As a registered dental professional and dental team trainer, I am fully aware that dental professionals want to do the best for their patients and, whenever possible, put their patients' interests first (GDC Standards for the dental team 2013 – Principle 1). This principle focuses the profession's mind upon each patient's best interests and uses a set of universal intentions and explicit guidance set out in practice policies and procedures to provide the team with 'tools to think with' to be applied to their day-to-day workplace experiences.

When a patient has a dementia diagnosis, dental professionals are able to use their training and professional skills to care for them and the team can implement carefully planned steps, as outlined in the FGDP(UK)'s Dementia-Friendly Dentistry: Good Practice Guidelines. When a patient has been diagnosed with dementia, it's reasonable to expect they will be accompanied by someone who can provide the familiarity and support they need and can act as a mediator. Under these circumstances, reference will be made to the Mental Capacity Act 2005 and its guidelines for matters such as consent, as set out in Section 9.

However, one of the most challenging and unpredictable patient groups in general dental practice are patients in the pre-diagnosis stages of a wide range of dementia conditions. As a carer of an elderly parent on a very long waiting list for a diagnosis of this ruthless condition, I can plainly see the potential problems awaiting the unaware dental professional when treating patients with dementia symptoms which have not yet been formally diagnosed.

As with all conditions, the signs and symptoms will vary from person to person. In my case it was easy to see that the condition had amplified some character traits, which have always been present, and eroded social filters. Worried about what was happening to them, the person tried to hide and deny events – the signs and symptoms that would alert family members that all is not well are likely to be deliberately hidden away. Only when looking back is it possible for family members, as lay people, to recognise that their family member has gone through the stages of grief for the decline of their mental capacity. These stages are denial, anger, bargaining, depression and acceptance.


The initial response is denial.

Over a period of time, the person will have experienced an increasing number of events which as an isolated event could easily be explained as the trials and tribulations of life. These may take the form of making appointments and forgetting them; turning up at the wrong time; losing things such as keys and phones – things that everyone will have experienced at some time, however, for this person they are happening all of the time. At home they can't find the most common everyday things like the iron or the kettle. They desperately need to conceal the fact this is happening from friends and family for fear that their 'secret' will be out and they will become labelled or at the very least diminished in the eyes of others.


They feel angry because they genuinely cannot grasp simple or sometimes even familiar concepts so, for example, the patient that has been attending your practice for 30 years, when called to the surgery cannot remember where to go. This leads to feelings of panic, which in turn makes other symptoms worse and may be expressed as criticism or anger toward the dental team – you may feel the patient is being aggressive. They may repeat the same questions or make the same statements over and over to you. Importantly, they may genuinely forget that they have consented to treatment or they may think they have paid when they have not.

In my case, I saw character traits and insecurities that once made her the person we knew but amplified, with some of the negative aspects projected onto others. This was along with a lack of the ability to temper comments, which were spoken unfiltered without regard for social niceties, in the same way as a small child may simply voice their honest observations.


Alongside all of the deeply felt concerns about the need to cover up events, there is a desire to normalise everything that is happening to them. In some cases, this becomes a need to distribute blame to others; this is where your adherence to practice policy and records keeping procedures will be fully tested. At this stage, the bargaining may be an attempt to convince themselves that all is well, they do not need help and they are the victims of other people's spite.


Anxiety and depression are both at the root of this condition. This can lead to a reluctance to maintain a healthy diet or keep up a healthy fluid level. It may lead to withdrawal from social activities or a lack of interest in pastimes previously enjoyed. It is typified by the failure to take prescribed medications, leading to an increase in confusion and further disorientation.


The ideal end point of this process is reaching a level of acceptance which allows the patient to secure the help and support they need. For many, this is a very difficult journey, which requires others to be aware of the individuals' needs and provide care that is directly linked to their dental needs as well as those needs associated with their declining mental capacity.

Dementia-friendly dentistry

To be a dementia-friendly practice you need to be:

  • Accepting of the patient's behaviour, even when it seems a little confused, critical, aggressive or defensive. Keep careful records of conversations and most importantly give the patient all important information in a written format

  • Aware that for many dementia sufferers, time is an issue and so delays and being kept waiting trigger their symptoms

  • Helpful and patient – stress increases confusion as too does a noisy environment; whenever possible find a quiet place to talk

  • Patient – don't rush them, give them the time they need to process information (MCA Principle 2 - Patients should be given the necessary support to enable them to protect themselves)

  • Aware that any changes in the practices will be problematic for dementia sufferers – be supportive

  • Prepared with 'in case of emergencies' contact details should you need to make a 'best interests' disclosure to the family about your concerns.

Remember that this condition is a physical illness. So that dental carers can accommodate the patients' need for all communication to be clear, they should imply that the question is being put for the first time, even when the same question has already been asked several times.