Emma Clayton explores the impact that health conditions such as Alzheimer’s, dementia and arthritis can have on patients and the dental team’s ability to deliver oral healthcare.
In the UK, we have a growing elderly population; a trend experienced throughout the developed world. The proportion of the world’s population over the age of 60 is predicted to double between 2015 and 2020, by which time the number of over 60s will outnumber children under five, according to the World Health Organization, 2018.
This aging population will present additional challenges for the dental team, not only in terms of service provision (in-practice versus domiciliary) but also with managing the range of potentially complex needs older patients may present with.
For instance, there are currently an estimated 850,000 people living with dementia in the UK, with the Alzheimer’s Society predicting that this figure will exceed one million by 2025.
With advancing dentistry sees more complex treatment needs – such as crowns/bridges/implants and veneers – in the elderly. As such, the skills of the dental team need to develop to meet these changing (and potentially more complex) requirements.
Links between poor oral health and systemic/general health
We can all appreciate that a clean mouth gives a sense of wellbeing and can boost our confidence and self-esteem. So why should this be any different for our elderly patients?
Poor oral health can result in infections and pain, which can sometimes lead to premature tooth loss. This can result in difficulty eating, which can have a negative impact on nutritional intake, affecting the ability to consume the nutrition a body needs to stay healthy.
According to the British Association for Parenteral and Enteral Nutrition (BAPEN), 1.3 million over 65-year-olds are affected with malnutrition, and with 93% living in the community, the dental team may have to manage the impact.
Evidence increasingly links poor oral health to a number of systemic health conditions, such as diabetes and heart disease, but are you aware of the links to aspiration pneumonia and dementia?
Aspiration pneumonia can be life threatening in the elderly. It is a condition whereby food debris, saliva and plaque can get inhaled into the lungs rather than being swallowed, causing an infection.
To reduce the risk to patients, it’s important for dental staff to educate carers on this current hot topic.
Problems faced by carers
Working for Knowledge Oral Healthcare (KOHC) visiting care homes and care settings, I regularly train staff on how to look after their residents’ oral healthcare needs to the best of their ability.
There are many barriers facing staff, but the most common are a lack of cooperation from patients due to health-related illness, such as dementia, and carers finding it unpleasant – especially with handling dentures.
There is, unfortunately, a lack of education for care staff and more needs to be done to try and help this vulnerable group of patients.
Most of us regularly advise our patients to brush their teeth for two minutes twice daily. However, brushing in the morning and evening may not be so easy for an elderly person – they may be tired first thing in the morning or last thing at night. To combat this, suggest a time of day more suited to them.
There are also a few ‘coping mechanisms’ that have been shown to be very successful to help with toothbrushing, especially for those with dementia:
- ‘Chaining’ uses a ‘follow my leader’ approach, whereby you sit in front of the individual, you both have a toothbrush and the patient copies what you do
- ‘Bridging’ is where you gently guide the patient’s hand into the areas they are missing
- ‘Distraction’ can be used to take their mind off what you are doing in their mouth. You may consider giving the patient something to read while you are brushing their teeth, for example.
Rheumatoid arthritis affects in excess of 400,000 adults in the UK, with 20,000 new cases each year (Wiles et al, 1999).
The condition can affect fine grasp when manual dexterity is compromised. Try suggesting a bicycle handle to put on the end of the toothbrush or something simple, such as a tennis ball or an elastic band, all of which provide a bigger handle for the patient to grip.
Personal experience has shown the tennis ball to be extremely useful and many patients have reported how much of a difference this has made.
Although tooth sensitivity can become less of a problem as we age, a few carers have picked up on patients complaining of the condition, due to gingival recession or tooth wear. Recommending products, such as toothpastes designed for sensitivity with an electric toothbrush with a pressure sensor, may help.
Dry mouth amongst patients is a huge problem, both in the care home and community settings. It is commonly associated with individuals being on a number of medications, with more than 500 medications listing dry mouth as a potential side effect.
Incidence and severity can increase when multiple medications are taken. And when you consider one in 10 75-year-olds are on 10 or more medications, it is little surprise we see an increase in dry mouth!
Of course, radiotherapy or chemotherapy treatment, diabetes, or autoimmune conditions (such as Sjogren’s) and mouth breathing may also contribute to dry mouth.
As there is no buffering action, due to the lack of saliva, dry mouth can cause pain and soreness, difficulty eating and plaque and food collecting in the mouth. Advice we can give to these patients includes:
- Drinking sips of water or carrying a travel bottle filled with water to have sprays to lubricate the oral cavity
- Avoiding alcohol mouthwash
- Chewing sugar-free gum
- Using toothpastes with no sodium lauryl sulphate in (SLS), such as Oralieve ultra mild toothpaste
- Using ‘saliva replacement’ products, such as Oralieve moisturising mouth gel or spray.
A number of elderly patients require assistance with toothbrushing, whether that be from carers or family members. As a dental professional, we wouldn’t think twice about this, yet it can be daunting for others. People may feel they are invading personal space, find it unpleasant or may find cooperation very difficult.
Daily care for the elderly should include the following:
- Brush twice daily – ideally morning and evening – with a fluoride toothpaste (avoid SLS if a dry mouth presents). However, adapt this to each individual
- It may be that you have to try and adapt the current toothbrush to provide better grip/larger handle. A mouth prop can be used if assisting
- Use interdental aids where possible (this may not always be the case, for example in end of life care/dementia patients)
- Assist if needed. However, try to help the individual retain some level of independence where possible. Try some of the coping mechanisms outlined above
- Remove dentures each evening and make sure they are cleaned daily
- Check for any oral conditions such as ulcers, dry mouth, candidosis and so on
- Provide appropriate advice for those suffering with a dry mouth.
This can be a very sensitive topic to talk to patients and carers about, however it’s so important for us as dental professionals to make sure the patient is kept comfortable throughout this time.
There are some products commonly used on patients in the past that are now not recommended, including:
- Petroleum jelly. This should not be used as there is a risk of it being inhaled if too much is used
- Glycerine swabs. These are acidic and may exacerbate an already dry mouth
- Pink mouth sponge swabs. These are now not advised due to previous reports of the heads becoming detached and being unsafe for use.
The following products should be used in replacement of these products:
- Damp, non-fraying gauze can be used to gently sweep along the buccal mucosa and inside the cheeks to remove any debris or soft plaque. A soft toothbrush with an SLS free toothpaste can also be used
- Moutheze is becoming more popular instead of pink mouth sponges, as the heads cannot be detached. The cone-shaped soft filaments cleanse the oral mucosa, collecting debris and plaque.
With palliative care, it is important to make sure the patient’s bed is raised and their head is turned to one side, allowing food and debris to exit the mouth onto a towel to avoid aspiration.
Wiles N, Symmons DP, Harrison B, Barrett E, Barrett JH, Scott DG, Silman AJ (1999) Estimating the incidence of rheumatoid arthritis – Trying to hit a moving target? Arthritis Rheum 42(7): 1339-46