As the elderly population increases, so does the number of older persons who retain their natural dentition or who have replaced their missing teeth.

The dentist may need to provide treatment for people with various medical, physical and mental conditions who face various barriers to seeking oral care. One of these challenging groups are persons with dementia.

Dementia patients may no longer have, or will reach a stage when they no longer have, the ability to voice their needs for oral care and treatment; lose the ability to carry out daily oral hygiene to a level that prevents dental disease; make informed choice for treatment options; and give valid consent for the treatment the dentist offers.

There are various personal factors influencing oral health in persons with dementia, including the ability to oral self-care and to routinely access the provision of oral care. This depends on the severity and stage of the dementia, the individual’s level of cognitive impairment and physical disability, the lack of personal perception of oral care problems and previous dental history, including oral care and dental assistance needed, especially from carers and the dental team.

People with dementia have generally poorer oral hygiene as the loss of cognitive and motor skills reduces the ability to self-care, including carrying out oral hygiene procedures. Reliance on carers is thus of utmost importance; however, some carers might not have the motivation, the knowledge, skills or training necessary to carry out oral care on such persons.

The dentist will, therefore, very often find an oral state of advanced gum disease; carious teeth; a heavy deposit of plaque and calculus; unrestored teeth; mobile teeth and heavily broken down teeth for extraction; missing teeth; dentures not being worn or broken dentures. Thus the severity of dementia; high carer burden; oral hygiene difficulties; use of medications that cause dry mouth; and previous caries experience are all risk factors that can lead to the deterioration of a previously healthy and sound dentition.

Early dental consultations are of paramount importance. Basic advice, ranging from the correct toothpaste and mouthwash to more elaborate oral health guidance, would be given.

The commonest medications used to treat dementia also have the potential to cause xerostomia (dry mouth) which will be a major factor in the accumulation of oral debris, gum disease, denture-wearing problems and dental caries.

A dental check-up can  sometimes be quite challenging for the dentist. An intra-oral assessment, which is usually very simple, and a clinical examination sometimes prove to be impossible to carry out.

Appropriate education and training for care workers and healthcare professionals should be ongoing, especially in residential homes for the elderly

Thus the dentist may rely on observed or reported behaviour of the patient to assess the dental problems. This information can be quite more effective than those based on clinical examination for individuals who are less able to be compliant. All this highlights that, in such cases, the dentist should form part of the multidisciplinary care team taking care of the dementia patient.

Changes in behaviour by the person reported by family members or the carers may be indicative of oral pain. Such behaviour may include refusal to eat (particularly hard or cold foods); constant pulling at the face; increased drooling; leaving previously worn dentures out of the mouth; increased restlessness; moaning or shouting; disturbed sleep; refusal to cooperate with normal daily activities such as grooming, washing and tooth brushing; and aggressive behaviour towards carers.

The intensity of any dental pain might be indicative of the severity of the dental problem. One should be able to interpret pain noises or vocalisations which may range from groaning, gasping or screaming, together with facial expressions like grimacing, frowning, tightening mouth and closing of the eyes. Other body reactions might be body movements like freezing, guarding, pushing or crouching.

So the dilemma dentists will face in these situations is whether to treat or not a sometimes vague clinical presentation: When does a dental condition require intervention? How will they realise if cognition is impaired to the point that pain perception is so altered that the patient neither perceives pain nor is able to describe it? How are they to predict when seemingly asymptomatic oral conditions become symptomatic in the absence of treatment?

Preventive measures are the first basic steps to take routinely every few months or weeks if necessary, depending on the case, to minimise dental disease.

Any dental intervention should take place in the early stages of the condition to manage outstanding dental treatment needs. The dental team should be trained to recognise − and be guided by the carers − that persons with dementia have good days and bad days. If possible, dental care is better postponed to a good day and to the individual’s best time of the day. Short attention spans mean the ability to cooperate is decreased. Dental appointments should be kept within the individual’s capacity to cope. If the visit is done by a regular dentist, the cooperation and understanding between all involved makes treatment manageable.

Training the dental team to care for persons with dementia will help them to understand that short-term memory loss means that communication can become difficult and tedious. The client is likely to ask the same questions repeatedly and, therefore, clear short instructions repeated in the same words are useful. Smiling and use of appropriate touch are useful, reassuring gestures.

The carer has a role in maintaining daily oral hygiene and in initiating dental treatment, whether it is a routine or emergency care and is thus part of the dental team.

A balance should be struck between maintaining independence and maintaining adequate oral health. So as manual dexterity decreases, electric toothbrushes or toothbrush handle adaptations may help to maintain independence. The carer needs instruction and support from the dental team to make sure any barriers encountered are resolved immediately.

Family members must also be trained in regular oral and denture hygiene procedures and not shift all the responsibilities on to the carers.

Development of teamworking is the way forward for successful dental treatment so that the person with dementia is free from any dental pain and a decent quality of life is maintained.

Appropriate education and training for care workers and healthcare professionals should be ongoing, especially in residential homes for the elderly. Access to information about oral healthcare and dental service provision should be easily provided.

Alexander Schembri is treasurer of the Maltese Association of Gerontology and Geriatrics.