the United States today, this rate has the potential to double by 2050. The rapidly increasing presence of such a debilitating disease raises serious concerns regarding healthcare costs and the availability of effective treatment options. As a result, we are already seeing inadequacies in dental care for patients with Alzheimer’s.

Poor training and strained communication are among the most prominent reasons dental pain among nursery home residents with Alzheimer’s goes undetected, and therefore untreated.
But the problem is a multi-faceted dilemma, one that will require the awareness and cooperation of patients, caregivers and dental professionals to overcome.

Understanding Alzheimer’s and Dental Care

Dr. Teryn Sedillo, DDS teaches courses and lectures on special needs dentistry at the Creighton School of Dentistry in Omaha, Nebraska.

In her experience as a dental professional, she has become familiar with the roadblocks standing between special needs patients and good oral health. “A lot of people don’t associate systemic issues, other body issues or organ issues linking to infections of the mouth,” she explains. “The mouth is the gateway to the rest of your body, so everything that you’re doing follows suit.” The relationship between oral health and general health is often misunderstood, which can result in general health becoming a priority while oral health takes the backseat.

This phenomenon is especially true for patients with Alzheimer’s, given the wide range of mental and physical problems that inevitably earn the attention of caregivers. Failure to provide patients with good oral care has led to an increase in edentulism (tooth loss), denture-related oral mucosal lesions, gingival bleeding, a higher accumulation of plaque and calculus and a decline in salivary gland function (among other symptoms).

These explicitly oral problems are just the beginning. Patients are highly susceptible to seemingly nonrelated issues that begin with poor dental care. Any infection, but “especially oral” infections, can cause “high blood sugar, which can then cause a whole host of other problems like kidney failure and pneumonia.”

Oral neglect is especially prevalent in patients with Alzheimer’s because they are more likely to be living in institutions, financially burdened, have previous instances of oral diseases, swallowing problems and an inability to meet nutritional needs.

Quality of life can decline so if you have dental pain and you don’t have the correct care, it decreases your desire to eat because taste changes, you have bad smell or bad taste in your mouth, maybe you have pain where you can’t even bite or chew on that side, which can lead to poor nutrition.

Patients are more likely to have overburdened caregivers, functional dependence, and irregular dental attendance. Any combination of these can result in oral health issues at some point in their lives. Unfortunately, caregivers are not always prepared or equipped to detect poor oral hygiene, and noncompliance further complicates the process.

According to Dr. Sedillo, this area of care has become “very overregulated and underfunded, so when you have that combination you’ll often times see a high turnover of staff. They get frustrated with the system because they want to help. Most of these people aren’t bad people that are in these facilities, they’re just underpaid and worked to death.”

Alzheimer’s Patients in The Dental Office

While getting the patient to the dentist’s office is a difficult task on its own, there are just as many challenges once the patient is in the chair. Professionals experience difficulties communicating with the patient, who may be confused or intimidated by the unfamiliar people and surroundings.

The standard approach one would take for the average person could prove counterproductive and even dangerous for the dentist and patient alike. Professionals often find that patients with Alzheimer’s are unwilling to cooperate, such as refusing to open their mouths or biting during the checkup.

Ensuring a Successful Office Visit

For a patient with Alzheimer’s, a successful visit to the dentist is a team effort. Dr. Sedillo claims that “as a dental professional, it’s important to get to know the patient and… the caregiver.” After all, “any time that you’re taking care of someone’s mouth, it’s considered to be intimate care. It feels very invasive of space and privacy for the… aging, elderly and frail population. It can be a very scary thing for them. So building trust and rapport with these patients is the number one key.”

If possible, the caregiver should be present throughout the process.
The support of the caregiver will provide comfort and familiarity for the patient and increase her cooperation with the dental professional.

For standard appointments, dental professionals and caregivers should both be aware of the steps that will help the process go smoothly:

• Send the patient a reminder at least one day in advance.
• Determine the patient’s best time of the day and schedule the appointment accordingly.
• Make sure the patient empties their bladder before the appointment.
• Maintain a quiet and private environment.
• Keep the appointment length to a minimum (no longer than 45 minutes).
• Be sure to check it the practice does or doesn’t accept the patients dental insurance

“We need to put our patients first. We can’t assume declining cognition or inability to make decisions on their own. We have to be able to have these conversations with the patient [and] involve the caregiver as a secondary,” Dr. Sedillo says. “Dentistry is dentistry. You don’t need to be trained any differently to do the actual dentistry or tooth extractions. It’s building that relationship with your patient, being accommodating and educating your staff.”
Dental professionals should provide clear follow-up instructions to the patient and the caregiver, including written instructions for the caregiver, who may be preoccupied with the patient during the appointment. For the treatment process, dental professionals should keep in mind the following responsibilities: plan multiple short appointments instead of fewer long ones, avoid treatment that will complicate home care, use local anesthetics with the shortest possible duration, keep the explanation of the treatment to a minimum to avoid patient anxiety, thoroughly explain the treatment and post-treatment instruction to the caregiver and follow up with the caregiver regarding pain or discomfort increased confusion or agitation after the visit.

More Caregiver Tips

Regular dental checkups are only part of maintaining good oral health. Dr. Sedillo suggests that caregivers “work on a preventative home care approach” which includes brushing two times daily and watching for changes in behavior. “Some of these patients can be super happy-go-lucky one day and the next day just be very groggy, impatient, frustrated and irritable.”

It is important for caregivers to
“be thinking of oral issues in the back of their mind whenever they see changing behavior, especially over a long period of time”
because “some caregivers just think about it as a behavioral issue.” Because patients may be unable to articulate that they are experiencing dental pain, caregivers must consider this possibility at all times.

When patients lose the autonomy that most of us take for granted, they lose the means of maintaining their own health, unless others step in with the proper knowledge and awareness to compensate. Dr. Sedillo works with dental students every day to prepare them for this initiative.

In her experience, she believes “we’re moving toward increasing the awareness, but at this point it’s not where it needs to be.” While progress has been made, there are still major challenges ahead, ones that will require great dedication on the part of dental professionals and caregivers to ensure the best oral care from cavities to wisdom teeth extractions, and in turn, the best quality of life for these patients.

Additional Resources:

For information on statistics of Alzheimer’s Disease, the 2018 report on the illness from the Alzheimer’s Association.
https://www.alz.org/media/HomeOffice/Facts%20and%20Figures/facts-and-figures.pdf

The Alzheimer’s Association caregiver center, for help for anyone who is a caregiver to an Alzheimer’s Disease patient.
https://www.alz.org/care/alzheimers-dementia-dental.asp

Alzheimer’s Disease and dental care helpful tips to increase efficiency of daily dental care for Alzehimer’s patients.
http://www.alz.org/living_with_alzheimers_10512.asp

The American Dental Association information on providing dental care for patients with Dementia and Alzheimer’s Disease.

Alzheimer’s information and additional resources for patients living in the United Kingdom, as well as helpful information dental care information for patients with Dementia.
https://www.alzheimers.org.uk/info/20029/daily_living/9/dental_care

Resources and information from “Dementia Today” that help to guide caregivers of patients with Alzheimer’s Disease in proper oral hygiene.
http://dementiatoday.com/alzheimers-and-dental-careoral-health/

Dr. Sedillo contact information:
Private practice located at: 12607 Gold Plaza, Suite #108, Omaha, NE
Phone Number: (402) 934-5200
Inquiries can be sent to drsedillo@pannetondental.com
Creighton School of Dentistry located at 2802 Webster St. Omaha, NE
Phone Number: (402) 280-5060