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Oral health for living better with dementia in residential care settings is a whole person affair

Whole person care involves mental health, physical health and social care. It is not easy to see at once how oral health fits into this.

The need for good oral health is significant with older adults for a variety of reasons. The progression of dementia varies enormously, as does the ability to cope with dental treatment. Some people are comfortable with a visit to the dentist, while others find the whole experience very distressing. The dentist, together with the person with dementia and their family or carers, will discuss treatment needs and agree on the best treatment plan. A dentist can provide guidance and support on how to assist in cleaning another person’s teeth. The technique will vary depending on the individual concerned. Oral health in nursing homes has sometimes been described as “deplorable” with evidence that “a high proportion of elderly nursing home residents suffer from poor oral hygiene and oral health neglect”. Oral problems are partially, perhaps, a result of barriers to dental services and changed self-perception of oral health on the context of multi-morbidity.

There are two main types of dental disease – gum (periodontal) disease and tooth decay (dental caries, more commonly known as cavities). Gum disease can cause inflamed and bleeding gums, gum recession (where the gum tissue is reduced, causing the roots of the teeth to become exposed), loose teeth and bad breath. Both can cause discomfort or pain and can lead to the development of infection. Indeed both pain and infection can worsen the confusion associated with dementia.

Oral neglect, as well as poor oral health and oral hygiene, is highly prevalent among the institutionalised elderly. Residents with dementia, who are functionally dependent and cognitively impaired, appear to be worst affected. This is a challenge to the dental profession as the proportion of frail elderly with dementia and disabilities is projected to rise over the coming decade in most developed countries of the world.

Problems swallowing (dysphagia) and bad oral health have been found to be strongly associated with aspiration pneumonia in frail people. Consequently, adequate oral health care in care home residents with dysphagia may decrease the number of respiratory pathogens and diminish the risk of aspiration pneumonia.Furthermore, improvement of oral health care may improve the swallowing and cough reflex sensitivity. Risk factors of aspiration pneumonia, such as dysphagia, should be prevented in frail older people whenever possible. Aspiration pneumonia, an inflammatory condition of lung parenchyma usually initiated by the introduction of bacteria into the lung alveoli, is causing high hospitalisation rates, morbidity, and often death in frail older people. There are therefore clear repercussions of bad oral health and physical dis-ease.

It is argued that in the last three decades, the oral health of nursing home residents has worsened as a consequence of inadequate mouth care. The trend toward worsening oral health among nursing home residents is complicated by the rising numbers of persons entering nursing homes with some or all of their natural dentition; more than half of all nursing home residents are dentate. Residents, especially those with dementia, require meticulous daily mouth care because they often lack access to routine dental care. Older adults form plaque more quickly than their younger counterparts when mouth care is not routinely performed; this may be due to gingival recession, which exposes more tooth to the oral environment, and to reduced salivary flow.

The majority of nursing home residents arrive dentate. As their dementia progresses, the person may lose the ability to clean their teeth, or lose interest in doing so, and carers may need to take over this task. Older adults experience faster plaque production than younger adults because of the dual effects of gingival recession and reduced saliva production. The reasons for the poor oral health of nursing home residents may be multifactorial. Physical and cognitive impairment makes oral hygiene difficult, making residents increasingly dependent on other people and often resulting in poor oral cleanliness. Because reduced cognitive functioning frequently results in greater levels of dependency, including for oral care, carer are of crucial importance in maintaining oral health.

Poor oral hygiene causes periodontal disease which in turn creates tooth loss. The remaining teeth shift, causing loss of occlusal surfaces and subsequent chewing and swallowing problems. These problems place older adults at risk for malnutrition. Other systemic diseases associated with poor oral hygiene include aspiration pneumonia, diabetes, and coronary artery disease. The need for good oral hygiene is complicated by the dependence many nursing home residents have on others to provide basic care. Most require assistance in at least one activity of daily living while more than half are dependent on others for all activities of daily living, including mouth care. In addition, dental treatment provision to nursing home residents tends to be emergency-based, with little time spent on prevention, especially among vulnerable residents with cognitive and physical impairment. Oral health is therefore intimately linked to living better with dementia in residential care settings.

Additionally, the rate of edentulism is declining; the current generation of elderly has more teeth than previous generations and will live longer than their parents. Many older patients have no remaining teeth and are termed edentulous. These patients may or may not be wearing full or complete dentures and complete denture wearing may be rendered more difficult with the advent of dementia. Tooth loss from periodontal disease causes the remaining teeth to shift to the point where occlusal surfaces no longer articulate, interfering with chewing and swallowing functions and placing residents at risk for malnutrition. The reason for this is that successful (complete) denture wearing depends to a great extent of what is termed neuromuscular control. It is not uncommon, therefore, for carers of edentulous patients who are living well with dementia to request that new dentures be made for such patients. In reality, new dentures may not result in an optimal outcome, although the concept of template or copy dentures makes it easier for patients to adapt to new dentures.

The combination of increased dependency and increased retention of teeth will lead to a high-risk cohort with complex dental needs and more prone to dental diseases. Residential aged care facilities are residential facilities provided to frail elderly whose care needs are such that they no longer remain in their homes. Not only does the nature of the disease result in deterioration of oral health; anticholinergics and neuroepileptics used for its treatment result in salivary gland hypo-function that increases the risk for oral and pharyngeal diseases. One of the main side-effects of these drugs is a dry mouth. Saliva acts as a lubricant and dry mouth can cause problems with dentures, including discomfort and looseness.

Moreover, care-workers have reported several “barriers” in caring for elderly with cognitive impairment and behavioural difficulty, with oral hygiene among the most difficult care-giving task. This might reflect differences in culture between dental and nursing staff. It is possible that the dental professionals’ knowledge about the consequences of neglected oral care make them believe that oral care is a more important part of total care than do other health professionals. In addition, many nursing homes aim not to use force or restraint. The law says that before a legal decision about the use of force or restraint is made, trust-giving behaviour should be attempted.

Nevertheless, there is emerging evidence that there is a lack knowledge of the specific oral hygiene requirements of people living with dementia, or do not have the time needed for adequate oral care. Nursing home culture change aims to improve resident quality of life and staff well-being by aligning structures and processes of care with residents’ needs and preferences. It embraces a comprehensive philosophy so as to structure practices and policies such that they are consistent with individuals’ welfare. Within this whole person approach, discrete components of culture change practice are many, and include promoting the resident’s meaningful engagement The ultimate vision of a person-centred culture change is that individualised care will improve quality of life and outcomes. Outcomes of interest include those of both a psychosocial nature (e.g., boredom, helpless) and, increasingly, of a health-related nature (e.g., physical function, pain, pressure ulcers). What may be missing from the promotion of culture change is the incorporation of individualised, evidence-based protocols shown to improve daily care. And there is a strong social component to the effects of oral health malaise.

So, oral health in living better with dementia in the residential care setting is very much a whole person affair.

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