Clinical Scenario

A 68‐year‐old male is referred by his neurologist for dental assessment as requested by the patient’s wife. She has noticed that her husband has bad breath, gets food trapped between his back molars and finds it difficult to clean his teeth. The patient has not complained of any dental pain or gum swelling. He does not understand why he needs a dental visit and he believes his teeth are healthy.

Structured Learning

1. Why does this patient’s perception of his oral health differ from reality?
   • Alzheimer disease results in a progressive decline in cognition
   • The patient is less able to recognise the signs of deteriorating oral health, such as bad breath
   • Deterioration of memory and executive functioning may result in poor recall of any signs or symptoms associated with dental disease
2. The patient’s wife reports that he has always had very good oral health in the past. What factors could have contributed to the decline?
   • Dementia: reduced ability to self‐care, tendency for an increase in cariogenic diet, irregular visits to the dentist, xerostomia secondary to medication
   • Stroke: reduced mobility may have an impact on ability to self‐care

   

   

3. Dietary analysis reveals that the patient increasingly consumes large quantities of high‐sugar foods. Why is this?
   • People with dementia often experience sudden changes in appetite preferences and an increase in unhealthy cravings
   • As the disease progresses, taste buds diminish, insulin in the brain can drop and some people experience intense cravings for high‐calorie foods
   • This leads to an intake of food with stronger flavours and increased sweetness
   • As appetite declines, adding sugar to foods may encourage eating
4. The patient has also noticed that her husband’s teeth are becoming more worn down and that #11 has recently chipped. What factors may be contributing to the tooth wear?
   • Attrition: awake/diurnal bruxism secondary to Alzheimer disease (present in ~4% of patients); nocturnal bruxism (sleep‐related disorder) may also be present
   • Erosion: increasingly acidic diet
     

     

   • Abrasion: due to repetitive toothbrushing action
   • Trauma: due to falls which may have caused #11 edge to fracture
5. What are the risks of leaving untreated dental disease in this patient?
   • Progression of dental disease can cause significant pain or discomfort
   • This can worsen confusion associated with dementia and translate to aggression or agitation
   • Poor oral health can also contribute to perceived stress and has a negative impact on quality of life, in particular self‐esteem, dignity, social integration and nutrition
   • Patient management in the dental setting will be more complicated as the disease progresses
   • There is also a potential relationship between poor oral health and cognitive decline, particularly in memory and executive functioning
6. Due to the extensive soft deposits/interdental food packing, you advise the patient that he needs further assistance from his wife with his toothbrushing, particularly with interdental cleaning. What practical steps would you recommend?
   • Break mouthcare tasks into small steps
   • Stand behind
   • Distraction – music, talking, stroking arm, another object to hold
   • Bridging – person holds same implement as carer
   • Hand‐over‐hand – carer guides person’s hands
   • Cueing – polite, one‐step commands
   • Visual prompts, gestures and mime
   • Mirror – person watches mouthcare in mirror
   • Rescuing – replacement of his wife with his son when care‐resistant behaviours escalate

7. Although the patient does not report any pain associated with #17, the ability to recall symptoms may be associated with his decline in memory and cognition. What other signs may indicate dental pain?
   • Inability to chew food
   • Refusal of food
   • Grimacing when tooth is touched
   • Frequently holding onto face, cheeks or mouth
   • Scratching or rubbing the tooth with his fingernail
   • Refusal to brush the teeth in the area of #17
   • Inability to sleep at night or disruption in sleep because of dental pain
   • Increasingly withdrawn or aggressive behaviour (compared to baseline behaviour)
8. What other factors do you need to consider in your risk assessment?
   • Social
     • Availability of an escort
     • Capacity may be impaired
     • Wheelchair access required, transfer arrangements to the dental chair
     • Stroke leading to reduced mobility and ability to self‐care
   • Medical
     • Potential risk of aspiration due to stroke
     • Hypertensive crisis risk and bleeding tendency
     • Bleeding risk due to aspirin
   • Dental
     • Xerostomia
     • Bruxism
     • Poor oral health
     • Inability to accurately report dental pain/symptoms
9. When discussing the need to extract #17 under local anaesthesia, how would you ensure that the patient understands and has the capacity to proceed?
   • Always start from the assumption that the person has the capacity to make the decision in question
   • Demonstrate that you have made every effort to encourage and support the person to make the decision themselves
   • Undertake a capacity assessment to determine if the patient can:
     • Understand the information given to them
     • Retain that information long enough to be able to make the decision
     • Weigh up the information available to make the decision
     • Communicate their decision – this could be by talking, using signs, including hand signals
   • Depending on the outcome of the capacity assessment, obtain informed consent or make a best interest decision

General Dental Considerations