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Toothache in those with dementia can be very distressing for the people themselves, for the carers trying to figure out what’s wrong with them, and for their families.
For the dentist, it’s work that requires sensitive people-handling skills as well as technical know-how.
“Most of this work can be done with good communication skills, good behavioural skills and a really good attitude to disability on the part of the dentiest,” says Dr Alison Dougall, consultant in special-care dentistry and a course tutor at Dublin’s Dental University Hospital.
It’s a changing field, she states.
“In the past, we expected people with disabilities and complex medical conditions to fit in with the system, but now new dentists are being trained to adapt their way of thinking and be open to trying different approaches. Singing or using music can help, for example, as well as choosing a time when the patient is most relaxed, say with their favourite pet on their lap. Approaching the person with a smiling demeanour is always important too.”
Each person looking after their teeth as they age is essential
Involved in setting up the course that now trains special-care dentists in Ireland, Dr Dougall likes the problem-solving aspect of her discipline.
“I like working preventively within the healthcare pathway and the skills and team work. It’s about working with carers and embracing diversity.”
Taking the person with dementia out of their home or nursing home environment to see a dentist is incredibly stressful for them and for their families, she states.
“This is why we don’t like to get into emergency situations.”
Each person looking after their teeth as they age is essential, she says.
“We are trying the stop the emergency situations by ‘future proofing’ people’s mouths. That means that early in the diagnosis of dementia, for example, that the person gets a full dental NCT. A dentist should be asked to do a thorough check up and if extractions or fillings are needed, they should be done before it becomes challenging or even impossible.
“The same should apply when anyone is admitted to a nursing home. After dental treatment, if they need it, it will be a case of regular check-ups and making sure that the teeth are cleaned every day – that’s very important.”
Uncleaned teeth and chest infections
People forget that uncleaned teeth and dentures in elderly patients can lead to infection, she says.
“Cleaning teeth and dentures needs to be seen as medically necessary in nursing and care homes.
“It’s not optional because poor gum health equals poor systemic health. Carers have to persist because pathogens that live in the plaque can cause chest infections and affect the heart as well.
“It’s important that everyone who has teeth or just wears dentures has an oral cancer check every year also.”
Patience may be necessary, she says.
“In nursing homes, even in relation to cleaning teeth, mornings may not be the best time for cleaning teeth, for example. You have to find the time when the person is most peaceful, which could be at another time of day. In residential homes, it can take two people to clean a person’s teeth and carers need to be trained to do this effectively.”
More rather than less visits to dentist needed as we age
She points out that while we all visit our doctors more often as we age, we visit our dentists less often.
“This is not a good idea because people’s teeth may be deteriorating for lots of reasons – ageing, because eyesight is failing, because manual dexterity is not as good due to arthritis…
“Medications may contribute to teeth getting worse, too, because many of the tablets that people take for blood pressure or depression or diabetes dry the mouth out, so saliva isn’t flowing and protecting the teeth. These are all additional risk factors.”
We all need to be encouraged to become more conscientious about looking after our teeth, she believes.
“Preventing problems is what’s important. Teeth are often forgotten. They aren’t seen as a problem until they go wrong, then they take over everything.
“Care visitors, nurses and doctors need to start to nudge and join the mouth up to the rest of the body. Reminders are needed that teeth are going to be rotting away unless they are cleaned or checked regularly. The medical profession, to a certain extent, hasn’t made the shift to realise that older people have got teeth. Local availability of specialist care is required as well as access to preventive care which can be delivered by a hygienist.”
Legislation needed to trigger culture change
Dr Dougall thinks that only legislation can bring about this culture change.
“Getting an oral care assessment must be mandatory in residential homes because, on admission, a patient may not have seen a dentist for 20 years. Carers need to be trained and educated, too, about the importance of oral health for those they care for – and for themselves. Often carers have so much on that they don’t give teeth priority until it’s too late.”
Lost dentures can be heartbreaking
Some older people have no teeth, she points out, and simply rely on dentures. Lost dentures can be very distressing and it is very difficult for frail, older people to get used to new ones.
“Older people are just as conscious of their appearance and dignity, remember. They want to smile and look well too. Losing dentures, then, is one of the most heart-breaking things and people with dementia often tend to lose things.
“Getting new ones made involves four dentist visits, four complex stages, moulds being made and so on. Going through this process and learning new skills like getting used to new dentures, therefore, can be very difficult. Patients may not get used to them at all so they may not be able to eat a healthy diet. While dentures can be made for patients in the home (domiciliary care) it is rarely ideal from a quality perspective.”
Dr Dougall’s top tips to avoid losing dentures
1. Name the person’s dentures. You can buy indelible pen kits from the chemist for marking them or a dental technician can put the name on them where it can’t be seen.
2. Have a spare set of dentures made when the person is well. Dentures can be copied, providing a ‘back-up’ in this situation.
3. Have a designated place to put dentures. “We hear of dentures being lost down the sides of sofas and even dogs running off with them, so looking after dentures is important. There should be a routine of putting them in a particular place/holder when they are out of the mouth.”
New speciality
Special-care dentistry is a relatively new specialty, the consultant says, to address the needs of complex patients. Ireland is leading the way with the training programme it now has.
“We’re one of the only places in the world that does a three-year training programme for dentists in this field. It started eight years ago, so we are in our third cycle of graduates now,” Dr Dougall adds.“However, training general dentists remains crucial to cope with the numbers of people with dementia and other medical conditions.”
Dr Alison Dougall won the Health Management Institute of Ireland Award 2015.
Anne O’Donnell is a dentist based in Mullingar who has serious concerns about the lack of service for residents of nursing homes.
“The situation is disastrous at present,” she says. “I’ve seen patients’ mouths in dreadful states.”
While those in nursing homes, under their medical card, are entitled to an annual examination, two fillings and, if in an institution, a cleaning as well, they must attend a dental surgery, she says.
“This is where the difficulty comes in. Very few attend for this treatment at HSE clinics as they are dependent on the nursing home to bring them to the surgery.
“For the nursing home, this means at least one carer leaving the nursing home to accompany the patient. This is a huge cost in terms of time and man power for the nursing home. Other services such as GP, physiotherapy, chiropody, and prescription services are all delivered to the nursing home. Dental services should also be delivered on site.”
Investment is needed in mobile equipment for dentists, private or public, she believes. In Anne’s experience, dental care is often not prioritised in nursing homes.
Older patients are slow to complain
“Sometimes carers or staff put off the task if they know the person doesn’t like it. It can sometimes get to a stage then where the person’s teeth are just not looked after.
“I have come across situations where patients had dentures in their mouths and no one knew until serious infection had set in. The patients hadn’t been checked when they were admitted. Also, many of these older patients are slow to complain and live with tooth ache or sore mouths rather than ask for treatment.
“Patients also need to be screened for oral cancer. I have seen patients experience horrific end-stage oral cancer because of late diagnosis.”
Anne became interested in this field when she was asked to attend some patients by a nursing home matron who told her that it was like “winning the lotto” to have an onsite visit.
“One suggestion I made to the HSE was to have new graduate dentists doing some of their vocational training in nursing homes. It would be such a help, even for a few months.
“The elderly in nursing homes need to be prioritised as per the Oral Health Care Strategy.
“When I asked for a meeting with the HSE to offer any help or ideas I could, based on my experience, I was told that the HSE was doing its own pilot projects and would be in touch when those are completed. I very much look forward to that contact.”
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