Is oral hygiene important for those with dementia after all we can just pull out all their teeth? Mina Borromeo

Transcription

1 Is oral hygiene important for those with dementia after all we can just pull out all their teeth? Mina Borromeo

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3 What is in the literature? Adapted interventions, staff training 3

4 Link between poor oral health and some of the symptoms seen in dementia sufferers a recurring, selfperpetuating loop 4 Dermot and Sadaghiani, 2014

5 WHY ARE THE ELDERLY DIFFERENT? Dental needs of elderly are uniquely complex due to a lifelong accumulation of physiological, disease derived, traumatic and iatrogenic effects on the oral structures Multiple restorations in various states of despair Changes to tooth components eg. shrinkage of pulp space, changes in structure of the dentine, missing and drifted teeth, occlusal attrition Physical effects of ageing eg. OA, visual changes, progressive loss of neuromuscular coordination, mobility issues Dental disease doesn t start in a nursing home!

6 What do we often associate with dementia patients (+/- elderly)? Bad breath Lots of plaque Dentures Broken or sharp teeth Decay No teeth at all Dry mouth Increased risk of untreated tooth decay Dentures Unhygienic mouth Unable to clean teeth Unwilling to clean teeth 6

7 WITHIN AGED CARE FACILITY AT THE DENTIST ACCESS parking appointments CHALLENGING BEHAVIOUR FEAR RE MGMT FINANCIAL CONSTRAINTS DOM NEED FOR SPECIAL FACILITIES RENUMERATION WHY ARE THERE UNMET DENTAL NEEDS IN DEMENTIA COHORT? UNWILLINGNESS TO PROVIDE CARE TRAINED STAFF TIME CONSUMING TEMPTATION TO PROVIDE SUBSTANDARD OR SUBOPTIMAL CARE EXOs, CLEANS, REVIEWS (-tmt)

8 IMPACT OF ORAL HEALTH ON GENERAL HEALTH 90% of older adults have some degree of treatable dental disease Poor oral health: Can affect dietary intake/nutritional status dehydration and malnutrition Can compromise other health conditions often leading to admission to acute care facilities Oral infections and sepsis Pain and discomfort Systemic illnesses CVD and aspiration pneumonia

9 COMFORT MAINTAINING QUALITY OF LIFE ORAL CARE IS ESSENTIAL PREVENTING INFECTION NUTRITION ORAL SYSTEMIC SELF ESTEEM APPEARANCE SOCIAL ACCEPTANCE

10 AIMS OF DENTAL TREATMENT NON DEMENTIA PATIENT Improve quality and quantity of life e.g. self esteem/dignity Dental care emphasis quality of life Optimum oral health care best possible treatment for the patient DEMENTIA PATIENT Improve quality and quantity of life e.g. self esteem/dignity Dental care emphasis quality of life Optimum oral health care best possible treatment for the patient in the context of their overall (medical) condition

11 Optimal treatment plan may not be ideal treatment plan Treatment plan must meet goals of providing an oral environment that is: Free from infection Cleanable Functional Aesthetic (limitations??) Lead to best possible quality of life Longest possible quantity of life

12 Pain in the dementia patient?

13 How do we know a patient may have pain of dental origin? Loss of interest in eating Sensitive to food Increased grinding (teeth or dentures) Refusal to wear dentures Refusal to clean teeth/mouth (????) Pulling/hitting of face Mood changes: aggression, somnolence, screaming, fearful, restless Patient can t directly express/communicate site or source of pain or pain per se Highly individual and varies from episode to episode 13

14 BARRIERS EXIST IT S ALL TO HARD What can we do about it? Oral health is part of overall good health Prevention is key wherever possible No one size fits all Be champions for our patients

15 IN REALITY As cognition declines Ability to self care declines (inc oral care) Ability to tolerate dentistry may reduce (especially complex care should it be avoided?)

16 WHAT CAN WE DO? Assess individual needs early (in the home, on admission to facility, early in diagnosis) Preventative plan Identify key dental help in the area (public/private) Regular recall (patient specific don t wait for a problem to present itself) Treatment plan Flexible (related to cognition level) Aims pain free, adequate nutritional intake

17 Restraint management where required during review/treatment (consent): Who provides it GP?, dentist? Anxiolytics, sedatives Holding patients where needed (safe environment)

18 DOMICILARY CARE As pt challenges increase familiar setting, fragility, falls risk, mobility issues Can t physically get to a dentist

19 4 KEY ISSUES TO CONSIDER Aid of the caregiver Modification of OH routine OH aids Type/frequency of professional care

20 A lot can be done to aid oral care

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22 PRACTICAL TIPS AGED CARE FACILITY Appointment timing mid morning (favourable re ADLs, cognition status, meds, calmer (?)), avoid around mealtime if possible, length of time (consult versus treatment) Family and facility involvement where possible consent (who/what), paperwork, records, test results, can family member attend for at least initial appointment, etc

23 IN THE HOME As above Have medications at the ready for review Patient in comfortable location eg armchair Lighting, hand washing, examination location Power points for equipment Quiet, calm environment Minimise others around eg neighbour, grandchildren etc

24 COMMUNICATION STRATEGIES THAT MAY ASSIST WITH INDIVIDUALS WITH DEMENTIA Chaining initiate activity and carer completes Bridging patient holds similar item to what you are using Hand-over-hand place hand over patients hand to guide the activity Rescuing replace caregiver with another who may be having difficulty performing the OH task Mirror-mirror complete task in front of a patient

25 org.au/files/hel psheets/

26 PROBLEMS BETWEEN PEOPLE WITH IMPAIRMENTS AND THE DENTAL TEAM Fewer dental visits Longer intervals bw visits Unwillingness of clinician to provide care History of extractions Emergency hospital care rather than planned community care Treatment with sedation or GA