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Alzheimer's disease and dental management

Article  in  Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology · June 2002
DOI: 10.1067/moe.2002.123538 · Source: PubMed

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 Vol. 93 No. 5 May 2002

ORAL SURGERY
ORAL MEDICINE
ORAL PATHOLOGY

MEDICAL MANAGEMENT UPDATE Editor: Donald Falace

Alzheimer’s disease and dental management

Hümeyra Kocaelli, PhD,a Mehmet Yaltirik, PhD,a L. Ilhan Yargic, MD,b and Hakan Özbas, PhD,c
Istanbul, Turkey
UNIVERSITY OF ISTANBUL

Alzheimer’s disease (AD) is a major disorder of old age and the most common cause of dementia. Dementia is loss
of intelligence, memory, and cognitive functions. It is usually associated with aging, but there are many possible causes. Older
adults are the most rapidly growing segment of the population. To maintain lifelong good oral health, the elderly need regular
dental care. This review of AD summarizes the causes, epidemiology, diagnosis, and dental management of patients with AD.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:521-4)

Dementia is a major disorder of old age leading to tions, regardless of number, occlusal surface area or
global impairment in higher cortical functions, time, do not relate to brain mercury levels.7
including memory and the capacity to solve the prob- Alzheimer’s disease has a complex etiology, with
lems of daily living.1,2 Dementia is a clinical syndrome environmental and genetic factors influencing the
characterized by a severe loss of intellectual function in pathogenesis.8 Although AD is a genetically heteroge-
an elderly patient for which no other cause is found. neous disorder, it is classified as familial or sporadic
Although atrophy is marked, the cause of dementia because the majority of cases are sporadic and a small
remains unclear.3 number display familial clustering.9 Studies report
Alzheimer’s disease (AD) is the prototype of cortical conflicting results on genetic epidemiology of
degenerative diseases. Alois Alzheimer’s original Alzheimer’s disease.10
description in 1906 detailed most of the familiar clin- AD is estimated to affect 10-15% of those older than
ical and neuropathological features. He called the clin- 65 years of age and 20% of those older than 80.11
ical presentation dementia if it developed in persons Women are living longer than men, and they account for
under the age of 65.4 two-thirds of all cases of AD. Ethnic minority groups are
AD is the most common cause of dementia and has also susceptible to AD. Because they are becoming a
been associated with many risk factors: age, gender, greater proportion of the elderly population, they will
apolipoprotein E4, advanced parental age, cerebrovas- represent an increasing proportion of individuals with
cular disease, head trauma, myocardial infarction, and AD.11 AD is characterized by decline in both mental and
immunological defects; genetic factors such as chro- physical health. Major presenting symptoms are usually
mosomal defects (Down syndrome); environmental subjective complaints of memory difficulty, language
factors such as infective agents, toxins, education, and impairment, and dysphasia.12 Clinically, Alzheimer’s
occupation.5 Dental amalgam releases low levels of disease is characterized by gradual, progressive loss of
mercury, a neurotoxin that has been speculated to play memory and other cognitive activity, leading to inability
a role in the pathogenesis of Alzheimer’s disease.6 But to recognize family or friends or to carry out the simplest
a careful study has shown that dental amalgam restora- tasks (such as combing the hair), general deterioration of
motor skills, disorientation, and grossly inappropriate or
bizarre behavior.13 Personality changes, delusions,
aDepartment of Oral Surgery and Medicine, Faculty of Dentistry. mood swings or depression and various behavioral prob-
bDepartment of Psychiatry, Faculty of Medicine. lems may be associated.14
cDepartment of Endodontics, Faculty of Dentistry.
Cerebrovascular problems are the second leading
Accepted for publication Jan 15, 2002.
© 2002 Mosby, Inc. All rights reserved.
cause of dementia. Dementia associated with stroke or
1079-2104/2002/$35.00 + 0 7/13/123538 cerebrovascular accident is marked by a sudden onset
doi:10.1067/moe.2002.123538 of focal neurological deficits. Cerebrovascular acci-

521
522 Kocaelli et al ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
May 2002

Table I. Diagnostic criteria for Alzheimer’s disease Medications and nutrition are important as both
A. Multiple cognitive deficits are manifested by causative and protective factors in AD. Studies have
1. memory impairment (impaired ability to learn new information shown the existence of a correlation between cognitive
and to recall previously learned information), skills and the use of estrogen and antiinflammatory
2. aphasia (language disturbance), drugs, as well as the serum concentrations of folate,
3. paraxial impairment (impaired ability to carry out motor
vitamin B12, vitamin B6, and homocysteine.19
activities),
4. agnosia (failure to recognize or identify objects), and Treatment of AD is predicated on an accurate
5. disturbance to executive function. diagnosis. Various therapeutic approaches, such as
B. Impairment in social or occupational functioning represents a acetylcholinesterase inhibitors and other cholinergic
significant decline. agents, antioxidants, antiinflammatory drugs, hormone
C. The course is characterized by gradual onset and continuing
replacement therapy, antiamyloid treatment, and
cognitive decline.
D. The aforementioned cognitive deficits are not the result of neurotrophic agents are available.12,20 Cholinergic
1. central nervous system conditions that cause progressive theory is currently the most popular one, and several
deficits in memory (eg, cerebrovascular disease, Parkinson’s pharmacologic approaches have been used in an attempt
disease, Huntington’s disease, subdural hematoma, brain to correct cholinergic deficits.21 Of these strategies, inhi-
tumor, hydrocephalus);
bition of acetylcholinesterase (ACE) is currently the
2. systemic conditions that are known to cause dementia (eg,
HIV infection, hypercalcemia); or most successful treatment of AD.22,23 Unfortunately,
3. neurosyphilis, vitamin B or folic acid deficiency, or hypothy- however, ACE inhibitors (like other pharmacologic
roidism. strategies) just slow down or delay the progression of the
disease but ultimately do not stop or cure it.24
The behavioral symptoms of AD can be managed
dents are caused by a thrombus formed at a site of arte- with a variety of antidepressants, anxiolytics, or
rial blockage or atherosclerotic debris that is dislodged antipsychotics.25 The final common clinical picture of
and ultimately causes arterial blockage in the brain.12 AD is of a bedridden patient, wholly dependent on
In dementia, the characteristic pathological lesions others for all basic functions–even turning in bed.
are neurofibrillary tangles and neuritic plaques Nutrition can often be provided only by nasogastric or
consisting of dying nerve fibers that are clustered gastrointestinal tubes.26 Death usually results from
around deposits of amyloid.15,16 Although plaques and pulmonary aspiration or from infectious processes
tangles may be detected in the brains of the nonde- associated with prolonged recumbency.22
mented elderly, they are more numerous in patients
with dementia.16 These neuronal changes progressively DENTAL ASPECT AND MANAGEMENT OF
result in impaired cognition and physical function and, ALZHEIMER’S PATIENTS
either directly or indirectly, are a major cause of death The number of AD-affected persons is expected to
among the elderly. Cholinergic deficits are the most double or triple in the next 25 years.27 Therefore,
common class of neurochemical disturbance in patients dental professionals will face a greater burden of main-
with AD and are thought to contribute to the deteriora- taining and preserving dental health in older patients
tion in memory and other cognitive functions.12 with dementia.28 Dental treatment planning, oral care,
The diagnosis of AD is made on the basis of a clin- and behavioral management for persons with AD must
ical history of progressive dementia in middle or late be designed with consideration of the severity of the
life.3 Diagnosis of any form of dementia requires a disease and must involve family members.29 It is
careful history and physical examination (Table I).12 important to anticipate future oral decline in treatment
Available technological diagnostic methods have not planning and to institute aggressive preventive measures
proved more sensitive or specific than astute clinical (such as the use of topical fluoride, chlorhexidine, or
evaluation in comparisons of patients with AD and both) and the practice of frequent recall visits and
healthy control subjects.17 daily oral hygiene.29,37,38 Family members must be
The differential diagnosis must include reversible instructed on assisting the patient in daily oral and
metabolic diseases such as myxedema and pernicious denture hygiene.12 Relatives feel considerably reas-
anemia, infectious diseases such as syphilis, and sured when the dentist is aware of the problems of AD
tumors such as frontal lobe meningiomas. AD should and understands the underlying nature of the disease.30
also be differentiated from depressive pseudodementia Clinicians should maintain updated medical and
that can be successfully treated with serotonin reuptake medication records on these patients to avoid possible
inhibitors.18 Delirium is common during the course of complications, such as postural hypotension, adverse
dementia and must be detected and treated appropri- interactions with epinephrine, the risk of oversedation,
ately, as it may be a fatal condition. and medication-induced salivary gland dysfunction.2
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Kocaelli et al 523
Volume 93, Number 5

The chief problems of persons with AD and many were significantly older and less clean. Soft-tissue
other types of dementia are behavioral.31 In the early deposits affected 71% of upper dentures and 66% of
stages, dental appointments and instructions are lower dentures in persons with AD; among controls,
forgotten. Later, there is progressive neglect of oral they affected 39% and 38%, respectively. This finding
health as a result of forgetting the need or even how to was in agreement with the known poor personal hygiene
brush the teeth or clean dentures.32 Dentures are also habits of elderly patients with dementia.2
frequently lost or broken. Later deterioration of dental Improved oral hygiene would benefit all patients with
care may lead to the destruction of dentition by caries and dementia. This care must be given with respect for the
periodontal disease. The problems of management may oral mucosa, however, as treatment and care without
increase because of halitosis and difficulty in eating.33 consent is an assault, except in an emergency.38,39 If a
Oral dysfunctions such as sucking reflex or involuntary person with AD has good oral heath initially and is accus-
oral movements limit dental function. Good muscular tomed to regular dental care, it is important to maintain
coordination is necessary for the stability of a denture and support this habit to preserve lifelong oral health. If
during use. Poor dentition status can impair the systemic there is initial oral deterioration, the realistic treatment
health of the aged and may lead to mental impairment.34 goal must be improving the condition, often by palliative
Therefore, the advantages of new dentures must always means.1 Short appointments for patients with AD can be
be considered in realistic treatment planning for a less stressful. Frequent recall and aggressive preventive
demented patient. Even minor changes in oral environ- measures should be continued. Treatment plans should
ment can be disturbing when the capacity for adaptation be designed with minimal changes to the oral cavity and
is impaired by AD. Successful management of poor oral should not involve complete rehabilitation.12
status by multiple restorations, crowns, bridges, or Intravenous sedation or general anesthesia can be
dentures is a difficult challenge in patients with AD.1 It considered for necessary dental care. During the treat-
should be kept in mind that adaptation to new prostheses ment procedure, it may be necessary to administer oral
may be difficult for these patients. Sometimes, the sedatives or anxiolytics, such as short-acting benzodi-
possible benefits in terms of better chewing function or azepines, before dental treatment to manage behavior.
better nutritional status may never be realized.1,5,30 Older patients may experience a greater duration and
It has been demonstrated that persons with AD have depth of sedation with subsequent cognitive, behavioral,
impaired oral health as a result of poor oral hygiene. and motor disturbances and therefore should be super-
For example, patients with AD have more gingival vised closely after the administration of oral sedatives.
plaque, bleeding, and calculus compared with age- Importantly, many pharmaceutical regimens have signif-
matched, gender-matched adults, and submandibular icant stomatologic side effects (eg, anticholinergic-
saliva output is impaired in persons with AD who are induced salivary dysfunction). Oral-health practitioners
taking medications.35 Poor gingival health and oral must be cognizant of the drugs their patients are taking
hygiene have been found to increase with the severity and must institute appropriate precautions to prevent the
of dementia. Therefore, dental professionals and care- deleterious consequences of medications.12,23
givers should use behavior management techniques for Adults with AD may not recognize their deficit. For
preventive oral care.36 Older adults with cognitive this reason, if a dental patient does not have a previously
impairment have significantly older dentures that are established diagnosis of AD but shows some of the signs
significantly less clean compared with persons who do and symptoms, medical consultation should be sought.
not have AD.35 Another problem is that AD patients’ Time-consuming and complex dental treatment
perception of pain may be distorted, and localization of should be avoided in persons with severe dementia.
dental pain is generally very poor.30,37 The emphasis should be on keeping patients free of
The most significant dental problems of patients with pain and being able to maintain adequate nutritional
AD result from a progressive diminution in oral self- intake, particularly if the patients are no longer able or
care. There is an increasing dependence on the caregiver willing to wear their dentures.12
to provide oral hygiene, and the dentist has a significant Although it is still possible to give dental treatment
role in ensuring that caregivers are able to take on these to these persons, it should be planned with the knowl-
tasks.30 In a study by Whittle et al,2 the dental health of edge that the patient will sooner or later become
community residents between 65 and 96 years of age in unmanageable. Treatment should, as far as possible, be
the early stages of dementia was compared with that of carried out in a familiar environment. Care should be
a control group. The two groups were similar with taken to avoid discomfort and to explain every proce-
respect to recent pain, chewing difficulties, retention and dure before it is carried out. Attention to oral hygiene
stability of dentures, uneven occlusion, and needs for and preventive care is important but, after a time, it
treatment. But the dentures of persons with dementia may no longer be practicable.15,30
 524 Kocaelli et al ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
May 2002

CONCLUSION 15. Chung JA, Cummings JL. Neurobehavioral and neuropsychi-

atric symptoms in Alzheimer’s disease: characteristics and treat-
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Transm Suppl 1998;53:91-5.
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Am J Manag Care 2000;6(22 Suppl):S1125-32.
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