The importance of oral health in

people with dementia

Katy Kerr MSc BDS DDPH RCS(Eng) PGCertCE

Regional Dental Adviser

HEE Thames Valley / Wessex

@NHS_HealthEdEng

What do older people want?

To have an aesthetic, functional

dentition, be free of pain and

have easy access to dental

services (Brocklehurst et al 2015)

Future oral care for older people

• Older population increasingly retaining their own teeth

• Life long exposure to dentistry

• Complex dental treatment, implants, crowns, bridges

with serious complications if fail

• Oral hygiene difficult to maintain

From 1998 to 2008

Adult Dental Health Survey – % Older Patients with

No Natural Teeth

1998 2008

65-74 yrs. 36% 65-74 yrs. 15%

74+ yrs. 58% 74+ yrs. 39%

First survey of adult dental health in England and Wales in 1968

and continued at 10 yearly intervals with the latest in 2008.

Trends in tooth loss

Adult Dental Health

Survey:

Total tooth loss in the

United Kingdom in 1998

and predictions for the

future

J G Steele, E Treasure, N B Pitts, J Morris & G Bradnock British Dental Journal 189, 598 - 603

(2000)

Edentulism or very few (one to nine) teeth may

be predictor of dementia late in life

Okamoto N, et al (2010) Relationship of tooth loss to mild memory

impairment and cognitive impairment: findings from the fujiwara-kyo

study. Behavioral and Brain Functions 6:77.

Poor oral health in dementia

• People with dementia are more likely to be unable to

perform oral hygiene

• Tend to have worse oral health, greater treatment need, yet

access care less frequently than general population

• Significant impact on general health and wellbeing, impacts

upon quality of life, diet and nutrition, and life-expectancy in

the longer term

– The build up of bacteria in the mouth is implicated in

aspiration pneumonia

– Both pain and infection can decrease cognitive function

Dental disease

•Gum (periodontal) disease

•Tooth wear (erosion/abrasion)

•Tooth decay (caries)

• 900 different predominant bacterial species, individual

variation and with differences across oral sites

• Oral disease changes the microflora composition and

increases number of anaerobic bacteria

• Dental treatment, brushing, flossing, chewing, in a patient

with periodontitis will release a bacteraemia

• Poor oral health particularly periodontal diseases produce a

mild but persistent systemic inflammatory response

associated with elevated levels of systemic inflammatory

markers such as interleukin (IL)-1 and IL-6

Ingar Olsen and Sim K. Singhrao: Journal of Oral Microbiology 2015, 7: 29143 -

http://dx.doi.org/10.3402/jom.v7.29143

Oral bacteria

6000 people oral health checked over 6 years in a Atherosclerosis Risk in Community study in America

Cognitive decline linked with:

• Increased tooth loss

• Decline in the frequency of tooth brushing

• Increased plaque scores

Even before cognitive impairment was diagnosed – oral health declined

Change in oral health could be an early sign of

memory loss

Naorungroj et al Journal of Dental Research Sept 2013 Vol 92 no.9 795-801

The dental team are key and important partners

in the care of older people

The practice staff have a role in supporting patients

with dementia:-

• Prevention of dental disease

• Early detection/diagnosis

• Effective oral health treatment

• Making dental practices safe environments

for all patients

Prevention

• Best estimates show that 10% of dementia cases may be

avoided by improvements in public health

• Brief interventions including Smoking Cessation services,

Physical Activity and Weight Management Programmes

• Recognise early signs of other diseases and refer as

appropriate (such as hypertension and diabetes)

• Ensure dental practices are environments for education

and social opportunity

What’s the problem?

Oral hygiene 48%

Safe staffing for older people’s wards 2012

Nurses reporting that activity

was left undone, or was done

inadequately on their last shift

due to lack of time

Approximately 85% of residents

in care homes require support

from carers to undertake mouth

care

• 40% of over 75s have tooth

decay rising to over 50% for

those who live in care homes

• Oral health not part of

general care plans

• Lack of staff training in oral

care

• Reluctance of staff to meet

oral health needs

Care-resistive behaviour

• Refusal, not opening mouth

• Needing prompting

• Not understanding caregivers' instructions

• Not able to rinse or spit

• Biting toothbrush or caregiver

• Physical/verbal aggression

• Not permitting removal/insertion of dentures

Chalmers et al (2008) Spec Care Dentistry

NICE guidance and CQC

NICE guidance (June 2016)

says that all adults in care

homes (older people and

learning disability) should

receive good oral care by

skilled staff.

Recommendations

Care homes need:

• Policies on oral health and providing residents with

support to access dental services

• Oral health assessment and mouth care plans

• Daily mouth care and keeping records

• To update care staff knowledge and skills

NICE Guidance

Practical tips for carers

• Not necessarily same regime twice a day-use best window

• Break mouth care task into small steps, stand behind

• Distraction- music, talking, stroking arm, another object to

hold

• Bridging – person holds same implement as carer

• Hand-over-hand – carer guides person’s hands

• Cueing – polite, one-step commands

• Visual prompts, gestures and mime

• Mirror – person watches mouthcare in mirror

• Rescuing – replacement of one carer with another when care

resistant behaviours escalating

• Rubbing – pulling at a face

• Facial expressions – clenching teeth

• Body language - huddled, rocking

• Change in appetite

• Being more restless, moaning or shouting

• Disturbed sleep

• Leaving out denture

Dependent on baseline behaviour

Need to develop dental pain assessment tool

Signs of dental pain in

late stages of dementia

Oral health training

resources

Caring for smiles

•www.knowledge.scot.nhs.uk

British society of Gerodontology www.gerodontology.com

‘Learning@NHSWales

www.1000livesplus.wales.nhs.uk/mouthcare

An e-learning package developed by HEE Thames Valley and

Wessex to support the training of all healthcare professionals involved in

mouth care

Three interactive levels:

• Introduction to mouth care

• Mouth care for Adults

• Mouth care for people with

additional needs

Free access to E-learning modules on E-Learning for

Health

Improving mouth care

(Developed in consultation with staff involved in the pre-registration nurse training and piloted by students

in Oxford Brookes, Southampton General and the John Radcliffe)

Interactive

Video links

Further reading and

practical exercises

PDFs of paperwork

Scenarios

Content

• Evidenced based mouth care- for natural teeth and

dentures

• Checking the mouth

• Assessment, care plans and documenting care

• Products

• Addressing common problems

• Strategies when oral care is difficult

Dementia care threaded through all the

modules

C • Check

H • Help

I • Inform

N • Note

We need to fund treatment within primary

dental care to make the person dentally fit and

put in place long term preventative plans to

maintain the individual’s oral health

Dental practitioners

• Provide residents in care homes with routine or

specialist preventive care and treatment as necessary, in

line with local arrangements

• Ensure dentures made for individual residents are

appropriately marked by the lab during manufacture.

Dementia awareness

Impact of the condition on the person and their

carers/ family

Law/ethics including mental capacity/

valid consent

Assessment and treatment of

dementia

Communication skills

Care pathways and integrated working

Person centred dental care

-dementia friendly environments

Safeguarding adults

Prevention, treatment planning and palliative dental

care

Training needs

The Appointment

Film available (free)

on YouTube

or from HEETV Dental School website

This video is based on an established collection of dementia awareness DVDs called “Barbara’s Story” originally

produced by Guys & St Thomas’s NHS Foundation Trust and White Boat TV.

Designed to be watched together as a team using

the accompanying resource pack for reflective

learning and working together to develop a

practice action plan alongside an audit tool

Developed to raise awareness regarding the issues that affect

provision of dental services for an individual with dementia

To support patients with dementia to live well

What are the biggest challenges?

Time orientation

for appointments?

Remembering

appointments?

Clarity of patient

leaflets?

Anxiety during

appointments?

Navigation to

the surgery?

Self-care?

Lost dentures? Consent?

other?

• Access to appropriate dental care is currently problematic

especially domiciliary care and patient transport

• Complexity of treating people with dementia is not

currently reflected in remuneration

• The existing NHS primary dental care contract does not

facilitate continuity of care or long term care planning

• The special care dentistry services have insufficient

capacity and often receive referrals at a later stage when

treatment options may be limited

Dentistry for older people

BDA February 2015

Dec 2006

www.gerodontology.com

Guidelines

Environmental assessment

tool Kings Fund

•Noise reduction

•Even lighting

•Matt, even coloured flooring

•Clear sight lines

•Discrete security measures

•Artworks/photos of seasons or local scenes

•Clear signage

•Handrails

•Appropriate seating in waiting area

•Easy read and large font information

•Accessible parking and toilets

• Prevention, prevention, prevention

• High quality and easily maintained treatment planning

• Shortened dental arch

• Partial dentures that can be removed easily/ adhesive

bridges

• Copy dentures

• Extract teeth of poor prognosis

Dental care for people

living with dementia

Delivering Better Oral Health

How does this relate

to people with

dementia?

• Prevention of caries in

adults

• Prevention of

Periodontal disease

Prevention of caries in adults

• Brush at least twice daily, with a small headed toothbrush

taking about 2 minutes

• Brush last thing at night and at least on one other

occasion

• Use pea sized amount of fluoridated toothpaste with at

least 1350ppm fluoride

• Spit out after brushing and do not rinse, to maintain

fluoride concentration

• The frequency and amount of sugary food and drinks

should be reduced

Those giving concern to their dentist- e.g. with obvious current active caries, dry

mouth, other predisposing factors: Dementia

Professional Intervention

• Use a fluoride mouthrinse daily (0.05% NaF) at a different

time to brushing

• Apply fluoride varnish to teeth at least twice yearly (2.2% NaF)

• For those with active coronal or root caries prescribe daily

fluoride rinse

• For those with obvious active coronal or root caries prescribe

2,800 or 5000 ppm fluoride toothpaste

• Investigate diet and assist to adopt good dietary practice in

line with the Eatwell Guide

Prescribing high fluoride

toothpaste

Fluoride varnish

Few studies specifically examine

the use of Fluoride on older people

DBOH-Minimum twice yearly application

Indication-benefit to vulnerable older people

Age and age related disease

• Multi-morbidity

• Care dependency

Diet and Dementia

“Many people with dementia experience sudden changes in appetite

preferences and an increase in unhealthy cravings. As the disease

progresses, taste buds diminish, insulin in the brain can drop and some

people experience intense cravings for high-calorie foods.”

“Food tastes may change, so try stronger flavours or sweet

foods.”

“For a person with Alzheimer's or dementia, poor nutrition may

increase behavioural symptoms and cause weight loss. ... But

note that in the later-stages of Alzheimer's, if loss of appetite is a

problem, adding sugar to foods may encourage eating”

“Food is one of the last things people can enjoy when they’re sick.”

Frequency of acid attacks

through the day

What is realistic?

Dentists to provide

information and

encourage tooth safe

options

• Leaflet

• Personalised written advice

• Carer training

Regular review

• Fluoride

Whilst considering

general nutritional issues

• Medical conditions

• Dietician

• Carers and family

pressures around feeding

• Dehydration

Remember to prescribe

sugar-free medicines

Access to dental care

Appropriate funding will facilitate:

• Improved access to services including domiciliary, client

appropriate information and effective primary and

secondary prevention

• Continuing care for an individual with dementia for as long

as possible within general dental practice, thus delaying

referral to more specialised (and more expensive) care.

• Less treatment needs in later stages and therefore patients

will experience fewer complications due to poor oral health.

Current dental commissioning does not compensate

for the increased difficulty and extra time spent

caring for people with dementia and the wider

impact on the members of the dental team and the

practice as a whole

• People with Dementia need to eat and drink and be pain

free

• Most people with dementia are living in their own home

• Once a person with dementia is admitted to hospital they

stay there longer and are less likely to get home again

• Avoidable hospital admissions cost money - everyone has

a part to play in reducing these

We need to shift the focus onto

providing treatment in the early

stages within primary dental care

Information at diagnosis

regarding oral health

• Collate existing training resources for the dental team and

host them on one site

• Support the development of a cost effective dental workforce

to deliver preventive oral care and access to appropriate

dental services as part of a dementia care pathway

• Develop oral health and dementia training resources for

healthcare professionals involved in dementia care, on the

basics of mouth care, and the links between oral health, and

general health and wellbeing.

National Dementia Friendly

Dentistry Group

• Pragmatic dental treatment including planning for failure of

restorations in old age

• Support early diagnosis and links to memory clinics /GPs

• ‘Life course approach’ and care pathways to identify older

people who are becoming dependent and at risk

• Training and education for people living with dementia and

their carers about mouth care

• Oral health promotion and prevention programmes

• Training the dental profession and skill mix with DCPs

• Referral process to appropriate local specialist dental care

and joint long term care planning with dementia teams

Going forward

Further information

• The NICE guidance: Oral health for adults in care homes

is available from:

www.nice.org.uk/guidance/ng48

• To access the modules visit E- Learning for Health. It is

a free resource and is available at:

http://www.e-lfh.org.uk/programmes/improving-mouth-care

• National HEE Dementia Guide for Carers

https://hee.nhs.uk/our-work/person-centred-

care/dementia/dementia-guide-carers-care-providers

• The Appointment film

https://www.youtube.com/watch?v=EnPUq00UA8c

for listening and I look forward to working together to

improve the oral health of people living with dementia

@NHS_HealthEdEng

Katy Kerr Mobile 07825901682

Email Katy.Kerr@HEE.nhs.uk