Free article: The urgent and growing problem of oral care of the elderly in dental practices

Joe Sullivan provides his opinion on dementia and the importance of oral care in the elderly.

Summary

  • Two thirds of those in care homes now suffer from dementia or memory loss.
  • The number of people in the UK with dementia is around 850,000.
  • Approximately 5% of the population is now edentulous.
  • An acceptance of the need for good oral care as part of a care plan is urgently required.
  • Home visits should be made a priority.

At least two thirds of those in homes for the elderly now suffer with dementia or memory loss. This is a problem no longer limited to homes for elderly mentally ill. The number of patients in health and social care has grown hugely but accounts for perhaps just a third of all dementia sufferers. The number of people in the UK with dementia is approximately 850,000 and is expected to exceed one million by 2025.

One feature of dementia is the loss of the ability to maintain oral hygiene. However, daily tooth cleaning is a very personal element of care and is therefore very often not included as part of a care plan by carers. But there appears to be another dimension to the problem. The inside of the mouth and its contents provoke disgust in many people. This is particularly the case when it comes to caring for the mouths of patients with dentures.

Cultural awareness

A cultural change in awareness of a growing problem of poor oral hygiene in the elderly and an acceptance of the need for good oral care as part of a care plan is urgently required.

A complex bridge supported by implants may seem to be the perfect option for comfort and aesthetics but thought should be given to how a failure can be managed if the patient develops alzheimer's or becomes seriously ill rendering them incapable of maintaining the necessary high level of oral hygiene.

The generation of patients that dental practices are beginning to see in care homes are presenting a new set of problems. There is a need for a joined up approach to planning for a growing problem. A dental treatment plan should be for all of life. Medical advice for anyone diagnosed with early dementia should include a recommendation for a dental plan which may prevent problems as the dementia progresses.

Oral health

In the past, elderly patients all had full dentures. The most recent survey of oral health shows that approximately 5% of the population is now edentulous. Advances in medical care have led to increasing longevity which is not always accompanied by good health.

Conscientious dentistry has enabled these patients to keep many of their teeth. The problem is the poor standard of oral health.

Poor oral hygiene is compounded by:

  • dry mouth
  • diabetes
  • poly-pharmacy
  • bad diet.

These are all features of ageing people of poor health who have declining mental and/or physical ability. They are all reasons why a patient should be extra vigilant in their oral care but dementia makes this impossible.

There are many projects around the country exploring ways to prevent and overcome the challenge. Caring for the oral health needs of those with dementia is one area of dentistry which should be of primary concern for the NHS but it is still an area which remains unresolved.

The greatest immediate need is in detecting urgent problems and relieving pain. It is not unusual during routine examination of a patient with dementia to find serious ulceration due to ill-fitting dentures or sharp broken teeth. The patient with dementia all too often dissociates from pain but is prevented from eating or talking by it.

The prototype new dental contracts are focused on only providing care once certain oral health milestones are achieved. When working with a patient with dementia it will never be possible to achieve levels of oral health which will satisfy a computer programme for treatment planning. The drive in the new NHS contract to improve oral health will exclude a group which desperately needs care.

Home visits

Amongst the reasons for unwillingness to pay for domiciliary care is the argument that all patients could be transported to the dentist just as they can to hospital for medical needs. There are many reasons why this will not work.

Why is it that a care home can have a doctor, psychiatrist, district nurse, physiotherapist or pharmacist, not to mention chiropodist and even a hairdresser visit but when it comes to dentistry for a seriously mentally or physically ill patient, but a visit by a dentist is considered inappropriate?

A few further reasons that a home visit may be preferable to the patient coming to the surgery include:

  1. Immobility – when the patient cannot move from a wheelchair, access to the mouth can be more difficult in the limited space of the surgery environment. Not many dentists will equip a surgery especially for wheelchairs. There are clever 'chairs' available that a wheelchair can be pushed into. This requires a separate surgery.
  2. It is very unfair to have a disorientated elderly Alzheimer's sufferer, who may be judged by others to have behavioural problems, sit in a waiting room in a busy practice.
  3. There are unfortunately the challenges of 'violent' behaviour.
  4. Incontinence is a common problem.
  5. Moving someone with dementia out of their usual home environment causes stress and can increase disorientation.

From a care home point of view, taking a service user with dementia to a dental practice also presents challenges. Funding has been squeezed to the extent that there cannot be a surplus of staff to provide the two members necessary to accompany those who may be suitable to travel.

Dental care is seen by the DoH as a cost which needs to be controlled and has therefore not been regarded as an essential service.

Treatment plan

Once a person has been diagnosed with alzheimer's or any other progressive dementia, a detailed dental treatment plan should be made. Everything possible must be done for all patients including a person who has been proud of their oral and general health, fitness and appearance, all their life, to help them preserve their dignity in their declining years.

A course of treatment to eliminate risk factors should be undertaken as soon as a diagnosis is made. The patient and their future carers should learn about great oral care. If dietary habits are changed early they will be lasting. But when the sad and difficult time comes and the patient is no longer making decisions for themselves, insistence on oral care by carers and the removal of refined sugars from the diet is essential, with root decay a condition of an ageing dentition.

It is predicted that one in five people living today will live past 100. Improving dental care will enable most people to retain their teeth but the challenges for the dentist caring for them are becoming complex.

Diagnosing a problem for a patient who cannot communicate is the first challenge. Being sure of consent is another. Access to the mouth and cooperation are further challenges. Then there are the problems of understanding the medical history and the implications of the medication which the patient is taking.

The philosophy of the new contract built on good oral health is sound. A patient should not have complex dentistry which will not be maintained if patients lose the ability to maintain the necessary level of hygiene.

Being able to relieve pain is the most rewarding aspect of a dentist's job. Preventing it is the real challenge.

About the author

Joe Sullivan photo

Joe Sullivan has provided domiciliary dental care to the elderly during all of his practising life. This service was provided as part of the normal day of a busy mixed private/NHS practice. He was also involved in ownership of a group of homes providing care across the spectrum of need, from able minded elderly needing care, to those needing nursing care and those with dementia. He now researches how best to train carers in supporting the needs of this group of patients. He was formerly editor of the GDP magazine.

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