Dental care is one of the most challenging aspects of Alzheimer’s and dementia caregiving. Proper oral care is necessary to prevent eating difficulties, digestive problems and infections. As a caregiver, you may have to assist with dental hygiene or take a more hands-on approach. Below are helpful tips from professionals at the Blende Dental Group, which is home of the House Call Dentists, serving patients with special needs, including people with dementia.
Dr. David Blende a graduate of the University of Southern California and has more than 30 years of experience. He is also chief of dentistry at both California Pacific Medical Center and Kaiser Permanente’s San Francisco Medical Center, and on staff at six additional Bay Area hospitals.
Michelle Bernardo has been a Registered Dental Hygienist since 1994 when she graduated from New York University School of Dentistry. She divides her time between the Blende Dental Group San Francisco office and visiting homebound and elderly patients throughout the Bay Area.
Dr. Blende, you were one of the first dentists to perform house calls for patients. How did the idea about House Call Dentists come about?
When I first began my practice in Beverly Hills, I saw virtually no Alzheimer’s patients. When I started doing work in hospitals, I was called out to see home-bound people or patients for whom transport to the dental office was overwhelmingly difficult.
This fit into my background quite well. My father was a physician in a rural town close to the Canadian border and I used to go on house calls with him. Up until 1940, 47% of all interactions between a physician and a patient occurred in the home. And now physicians and medical groups are coming back around to that model.
Why is dental health critical to the health of people with Alzheimer’s?
There’s a huge taboo about being in the mouth of someone past a certain age and certainly in the mouth of our parents or spouse. 95% of all disease in the mouth is preventable. When we see patients who’ve had 35 years of good dentistry, we want to make sure that they hold on to that right to the very end.
A healthy mouth is one of the great privileges of health. Enjoying a meal is a great privilege of health. But because of these taboos about getting into a husband or a wife’s mouth, things go undiscovered. And when a problem is undiscovered, it becomes akin to abandoned because the patient ceases to brush their teeth regularly.
An abandoned mouth ultimately becomes a true nest of infection. The bacteria in the mouth overgrow and seed out into the heart, lungs and kidneys. We know now that one of the major causes of aspiration pneumonia are the bacteria that are harbored in between the teeth in an infected mouth. We also know that a lot of patients with late stage kidney disease have oral bacteria down in the kidneys.
We recommend that caregivers take their partners or parents who have Alzheimer’s to their regular dentist as soon as symptoms appear. Insist that the dentist clean up their mouth so that it can last the 7 to 10 years that are still before them.
Michelle, what are some warning signs that caregivers should watch out for to recognize when there might be a problem?
When a caregiver is taking care of a patient, what they want to look for immediately is an increase of plaque accumulation on the gum line. This is either due to dexterity issues or the person forgets to brush. Ultimately, this plaque accumulation would lead to tooth decay or gum infection. Another sign to watch out for would be if the person stops eating comfortably or you start to notice an unfinished plate at the end of the meal.
Do you have any prevention tips for caregivers?
Sure, as a caretaker you want to make sure you’re brushing the person’s teeth after every meal, ideally, but at least two times a day. Have the person rinse their teeth after snacks or after drinking juices. If the person has lost their ability to rinse, make sure you wipe the inside of their mouth with either a piece of gauze or wet wash cloth to get sugar and food particles off the teeth and cheeks. And then you’ll always want to be pulling the cheeks away from the teeth to see if there is anything broken or if there are any sores.
Dr. Blende, what do you advise the caregivers that you meet in your practice?
When we make house calls, the first thing we do is we ask the caregiver to show us their mouth. We want to know how well caregivers take care of their own mouth. That then becomes another part of the education. If they’re taking good care of their mouth, then we’re advancing down the line.
A great reminder for caregivers is to make sure that the person you are caring for has a good routine. It’s also important for the patient to be on a dental routine with their dentist, so make sure to have their mouth checked every few months. When someone has a toothache, it’s pretty simple to diagnose or if their face is swollen, that’s pretty simple, as well. But probably 85% of the insidious disease and the real infection is very silent and it slowly but perniciously starts to destroy the mouth so you have to get someone to look at it. Sometimes, I know, a client might have a headache because he takes a dose too high. You then should first refer him to a lower daily dose and see if he still has a headache. Other active molecules can also be tried, as they vary in the impact on an individual and may go through the body completely unnoticed when it comes to side effects. And finally, if falls short of his expectations, we have to discuss with a client all the means at our disposal: there are local creams, intracavernous injections and pumps.
Another problem is that as we age into 60’s, 70’s or 80’s, our saliva can diminish. When someone becomes distressed and they’re given anti-anxiety drugs or heart and pain medication, all of those have a side effect of drying out the mouth. And if the saliva dries, the mouth dries up. We like to tell people that saliva is like the tide at the beach. The tide comes up on the beach, picks up the kelp, makes it all wet, takes it into the ocean and puts it back on the beach. If someone, who’s been taking good care of their mouth for many years, begins taking one of the 400 drugs that causes dry mouth, you have a recipe for disaster.
What methods of treatment have you provided to individuals with dementia?
By the time we see an Alzheimer’s patient, they’ve been referred from their caregiver or from another dentist because they’ve fallen beyond the scope of that office’s ability to treat them. We gather the family together and individualize care. Some patients have had good care and some, unfortunately, are dealing with years of deferred maintenance and neglect. For these patients, we either offer palliative care, or if they want to restore the mouth so they can go back to enjoying food, we offer that option.
We treat patients either at our office with a physician anesthesiologist or in a hospital, depending on their health conditions. 70% of what we do is done under general anesthesia because by the time we see these patients, there’s a lot of catch-up treatment.
That’s the important point that I’d like to get across to families – if you can get their mouth stabilized before they go into the later stages of the disease, they’re way ahead of the curve. As the chief of a hospital division, before someone has to have radiation, they tell us to clean their mouth. Before chemotherapy, they ask us to clean up the mouth because they know what’s coming down the line. It should be the same way with Alzheimer’s. We know that there is a natural trajectory to the disease and what we want to do is make sure that oral disease is a non-issue in the late stages.
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