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Alzheimer's Disease Patients

Dental Hygienist and its importance with Alzheimer's patients

Alzheimer's Disease Patients

Alzheimer's disease patients

With the increase in Alzheimer's disease patients, dental hygienists must be well trained and adapted to anticipate the needs of Alzheimer's patients and their caregivers throughout the disease process in order to improve their quality of life. In this article, the author details some of the most common oral manifestations of Alzheimer's patients and how planning will be one of the bases in the clinical and dental management of Alzheimer's patients, taking into account the needs of each patient.

Since the middle of the 20th century, the world's population has experienced an increase in life expectancy. With the lengthening of the aging period, there is an increase in the number of illnesses associated with it, with an increasing course since its diagnosis, as is the case of Alzheimer's Disease.

For this reason, dental hygienists, as staff and health educators, must be well trained and adapted to anticipate the needs of this type of patients and those of their caregivers, who travel in parallel in the process of the disease, and trying to improve the quality of life of these patients.

We have evidence of Alzheimer's disease since 1906 when Dr. Alois Alzheimer, a German doctor, studied the case of a 51-year-old patient named Auguste Deter, whose behavior, associated with a depressive process, referred to a state of cognitive deterioration.

AD is a neurodegenerative disease, whose neuronal damage begins to manifest between 10 and 15 years before clinical symptoms appear.

Unfortunately, there is currently no curative treatment, only cholinesterase inhibitors are palliative treatment. There is a higher prevalence in women and some associated risk factors are age, family history, and stress.

Alzheimer's disease is characterized by loss of memory and cognitive capacity, leading these patients to suffer a total disability.

The mouth, the great forgotten

It is important to bear in mind that these patients have age-related pathologies, such as high blood pressure, diabetes, etc., which makes it even more difficult to care for these patients. At an oral level they are patients with a lack of hygiene, since, if they do not have an established routine, the Alzheimer's patient does not remember having eaten so it will be difficult to remember to carry out brushing. In addition, the mouth is the great forgotten for the caregivers of these patients, perhaps due to lack of information, training and even the difficulty involved in working in the oral area.

As a consequence of drugs and dehydration due to a lack of feeling the need to drink, Alzheimer's patients suffer from xerostomia, a fact that will favour the appearance of caries, the maladaptation of dental prostheses and even the appearance of candidiasis. Perhaps the worst part is not being able to explain the feeling of discomfort that this symptom picture can generate.

Another oral manifestation in this type of patient is sialorrhea or false sialorrhea due to the incompetence of the labial seal, which will favour the appearance of cheilitis. It should not be overlooked that because of neurological degeneration these patients may present dysphagia (difficulty in the deglutition process), so their diet should be adapted. Patients with dysphagia tend to accumulate a greater amount of oral waste which, if not properly removed at the right time, favours the appearance of bronchoaspirations due to silent aspirations.

For all these reasons, it is important that dental hygienists are properly trained and familiar with the scales of evaluation of autonomy in tasks of daily life in these patients (personal hygiene, nutrition, independence...), either because they can bring reports with the evaluation already carried out or because of their usefulness to incorporate them in the protocols of anamnesis in the clinic.

Planning key to Alzheimer's patients

The planning will be one of the bases in the clinical-dental management of Alzheimer patients and even the process of organizing the appointments will give the possibility of optimizing the schedules according to the needs of the patient.

At the first appointment in the dental office, it would be advisable for the caregiver to come, bearing in mind that if the caregiver is a family member of the patient, he or she may manifest great stress due to the personal situation.

It is essential that the anamnesis provides us with as much information as possible about the state of the patient and the stage of the disease in which he or she is. It is also important to know if the patient has any sensory disability resulting from age or cognitive impairment: hearing status, visual problems, speech difficulties, as well as whether they are properly compensated.

We also need to know the patient's degree of motor autonomy, whether he or she walks alone or requires a wheelchair or walker, in order to have as much planning as possible when it comes to establishing the consultation and the possible necessary support.

It is important to know if the patient is capable of carrying out his or her own hygiene and if it requires supervision, as well as the utensils and adaptations required.

With this information we will schedule the appointment of the patient, bearing in mind that it must be an hour and a half after taking the medication. Noises and long appointments should be avoided, as well as the use of children's language. It is better to speak slowly and at eye level, bearing in mind that the best tools with a patient are physical contact and good communication.

Once in the cabinet, they will be helped to sit in the dental chair, bearing in mind that the position should not be greater than 45º because of the ortho-static pressure. If possible, 4 hands should be used.

In order to maintain the patient's optimum collaboration, we should provide him with sensory anticipation, giving him, through the senses, a brief perceptive description of what will happen in the consultation during his visit, for example, letting him feel the ultrasound water. Keep in mind that in the mouth we have a greater number of nerve endings, both sensory and motor.

Once the oral situation of the patient has been assessed, we will proceed to establish a hygiene protocol adapted to his/her needs, always bearing in mind that the patient must be helped to maintain his/her dignity: the patient must brush himself/herself. To this end, dental hygienists, such as staff and health educators, will provide the necessary tools for each patient, delivering these guidelines in a third visit, without the patient being obliged to come.

The patient's comfort zone must be agreed with his or her caregiver, as he or she should not brush standing in front of the toilet. It is important to know that the mirror can become a double-edged sword for Alzheimer's patients, as they do not recognize their image and can manifest an attack of aggressiveness as a result of the deterioration of the disease.

Thus, they can brush themselves sitting in a quiet space and sometimes listening to music stimulates them and is a good routine tool. It may help for the caregiver to brush in parallel, making Alzheimer's an action mimic and a special exercise rather than a fractious moment.

The toothbrush should be manual, as the noise of the electric toothbrush can alter them. There are brushes on the market with three rows of tufts, which in a single sweep will facilitate the hygiene of the patient. The toothpaste will be little soapy, to avoid the appearance of foam, it is advisable that it is rich in fluorine. There will come a time when the deterioration of the patient will make him/her unable to spit, so the use of toothpaste will be avoided.

In the final stage of the disease, if the patient is bedridden, oral hygiene should be carried out using a swab impregnated with chlorhexidine or oral serum to avoid aspirations.

The plaque control check-ups, in this type of patients, should be carried out every 3 months, bearing in mind that the disease process will lead to the patient's immobility. 

The fact that the dental hygienist can provide a breath of help to the caregiver and the patient with Alzheimer's, establishes a bridge between our profession and the patient, demonstrating the urgent need to claim our presence in the interdisciplinary team that attends to this group of patients with neurological alterations.