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Introduction

The Adult Dental Health Survey (ADHS) revealed that over half of older people (aged over 60) are maintaining some, if not all, of their natural dentition.1 However, although people are 'keeping their teeth' to old age, there is an increased prevalence of tooth decay and dental pain in the older population - with poor dentition increasing more rapidly in those aged 80 and over.1 One local Joint Strategic Needs Assessment in the UK2 estimated that 20% of older adults in the South East and Coastal Region have active tooth decay and 25% of older adults suffer from severe gum disease. Equally, 7% of older adults reported they suffered from dental pain at the time of the survey. For patients living with dementia there is an increased risk of deteriorating oral health - and thus the potential to experience dental pain - brought about by factors such as poor monitoring of oral hygiene and the effects of poly-pharmacy.3 It has been found that dental pain is frequently undetected in people living with dementia - for example, in a US study, Cohen-Mansfield and Lipton4 found that up to 60% of their sample of people living with dementia had a dental condition which was likely to cause pain.

Dementia is one of the biggest health challenges facing the NHS in the UK; there are currently 944,000 people living with dementia in the UK and it is estimated that there will be 1.6 million people living with dementia in the UK by 2050. It is imperative that dementia awareness is introduced into the undergraduate curriculum to ensure that in the future, the dental workforce can meet the dental needs of this growing population.

Patients with dementia are increasingly more likely to present in primary care and this short article will provide a number of tips on how primary care practitioners may optimise outcomes in often very challenging circumstances.

Top tips

  1. 1.

    Access to treatment

The first difficulty that people living with dementia experience when seeking dental treatment is accessing dental care and many barriers to this have been cited.

Getting to the dental surgery can be a major challenge in itself with patients reliant on carers/family members to transport them to appointments or patients may be reliant on hospital transport services if treatment is planned in a secondary care setting. Carers are often family members who are also elderly and may not drive; they have many other more pressing issues than bringing their loved ones to appointments. The dental team must be mindful when booking appointments to offer appointments at times when carers can bring patients and allow extra time when they are reliant on hospital transport services. In some regions, domiciliary care is offered but there is a large geographical variation.5

Since the introduction of the new dental contract in 2006, dentists can no longer claim a 'call-out' fee for providing home visits and post 2006, general dental practitioners must have a special contract if they want to be paid for domiciliary care. This has limited NHS domiciliary care to few general dental practitioners and salaried services and the number of domiciliary visits being carried out has diminished. Services offered on a domiciliary basis vary from screenings in residential care homes to simple treatments being carried out in patients' homes or mobile dental units.6 For practitioners considering carrying out domiciliary dental services, guidelines relating to domiciliary dental care may be accessed via the British Society of Special Care Dentistry (BSSCD) (formerly the BSDH) website (https://www.bsdh.org/).

In addition to the difficulties in attending appointments, another barrier to accessing dental treatment is financial. In the UK, there is a lack of NHS treatment charge exemption based on either age or cognitive impairment so patients not receiving any government benefits are liable to pay full NHS charges for dental treatment.

  1. 2.

    Designing a practice suitable to provide care for patients living with dementia

Meeting the needs of patients living with dementia will require some adaption of the practice environment and the way that dental services are offered.7 All members of the team can be involved in the process of welcoming the patient to the surgery and it is useful for the team to be informed beforehand that a patient with a cognitive impairment is due to attend, particularly if they are attending alone in the early stages of the disease.

Equality legislation in the UK has ensured that reasonable adjustments are made to support people with disabilities to give them the right to equal standards of health and care. Regarding the practice environment, for patients living with dementia, much research has been carried out in hospital and general practice settings as to how to achieve a calm, safe environment for patients. This can be translated into a dental setting.8,9 Table 1 gives some useful pointers as to how to adapt surgery settings to improve the environment for people living with dementia. They are informed by the Department of Health's comprehensive guidance.10

Table 1 Surgery design, adapted from A. Geddis-Regan et al., Primary Dental Journal, 20209
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Figure 1 shows how simple yellow and black signs at the correct height make the dental experience more inclusive for those accessing services.

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Simple yellow and black signs at the correct height make the dental experience more inclusive for those accessing services

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Communication

Often people with dementia have limited communication skills and struggle to express themselves verbally.11 Communication is vital for taking a medical history, dental history and pain history. If a patient is able to communicate, they will be less anxious about having dental treatment so it is important that the patient living with dementia is supported to communicate more effectively.

It is useful if the patient is accompanied by someone who knows them well such as a carer, relative or friend who may be able to support them in giving a history and formulating a treatment plan. If the patient consents, the accompanying person may be involved in discussion about their treatment and their overall care and they may also aid them in completing the relevant paperwork when applying for exemptions to dental payments.

The communication of dental pain is particularly important and in the later stages of the disease, it may be very difficult to determine whether a patient with dementia is experiencing dental pain. Non-verbal cues may indicate pain such as frowning, drooling, grimacing, face holding or screaming.12 Changes in behaviour may also be noticed such as trouble sleeping/relaxing, anger, refusal to eat or maintain oral hygiene procedures and difficulties in wearing dentures. Carers are often best placed to see the signs and symptoms of oral pain and discomfort as they care for the person all day.

The presentation of written information to people living with dementia and their carers needs to be carried out thoughtfully. Frequently, people with dementia have other comorbidities such as visual and hearing impairments and both people living with dementia and their carers are often not accustomed to using digital media for imparting information.

Point size of text should be large as elderly people with dementia often have visual impairments, 14pt is ideal and Arial/Times New Roman is recommended as a font as they are uncluttered and do not have 'curly bits' and serifs.13

Training

It is imperative that dementia awareness is introduced into the undergraduate curriculum to ensure that in the future, the dental workforce can meet the dental needs of this growing population.

There is a need for current staff training to raise awareness of dementia and to provide better care. The Alzheimer's Society provides training and produces supporting materials which can be used in the practice (https://www.alzheimers.org.uk/).

Health Education England has produced an excellent training video entitled 'The Appointment' which highlights a patient living with dementia's visit to the dentist and can be used for staff training within practices (https://thamesvalley.hee.nhs.uk/dental-directorate-thames-valley-and-wessex/dementia/the-appointment/).

Conclusions

General dental practitioners will increasingly be managing patients with dementia at various stages of progression. The tips provided above will help in managing patients and communicating with patients and family members alike. Often small changes as suggested above can make a big difference to patients with dementia. In the second part of this series we discuss clinical management at various stages.