This course was published in the September 2023 issue and expires September 2026. The authors have no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.
AGD Subject Code: 750
After reading this course, the participant should be able to:
- Identify the demographics and background of patients living with Alzheimer disease/dementia (AD/D).
- List oral hygiene modifications that can help patients maintain their oral health and sense of independence.
- Note the importance of the caregiver in supporting oral hygiene.
- Explain a possible workflow to develop dynamic and consistent review of oral hygiene instruction modifications for patients with AD/D.
The functional changes caused by dementia, such as a decline in hand grip strength and manual dexterity, can make performing oral hygiene challenging. Without appropriate oral hygiene modifications, individuals with AD/D are at greater risk for dental caries, gingivitis, and periodontitis. Periodontitis is associated with a variety of systemic disorders such as type 2 diabetes and cardiovascular disease. Practicing good oral hygiene at home plays a quintessential part in reducing systemic health risks and maintaining good oral health.
Enhancing the oral hygiene and dental health of individuals with AD/D can be achieved through several means, including educating both formal and informal caregivers on proper oral care techniques, utilizing oral hygiene assessment tools, and providing regular professional dental care. Over time, these interventions can be tailored to address specific patient needs.1–3
In 2022, approximately 6.5 million Americans age 65 and older were diagnosed with AD/D. Almost three quarters of this population are older than 75. By 2050, the number of Americans living with the disease is expected to increase to more than 12 million; worldwide this number is estimated to be 152 million.1,2 The majority of aid provided to older adults living with AD/D comes from family, friends, or caregivers who provide help with activities of daily living. These may include personal hygiene activities, such as bathing and dressing; transportation; eating; maintenance of medication regimen; and other tasks that directly impact quality of life. Often, caregivers who assist do not receive payment for their work.1
Oral Systemic Link
Emerging studies point toward a link between poor oral health and AD/D. Periodontitis may play a role in AD/D progression.3–6 Although research has begun to show evidence of a possible connection between periodontitis and the presence of dementia, a concise description of the relationship between the two remains unknown. Currently, there is a lack of well-designed studies that support this connection, but cohort and case-control studies of medium and high quality indicate a lack of daily performance of oral hygiene (eg, toothbrushing) and gingival inflammation are associated with the development of dementia.3,4
With the direct correlation between poor oral hygiene and dental caries, infection, and tooth loss, oral hygiene is critical in this patient population. Demonstrating modified oral hygiene techniques and recommending supplemental oral hygiene tools can significantly improve patients’ oral health and overall health.
If patients with AD/D can no longer effectively brush and floss, modifications should be implemented to improve performance and preserve independence. If patients can no longer execute effective oral hygiene even with modifications, then the caregiver should be given instructions and appropriate modification suggestions to optimize the oral care regimen performed at home.
Oral Care Strategies
A variety of tools are available to help patients improve their oral hygiene regimen. Recommendations should be based on patients’ specific limitations. Depending on patients’ physical abilities, caregivers may also need instruction to either assist in daily oral hygiene activities or take them over completely.
Prior to the initiation of any examination or treatment, patients must have the consent of their legal guardian if guardianship is in place. In this instance, patients may no longer be able to make decisions about their healthcare, and cannot consent to treatment alone.1 Documentation should be presented at the initial appointment, and the guardian should be present or contacted to give consent to any treatment. Documentation should be kept in patients’ secured charts/records. If there is ever any doubt of whether a patient is able to make treatment decisions alone, his or her primary care provider should be consulted.
When the problem is poor grip strength, a number of modifications can improve patients’ abilities to perform oral hygiene at home. Inexpensive modified silicone or rubber-based grips increase the diameter of the toothbrush handle, making it easier for patients to grasp during brushing. Alternatively, a small hand towel wrapped around the toothbrush handle and secured with rubber bands can also work. If these solutions are not effective, a three-dimensional printed grip can be fabricated from a functional impression of the patient’s hand.
If patients have issues with dexterity, it may be difficult for them to execute the fine motor skills needed to properly brush. Introducing an electric toothbrush may help. A modified grip that extends the toothbrush handle so patients do not need to their lift arms into an uncomfortable position for a prolonged period of time is another option.
A three-sided toothbrush can be incorporated into the patients’ regimens. Because the buccal, occlusal, and lingual surfaces can be cleansed simultaneously, this brush reduces the amount of motion patients need to execute to achieve proper plaque removal.
A more recent entry in the toothbrush market is the u-shaped toothbrush. It requires a small range of motion to operate, but studies indicate it may not be effective at removing dental plaque.10,11
Flossing may also become more difficult as manual dexterity diminishes. Without flossing, oral health is difficult to achieve and maintain, increasing the likelihood of caries and periodontal disease progression, especially in the molar areas.12 Using a flosser with a toothbrush-like handle allows patients to modify their grip. Patients may find this flosser easier to use than traditional floss. Water flossers can also be used; they have been shown to be as effective as conventional flossing in plaque removal.7–9
If patients are showing signs of forgetfulness, memory aids can be incorporated into their daily routines. Something as simple as a memory board or gentle, consistent reminders from a caregiver can improve compliance. Do not give patients vague instructions. Use short, simple sentences to guide the patient step-by-step through the procedure, such as brushing or flossing.1 Oral hygiene techniques should be modified so patients can independently complete this daily task.
Focus on the Caregivers
If patients can no longer brush and floss due to advanced disease or severe limitations, caregivers become pivotal in maintaining adequate at-home oral care. Speaking with caregivers/guardians via phone, video, or chairside to provide solutions is key.
Oral health professionals need to demonstrate how and when to put in and take out any dental appliances such as partials or dentures, as well as instruction on cleaning and storing these appliances at bedtime. Providing information, training, and tools to help caregivers support patients’ oral hygiene greatly improves their chance of maintaining their oral health.
The use of traditional mouthrinse may raise the risk for aspiration among patients with advanced AD/D.13,14 Mouthrinse strips may enable patients to use this product safely.
Brushing can be a challenge for caregivers, even with instruction. Caregivers have limited vision and often cannot see how effective their brushing technique is in the posterior region. It may also be difficult for caregivers to know how far posteriorly to place the brush head, which could cause discomfort. A three-sided toothbrush may simplify brushing. The brush’s head is often smaller and easier to place in posterior areas for more effective plaque removal.15,16
The use of flossers and interdental brushes with longer toothbrush-like handles eliminates the need for the caregiver to place fingers inside of the patient’s mouth, thus preventing any accidental biting during flossing.
Educating caregivers on how to detect potential issues related to patients’ oral health is critical. As the disease progresses, patients alone may not be able to identify the need for dental care. Caregivers should contact the dental care provider if they see any obvious dental issues (eg, broken fillings, sores, swelling, pain, discomfort, sensitivity, poorly fitting dental appliances, etc).
Oral Hygiene Pathway
Devising a systematic pathway to evaluate the need for oral hygiene modifications can be instrumental in ensuring that the oral hygiene instruction (OHI) fits the patient’s needs (Figure 1). It also allows for consistent review and additional modifications to continually support patients in their quest to maintain good oral health.
As AD/D progresses, the efficacy of the patients’ oral hygiene routines may need to be re-evaluated to ensure they are being supported. This also provides an opportunity for dental care providers to identify when caregivers should become more actively involved in the daily oral hygiene care process.
In order for it to work at its highest efficacy, OHI must be modified to fit the needs of the patient. Vigilance is also key, since AD/D is a progressive disease with no known cure. Re-evaluating patients’ abilities to perform oral hygiene at regular intervals ensures that modifications are implemented in a timely fashion, reducing the likelihood of prolonged lapses in adequate at-home oral care. When traditional instruction no longer yields oral health, the reason for the change must be identified. A systematic protocol has the potential to provide an environment conducive to maintaining oral health in spite of disease progression in this patient population.
The authors would like to thank Claudia Espinal, Stephanie Diaz, and the South East Texas Geriatric Workforce Enhancement Program for their help with this manuscript.
- Alzheimer’s Association. Alzheimer’s Disease and Dementia. Available at alz.org/alzheimers-dementia/facts-figures. Accessed August 22, 2023.
- Li X, Feng X, Sun X, Hou N, Han F, Liu Y. Global, regional, and national burden of Alzheimer’s disease and other dementias, 1990-2019. Front Aging Neurosci. 2022;14:937486
- Elwishahy A, Antia K, Bhusari S, Ilechukwu NC, Horstick O, Winkler V. Porphyromonas Gingivalis as a risk factor to alzheimer’s disease: a systematic review. J Alzheimers Dis Rep. 2021;5:721-732.
- Daly B, Thompsell A, Sharpling J, et al. Evidence summary: the relationship between oral health and dementia. Br Dent J. 2017;223:846–853.
- Noble JM, Scarmeas N, Celenti RS, et al. Serum IgG antibody levels to periodontal microbiota are associated with incident Alzheimer disease. PLoS One. 2014;9:e114959.
- Sparks Stein P, Steffen M J, Smith C, et al. Serum antibodies to periodontal pathogens are a risk factor for Alzheimer’s disease. 2012;8:196–203.
- Abdellatif H, Alnaeimi N, Alruwais H, Aldajan R, Hebbal MI. Comparison between water flosser and regular floss in the efficacy of plaque removal in patients after single use. Saudi Dent J. 2021;33:256–259.
- Lyle DM, Goyal CR, Qaqish JG, Schuller R. Comparison of water flosser and interdental brush on plaque removal: a single-use pilot study. J Clin Dent. 2016;27:23-26.
- Goyal CR, Lyle DM, Qaqish JG, Schuller R. Comparison of water flosser and interdental brush on reduction of gingival bleeding and plaque: a randomized controlled pilot study. J Clin Dent. 2016;27:61-65.
- Nieri M, Giuntini V, Pagliaro U, Giani M, Franchi L, Franceschi D. Efficacy of a u-shaped automatic electric toothbrush in dental plaque removal: a cross-over randomized controlled trial. Int J Environ Res Public Health. 2020;17:4649.
- Schnabl D, Wiesmüller V, Hönlinger V, et al. Cleansing efficacy of an auto-cleaning electronic toothbrushing device: a randomized-controlled crossover pilot study. Clin Oral Invest. 2021;25:247–253.
- Marchesan JT, Byrd KM, Moss K, et al. Flossing is associated with improved oral health in older adults. J Dent Res. 2020;99:1047-1053.
- Arcand M. End-of-life issues in advanced dementia: Part 2: management of poor nutritional intake, dehydration, and pneumonia. Can Fam Physician. 2015;61:337–341.
- Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361:1529–1538.
- Al-Omiri MK, Al-Shayyab MH, Alahmari NM, et al. Impacts of the triple bristles three-sided sonic powered toothbrush on tooth shade, plaque control and gingival health. Int J Dent Hyg. 2021;19:382–397.
- AL‐Omiri MK, Abu‐Awwad M, Bustani M, et al. Oral health status, oral health‐related quality of life and personality factors among users of three‐sided sonic‐powered toothbrush versus conventional manual toothbrush. Int J Dent Hyg. 2023;21:371-381.
Resources for Caregivers
Oral Hygiene for Caregivers and Families With or Without Dementia https://youtu.be/XHpfP_pHTb8
Demonstrating Oral Health Assessment for Nondental Professionals https://youtu.be/wXuYxQNd7gs
From Dimensions in Dental Hygiene. September 2023; 21(8):36-41.