Oral Health in Dementia
Safe and appropriate dental treatment for the patient with dementia must be based on a comprehensive assessment of oral health, current medical status, and degree of cognitive impairment. Good communication must be established with the patient, the patient's spouse, family member, or caregiver, and the patient's medical care providers. Because these patients may be unable to provide accurate information, consultation with the patient's physician and communication with the patient's legal healthcare proxy are required.
Mrs. K, a 71-year-old woman with a 4-year history of rapidly progressing Alzheimer disease, presented for evaluation to the dental clinic accompanied by her husband. With an assistant mildly restraining her head, visual oral examination of Mrs. K's dentition was accomplished. Significant accumulations of dental plaque covered her teeth. In addition, multiple carious lesions were visible involving the coronal and root surfaces of her teeth. Prior to the onset of Alzheimer disease at age 67, Mrs. K had meticulous oral hygiene and was caries-free for more than 20 years.
Role of healthcare proxy. Early in the dementia process, the patient may have sufficient cognitive abilities to provide information and make informed decisions about his or her healthcare. As the condition advances and the patient loses the ability to answer questions or make proper risk/benefit decisions about care, consent for treatment and decision-making on the patient's medical and dental care would be the responsibility of the patient's legally assigned healthcare proxy (usually a family member or caregiver). It is essential that the dentist be aware of the proper individual legally responsible for consent and treatment decisions and that no care is started before this consent is appropriately obtained and placed in the dental record.
Medical care provider. Prior to initiating oral healthcare, a discussion with the patient's medical provider about the patient's current medical status and any proposed dental treatment of the patient is strongly recommended. The dentist should obtain details about the patient's cognitive abilities, comorbidities, current medications, prognosis, and rate of advancement of the patient's dementia. The dentist is advised to contact the patient's physician prior to any invasive and/or irreversible oral treatment, especially if sedation or general anesthesia will be used, and to determine if temporary cessation of any of the patient's medications (such as anticoagulants) is warranted.
Oral health assessment. The major steps in obtaining an accurate oral health assessment include:
Details of particular importance include the presence of drug-induced xerostomia, involuntary facial movements (such as tardive dyskinesia and bruxism), and change in caries rate or periodontal status. These factors have a direct effect on what dental procedures can and should be performed. For example, xerostomia may promote a higher caries rate and result in rapid breakdown of natural teeth, and failure of dental restorations and bruxism may result in the fracture of natural teeth.
Cognitive evaluation of a patient can be determined by tests such as the Mini Mental Status Examination (MMSE). Created by Dr. Marshall Folstein in the 1970s, it is a widely used method for assessing cognitive mental status. The dentist may learn the patient's MMSE score when discussing the patient with the physician, or the MMSE may be used by dental health professionals directly. If a recent MMSE assessment score is available, the dentist would be able to use that in planning care and not necessarily have to repeat the MMSE. If no recent cognitive assessment is available, the dentist should administer the MMSE.
The MMSE is a short and quick assessment of a patient's cognitive status and has been successfully used in the medical and dental environment to help determine the level of mental ability in patients with dementia.
Briefly, the MMSE assesses the following abilities:
The maximum MMSE score is 30 points, and a normal score is 25 or higher. Scores of 21-24 suggest mild cognitive impairment, scores of 10-20 suggest moderate impairment, and scores of 9 and under are associated with severe cognitive impairment. Scores can be interpreted differently when taking educational level into account (complete tool available online).
Assessment of Mrs. K. After talking to the primary physician, it was learned that Mrs. K's MMSE score was 7, suggesting severe impairment. On visual examination, several teeth throughout her mouth had large carious lesions. She became combative, however, whenever an attempt was made to manually examine her mouth. It was decided that management of Mrs. K would not be possible in the conscious state. After consultation with her husband, who was her healthcare proxy, and with her physician, it was decided to treat Mrs. K in the operating suite using general anesthesia. A follow-up visit was scheduled.
History and Assessment of Patients With Dementia
Safe and appropriate dental treatment for the patient with dementia must be based on a comprehensive assessment of oral health, current medical status, and degree of cognitive impairment. Good communication must be established with the patient, the patient's spouse, family member, or caregiver, and the patient's medical care providers. Because these patients may be unable to provide accurate information, consultation with the patient's physician and communication with the patient's legal healthcare proxy are required.
Case Presentation: Mrs. K
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| A woman with Alzheimer disease needs dental care. |
Mrs. K, a 71-year-old woman with a 4-year history of rapidly progressing Alzheimer disease, presented for evaluation to the dental clinic accompanied by her husband. With an assistant mildly restraining her head, visual oral examination of Mrs. K's dentition was accomplished. Significant accumulations of dental plaque covered her teeth. In addition, multiple carious lesions were visible involving the coronal and root surfaces of her teeth. Prior to the onset of Alzheimer disease at age 67, Mrs. K had meticulous oral hygiene and was caries-free for more than 20 years.
Role of healthcare proxy. Early in the dementia process, the patient may have sufficient cognitive abilities to provide information and make informed decisions about his or her healthcare. As the condition advances and the patient loses the ability to answer questions or make proper risk/benefit decisions about care, consent for treatment and decision-making on the patient's medical and dental care would be the responsibility of the patient's legally assigned healthcare proxy (usually a family member or caregiver). It is essential that the dentist be aware of the proper individual legally responsible for consent and treatment decisions and that no care is started before this consent is appropriately obtained and placed in the dental record.
Medical care provider. Prior to initiating oral healthcare, a discussion with the patient's medical provider about the patient's current medical status and any proposed dental treatment of the patient is strongly recommended. The dentist should obtain details about the patient's cognitive abilities, comorbidities, current medications, prognosis, and rate of advancement of the patient's dementia. The dentist is advised to contact the patient's physician prior to any invasive and/or irreversible oral treatment, especially if sedation or general anesthesia will be used, and to determine if temporary cessation of any of the patient's medications (such as anticoagulants) is warranted.
Oral health assessment. The major steps in obtaining an accurate oral health assessment include:
Inquiring about chief oral complaint;
Consent for examination and treatment (patient, healthcare proxy, etc);
Medical, pharmacologic and social history, including primary physician's name and contact information;
Comprehensive head and neck examination, including a cranial nerve examination;
Comprehensive soft and hard tissue intraoral examination;
X-ray examination;
Prosthetic appliance evaluation, if indicated; and
Other diagnostic tests, as indicated.
Details of particular importance include the presence of drug-induced xerostomia, involuntary facial movements (such as tardive dyskinesia and bruxism), and change in caries rate or periodontal status. These factors have a direct effect on what dental procedures can and should be performed. For example, xerostomia may promote a higher caries rate and result in rapid breakdown of natural teeth, and failure of dental restorations and bruxism may result in the fracture of natural teeth.
Cognitive Assessment
Cognitive evaluation of a patient can be determined by tests such as the Mini Mental Status Examination (MMSE). Created by Dr. Marshall Folstein in the 1970s, it is a widely used method for assessing cognitive mental status. The dentist may learn the patient's MMSE score when discussing the patient with the physician, or the MMSE may be used by dental health professionals directly. If a recent MMSE assessment score is available, the dentist would be able to use that in planning care and not necessarily have to repeat the MMSE. If no recent cognitive assessment is available, the dentist should administer the MMSE.
The MMSE is a short and quick assessment of a patient's cognitive status and has been successfully used in the medical and dental environment to help determine the level of mental ability in patients with dementia.
Briefly, the MMSE assesses the following abilities:
Orientation to place and time: What year is this? Season? Month? Week? Date?
Memory: Remember 3 words (eg, pen, ball, ring, and rename later in the test.)
Attention and calculation: Subtract 7 from 100 and continue, and spell "world" backwards.
Language, writing and drawing: Ability to write, copy, and remember named objects.
The maximum MMSE score is 30 points, and a normal score is 25 or higher. Scores of 21-24 suggest mild cognitive impairment, scores of 10-20 suggest moderate impairment, and scores of 9 and under are associated with severe cognitive impairment. Scores can be interpreted differently when taking educational level into account (complete tool available online).
Assessment of Mrs. K. After talking to the primary physician, it was learned that Mrs. K's MMSE score was 7, suggesting severe impairment. On visual examination, several teeth throughout her mouth had large carious lesions. She became combative, however, whenever an attempt was made to manually examine her mouth. It was decided that management of Mrs. K would not be possible in the conscious state. After consultation with her husband, who was her healthcare proxy, and with her physician, it was decided to treat Mrs. K in the operating suite using general anesthesia. A follow-up visit was scheduled.
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