As dentists today, we see a huge number of different patients with a variety of needs. It is our job to tailor our care in a way that best supports each individual in the dental chair. As Alzheimer’s disease is promoted around the globe throughout September, I thought this a good opportunity to reflect on how we may adjust our approach when treating patients that are experiencing cognitive impairment.
The challenges faced
Alzheimer’s disease is estimated to affect more than 980,000 people in the UK, though this is expected to rise to 1.4 million by 2040.[i] This means that we will see an increasing number of patients in the dental practice who may be living with the condition.
The links between Alzheimer’s disease and oral health are well-established. Those with the condition are often at higher risk of everything from tooth decay to tooth wear, gingival disease and dry mouth, compared to the rest of the population.[ii] Unfortunately, there is evidence of the relationship working the other way too. People with poor oral health are at a two-fold greater risk of developing Alzheimer’s.[iii]
Two 2022 studies have been helpful in determining the potential mechanisms at play, linking gingival bacteria with cognitive decline. The first[iv] showed that tau – a protein found in the brain – is released from the nerve cell when it comes into contact with the gingipains enzyme – which is produced by P. gingivalis during the destruction of the soft tissue. Once free, tau re-attaches to the nerve cell to create neurofibrillary tangles that kill the nerves, causing cognitive decline.
The second study[v] demonstrates that the aforementioned gingipains enzyme can also help form amyloid-beta plaques, which have also been found in the brains of those diagnosed with Alzheimer’s.
Tailoring dental support
The nature of the disease means that patients will often become forgetful, confused or anxious when it comes to daily tasks like oral hygiene. Keeping oral hygiene advice simple is, therefore, crucial. So too is creating as comfortable an environment as possible in order to reduce anxiety within the dental practice.
When it comes to any treatment indicated, it is important to consider the entire patient experience. What may be an easy procedure for a healthy patient, may put someone with Alzheimer’s in considerable discomfort. The spotlight should be put on prevention, managing and arresting any active disease during the early stages of Alzheimer’s if possible. The goal is to avoid the need for invasive or extensive treatment once the dementia has progressed, to prevent significant patient distress.[vi]
Assessing mental capacity
Of course, dental professionals must be aware of the regulations and guidelines around caring for a person who may have reduce mental capacity. Though the rules are slightly different throughout the UK, they are all essentially designed to protect the patient and ensure that they receive the very best possible standard of care. In England and Wales, the Mental Capacity Act[vii] requires an assessment of the patient’s capacity where they are unable to adequately understand or retain relevant information (including treatment risks and benefits), compare their options and/or communicate their decision by verbal or non-verbal means.
Patients with more advanced Alzheimer’s disease will typically need to have their care overseen by a designated carer. They then become the person responsible for decision-making with regards to their dental – and any other – care. It’s important that we remember a person’s mental capacity may fluctuate over time, so an assessment should be made during every appointment.
Where we see a patient soon after an Alzheimer’s diagnosis, who is still early in the disease development, it may also be useful to create an advanced care plan.[viii] This can establish the patient’s preferences and guide professional recommendations even once they experience cognitive decline. This is not a definitive solution, but it does help to ensure that their wishes are met as much as possible.
Patient-centred care
No matter what our patients need, it is our duty as healthcare providers to tailor our approach to them. Supporting individuals with Alzheimer’s disease can be difficult, but we can make a considerable difference to their quality of life.
For further information please call EndoCare on 020 7224 0999
Or visit www.endocare.co.uk
Author: Michael Sultan
EndoCare, led by Dr Michael Sultan, is one of the UK’s most trusted Specialist Endodontist practices. Through the use of the latest technologies and techniques, the highly-trained team can offer exceptional standards of care – always putting the patient first. What’s more, EndoCare is a dependable referral centre, to which dentists from across the country send their patients for the best in specialist endodontic treatment.
[i] Alzheimer’s Society. Local dementia statistics. https://www.alzheimers.org.uk/about-us/policy-and-influencing/local-dementia-statistics#:~:text=There%20are%20currently%20estimated%20to,dementia%20will%20only%20become%20greater. [Accessed July 2024]
[ii] Alzheimer’s Society. Dental and mouth care. https://www.alzheimers.org.uk/get-support/daily-living/dental-mouth-care#:~:text=Many%20people%20with%20dementia%20develop,can%20also%20be%20very%20painful. [Accessed July 2024]
[iii] Kulkarni MS, Miller BC, Mahani M, Mhaskar R, Tsalatsanis A, Jain S, Yadav H. Poor Oral Health Linked with Higher Risk of Alzheimer’s Disease. Brain Sci. 2023 Nov 7;13(11):1555. doi: 10.3390/brainsci13111555. PMID: 38002515; PMCID: PMC10669972.
[iv] Kanagasingam S, von Ruhland C, Welbury R, Singhrao S K. Antimicrobial, polarizing light, and paired helical filament properties of fragmented tau peptides of selected putative gingipains. J Alzheimers Dis 2022; doi: 10.3233/JAD-220486.
[v] Kanagasingam S, von Ruhland C, Welbury R, Chukkapalli S S, Singhrao S K. Porphyromonas gingivalis conditioned medium induces amyloidogenic processing of the amyloid-ß Protein precursor upon in vitro infection of SH-SY5Y cells. J Alzheimers Dis Rep 2022; doi: 10.3233/ADR-220029.
[vi] Faculty of General Dental Practitioners (UK). Dementia-Friendly Dentistry: Good Practice Guidelines. London: Faculty of General Dental Practitioners (UK); 2017. Available at https://www.fgdp.org.uk/guidance-standards/dementia-friendly-dentistry
[vii] Department for Constitutional Affairs. Mental Capacity Act 2005 Code of Practice. [Internet]. London: The Stationery Office; 2007. Available at https://www.gov.uk/government/publications/mental-capacity-act-code-of-practice
[viii] Geddis-Regan A, Kerr K, Curl C. The Impact of Dementia on Oral Health and Dental Care, Part 2: Approaching and Planning Treatment. Primary Dental Journal. 2020;9(2):31-37. doi:10.1177/2050168420923862
