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Part I of this article covered the epidemiology and classification of dementia, and proposed mechanisms of interaction between periodontal disease and dementia. It was established that optimizing oral health through nonsurgical and surgical means could be a viable intervention to reduce the direct and indirect influences of oral bacteria and their by-products on the brain and their potential influence on cognitive decline.
Part II will address oral hygiene in patients with dementia, including delivery of oral home care by primary caregivers and adjunctive therapies to improve oral health in patients with dementia. Also covered is interdisciplinary care for individuals in residential nursing facilities.
Delivery of preventive and minimally invasive care for periodontitis and caries within a nursing home environment is challenging, but simple interventions and coordination between interdisciplinary healthcare providers can improve outcomes for patients.
Oral Hygiene in Patients With Dementia
Oral bacterial biofilms are living entities that can transform over time from a commensal group of organisms to a pathologic one if left undisturbed in susceptible individuals.1,2,3 Co-aggregation of periodontal pathogens allows innocuous bacteria to transform in the presence of more virulent pathogens.3 This overall increase in virulence of the bacterial biofilm allows a shift in the balance in the local and systemic environments from homeostasis to dysbiosis, which can then impair the host immune surveillance and cause dysfunction in the inflammatory repair mechanisms.3A recent review of the literature concludes that the oral health and hygiene of elderly individuals with dementia are inadequate and should be improved through oral health education of formal and informal caregivers.4,5 Given the importance to oral and overall health of maintaining optimal oral hygiene, it is critical for individuals with dementia to have effective oral hygiene measures performed by them or for them by caregivers.
Delivery of Oral Home Care by Primary Caregivers
Common oral health problems in older individuals include caries, periodontal disease, xerostomia, candidiasis, and mucosal lesions.6,7 All these conditions show an increased prevalence associated with age, which is likely due to age-related aggregation of risk factors, polypharmacy, and decline in dexterity leading to decreased efficiency in plaque removal.8-12 These oral conditions are also more prevalent in individuals with cognitive impairment or dementia.13,14 Older patients and those with motor-neuron diseases (eg, Parkinson's disease, Lewy body dementia) are also more likely to experience dysphagia and difficulty swallowing, which can make performing dental procedures on these patients more complex.15,16
Individuals with dementia who reside in nursing homes often have poor oral hygiene-oral hygiene practices are likely to be omitted or provided with chemical anti-plaque agents rather than toothbrushes.15,16 A failure to fully interrupt dental biofilm transformation to dysbiosis on a regular basis and sole reliance on chemical detoxification of plaque bacteria can be significantly less effective in preventing gingival inflammation and caries than mechanical plaque removal or combined mechanical and chemical methods.17-19 Because more than half of individuals with dementia rely on caregivers for many activities of daily living, including oral hygiene delivery, it is imperative that those caregivers have the knowledge and skills to effectively deliver oral preventive care.20
One obstacle often encountered by primary caregivers is care-resistant behavior (CRB) to oral hygiene delivery in patients with dementia.21 CRBs are defined as behaviors in which persons with dementia withstand or oppose the helping efforts of a caregiver and may be recognized as uncooperative/disruptive behavior or agitation.22-27 About 80% of certified nursing assistants (CNAs) have reported CRBs in response to the delivery of oral hygiene28; these behaviors have been shown to be reduced by increasing caregivers' awareness of best practices for oral hygiene,29-31 recognition of CRBs,21,32 and strategies to reduce threat perception in patients with dementia.29,33,34,35 Some especially effective strategies for threat reduction during delivery of oral hygiene measures include smiling, bridging-the use of a prop for the individual receiving care that triggers the activity for them (eg, having the elderly patient hold a toothbrush while the caregiver is delivering oral hygiene), and the use of polite, one-step commands.33,34 Inclusion of these simple steps in the oral hygiene routine of caregivers can increase cooperation for elderly patients with dementia significantly and improve oral hygiene quality and quantity.33,34
Adjunctive Therapies to Improve Oral Health in Patients With Dementia
Caries incidence increases in older adults, and root caries are a particular problem due to gingival recession, xerostomia, and poor plaque removal.14,36 These problems are particularly pronounced in patients with dementia who are unable to care for their teeth themselves, may be taking multiple medications that cause xerostomia, and may not be able to receive treatment for caries in an outpatient dental office.36,37 Silver diamine fluoride (SDF) is an alkaline topical solution containing fluoride and silver that has been approved by the Food and Drug Administration (FDA) for both caries arrest and root desensitization.38,39 SDF is effective in caries arrest through remineralization and inhibition of collagenases and cysteine cathepsins.40 Yearly SDF application on exposed radicular surfaces has been shown to be effective in reducing caries progression when compared with fluoride varnish and placebo, with rare complaints about the dark staining that is seen with SDF.41 Given the low cost, the infrequency of application, the relative noninvasiveness of treatment, and the simplicity of the therapy, SDF can reasonably be considered as a preventive measure for oral health promotion in older adults with dementia.
Interdisciplinary Care for Individuals in Residential Nursing Facilities
A multidisciplinary approach should be employed for effective oral care in patients with dementia. Dentists, dental hygienists, dental assistants, physicians, nurses, nursing assistants, and familial and other caregivers each have a unique role in providing oral healthcare to these patients. Communication among these individuals, as well as better definition and coordination of roles within the team caring for patients with dementia, can increase the likelihood that oral inflammation will be identified early and effectively managed in this vulnerable patient population.
Dental healthcare providers play a central role in creating a customized, long-term dental care plan for a patient newly diagnosed with dementia.42 Dental professionals should attempt to make a plan that includes patient-specific information and involve the patient with dementia and the family during the early stages of dementia.41 Such a plan may allow increased buy-in and autonomy in treatment decisions from the patient, who may then be more open to treatment and more engaged in making decisions. The plan should concentrate on eliminating pain, managing infection, and preventing new disease and should include establishing a functional dentition that can be maintained without risk of development of caries and significant periodontal inflammation.42
Education of nurses, nursing assistants, and caretakers is critical to ensure the success of proper oral care in patients with dementia.43 Dental prostheses are growing increasingly diverse, including natural teeth, fixed bridges, dental implants, and removable prostheses.43,44 Natural teeth require brushing and interdental cleaning,30 whereas dentures must be removed to be cleaned.29 Dental implants also require thorough preventive care to prevent inflammation and bone loss.29 Many nurses, CNAs, and other caretakers lack training in the complex care required to maintain different dental prostheses, and assessment of oral health status by individuals without specific training can be limited.43 In addition, CRBs exhibited by patients with dementia are a major obstacle to providing effective oral care.33 Offering strategies to improve oral disease recognition, delivery of effective therapeutic interventions, and plans to maintain oral health for patients with dementia are essential components to reduce the oral and systemic risk conferred by poor oral health.45 Those primary caregivers are generally the individuals who delivery day-to-day oral care; therefore, education and communication to improve their ability to care for patients with dementia is critical.33 Strategies offered may include Managing Oral Hygiene Using Threat Reduction (MOUTh) interventions.33MOUTh intervention is a nonpharmacologic, relationship-based intervention.33 Some tactics include forming a connection by approaching the patient at or below eye level, using a friendly and calm attitude, and using brief, one-step commands.32,33 A summary of strategies to address CRBs during mouth care is provided in Table 2. Care providers may have a better chance of completing mouth-care activities if they are aware of different approaches that reduce CRBs in patients with dementia.33
Because of the progressive nature of dementia, verbal communication between the patient and the healthcare provider or caretaker may decrease as the disease progresses.42 Consequently, verbal communication may no longer be the best way to recognize health problems, such as tooth pain. Healthcare professionals and caretakers should be aware of nonverbal cues of dental discomfort.43 These signs include avoiding meals and being disinterested in eating; chewing of the lip, tongue, or hands; pulling at the face; not wearing dentures; and aggression (particularly during activities of daily living, including oral hygiene).43
Healthcare professionals and caretakers should also consider their patient's progression and stage of dementia. The different stages of dementia can affect how a patient will cope with dental treatments and interventions.43 Healthcare professionals and caretakers must be aware that strategies that are effective in one patient may not be effective for others.43 Furthermore, a strategy that may be effective for a patient one day may not work the next week for that same patient.43 Healthcare professionals and caretakers should recognize that treatment plans may need to change over time as the patient's disease state changes.43 Some examples of effective and ineffective methods to deliver routine oral hygiene to patients are outlined in Table 3, but these may not work for all patients.
Oral hygiene and other oral health interventions to reduce caries rates and minimize oral inflammation must be seen as an integral part of overall wellness and healthcare for a patient with dementia. An interdisciplinary approach allows the benefits of effective oral health to be achieved through examination to identify ongoing oral disease and effective regular biofilm control after oral health has been established. Benefits of an increased focus on oral health may include decreased tooth loss, improved oral cancer detection, and decreased oral pain and infections. With improved oral health, patients with dementia may also experience decreased agitation associated with discomfort and improvements in nutrition, appearance, and overall health.
Finally, in patients with other risk factors for dementia or family history of dementia, education regarding the emerging evidence linking oral inflammation and the ultimate development and progression of dementia and discussion of strategies to establish and maintain oral health throughout life and particularly as patients age may be critical to reducing the incidence and societal burdens of dementia. Regular professional dental care and optimal oral home care as a health-promoting behavior should be considered as one part of risk-reduction strategies for at-risk individuals.
Summary
Both the inflammation and oral bacteria and their by-products associated with periodontitis have been implicated in the development and disease progression of dementia and Alzheimer's disease. Because these diseases may interact, it is critically important for older adults to proactively maintain their oral health. Oral care delivery for patients with dementia can be difficult because of lack of education about oral healthcare and inability to address CRBs in patients with dementia. Older individuals with dementia also experience higher rates of caries, xerostomia, and multimorbidity associated with their dementia symptoms or pharmacotherapies. Delivery of preventive and minimally invasive care for periodontitis and caries within a nursing home environment is challenging, but simple interventions and coordination between interdisciplinary healthcare providers can improve outcomes for patients.
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