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Aims:
  • To raise awareness of the dento-legal issues that can arise during the treatment and management of patients with dementia and other cognitive impairments.
Objectives:
  • To provide information on current guidance and best practice relating to the treatment and management of patients with dementia and other cognitive impairments.
  • To give dental professionals a basic understanding of the requirements and considerations that should be taken into account to ensure such patients are appropriately treated.
Anticipated learning outcomes:
  • To be aware of the dento-legal issues that can arise during the treatment and management of patients with dementia and other cognitive impairments, as well as how to mitigate such factors in their own practice.
  • To be aware of current guidance and best practice relating to the treatment and management of these patients.
  • To have an understanding of the requirements and considerations that should be taken into account to ensure such patients are appropriately treated.

Dementia is one of the biggest public health challenges of our time. Globally, the number of cases is expected to triple in the next thirty years, from 50 million to 152 million by 2050, according to the World Health Organisation (WHO). In Britain alone, there are thought to be 850,000 people living with dementia but the Alzheimer's Society predicts this will reach two million by 2051.

As these sobering numbers suggest, most of us will know someone - a family member, neighbour or friend - who has the condition. And within the average dental practice it's likely that some patients will be affected. In fact, dental professionals may be the first to notice changes in a patient's behaviour during a routine check-up that may not be as apparent to those who see the patient every day.

Christine Osborne remembers just such an incident from her Surrey dental practice. 'Some years ago, one of our long-standing patients was sitting in the waiting room and repeatedly asking staff what the time was. Because we knew the patient so well, it was obvious something was wrong. When the family heard about our concerns, it seemed to crystallise things for them and they decided to take the patient to see their GP.'

In her 37 years as a GDP, Christine has become experienced in treating patients with dementia, both at her surgery and during domiciliary visits to three local care homes. 'Surrey has an ageing population,' she says. 'Around 14,000 people in the county are estimated to have dementia but this is forecast to rise to 17,000 by 2020. I have patients who have been diagnosed but I am certain there are more who have the condition in its early stages.'

Making a difference through dentistry

Christine believes dental care can make a huge difference to these patients' wellbeing, a view endorsed by the Faculty of General Dental Practice (FGDP). In its recent Dementia-Friendly Dentistry: Good Practice Guidelines, the FGDP states: 'Maintaining oral health brings benefits in terms of self-esteem, dignity, social integration and nutrition. Poor oral health can lead to pain, which the individual may have difficulty articulating, and tooth loss. It can negatively affect self-esteem and the ability to eat, laugh and smile. Both pain and infection can worsen the confusion caused by dementia.'

At the same time, providing care for people with dementia presents some challenges for GDPs. 'There is no getting away from the fact that the patient's dental health will often go downhill as the disease progresses,' says Christine. 'Patients are more likely to forget to brush their teeth and dry mouth is a common side effect of many of the drugs prescribed to the elderly, increasing the risk of decay and infection.

The FGDP says most types of care are still possible for those with early stage dementia but dental professionals should be mindful of the fact that the patient may be unable to look after their own teeth in the long-term. It recommends making preventative measures, such as fluoride varnish and high fluoride content toothpaste part of any oral care plan and says restorative treatment should be 'high quality and low maintenance'.

'We typically recall these patients at three-monthly intervals for cleaning and to ensure they are comfortable,' says Christine. 'And between appointments, I recommend the use of chlorhexidine dental gel and high fluoride toothpaste to protect against decay and reduce the bacteria levels in the mouth.'

Dental professionals may be the first to notice changes in a patient's behaviour during a routine check-up that may not be as apparent to those who see the patient every day.

In the event of a dental emergency, dental professionals need to consider whether the clinical need for a procedure outweighs the possible risks and distress for the patient. 'I had a patient who developed a dental abscess (with a visible swelling) shortly after being admitted to a nursing home,' Christine recalls. 'Sadly, his dementia was going downhill rapidly by that stage so I prescribed a course of antibiotics, rather than attempting root canal treatment. Local anaesthesia, rubber dam placement and canal access would all have been far too frightening for him. I discussed it with his wife and explained why I was doing this and she was entirely in agreement. In the end it is what is in the patients' best interests.'

Assessing the best interests of a patient with dementia can be complex and is easier if the dentist-patient relationship is well-established. The FGDP recommends: 'Where a person with dementia already has a dentist they know and trust, this relationship should continue if possible.' Christine's long-standing relationships with her patients gives her an insight into their concerns and priorities.

'If something felt good before a diagnosis then the chances are it will do so afterwards,' she observes. 'For example, I had a patient with late-stage dementia who had always been very particular about her teeth. Ordinarily she wouldn't open her mouth, but when her daughter turned on her electric tooth brush she would smile and open her mouth. Her daughter would gently move the brush on one side of her mouth while I did an examination and scaling on the other side. Then we would swap sides. We know emotions are one of the last things to go for someone with dementia and this patient associated having clean teeth with feeling happy.'

However, some patients can be confused or unsettled to find themselves in the dental chair. This is more likely if they do not have a history of regular attendance, but a feature of dementia is that sufferers will have good days and bad days.

If a patient becomes distressed or aggressive during treatment, Christine advises dental professionals to stop what they are doing. 'I will take my mask off and sit them up and we have a chat until the patient is calmer. It can also help to hold their hand or touch their shoulder. Body language is really important so try to make horizontal eye contact with the patient rather than peering down at them. I like to sit lower than the patient so they look down at me.'

Environmental changes

Practice surroundings can also be disorientating and overwhelming for patients as their cognitive function deteriorates and it becomes harder to put sensory experiences into context. Glaring lights, noise and even a reflective shiny floor can cause real difficulties, alongside more obvious challenges such as wheelchair access.

When Christine's own practice was purpose-built six years ago, she consciously tried to make it disability-friendly. 'The building is on a single floor,' she explains, 'and we have a wheelchair on the premises, as well as room for a hoist, if necessary. I deliberately brought some of my old waiting room chairs from my old practice so there was something familiar for patients.'

Assessing the best interests of a patient with dementia can be complex and is easier if the dentist-patient relationship is well-established.

Of course, rebuilding from scratch won't be an option in most cases, but it is possible to make small changes to make the practice more comfortable. Something as simple as improving signs can make a major difference for everyone, as Christine observes. 'I once went to a newly built hospital for a meeting and couldn't find the right place because the signage was so poor. To be effective, practice signs should be positioned at eye-level; they should be matt to minimise reflection and there must be a good contrast between the text and background.'

But even while making adjustments for patients, dental professionals should be careful not to assume that dementia is the only explanation for any challenging behaviour. 'Recently one of my patients from the care home was quite aggressive and confrontational when she arrived,' Christine remembers. 'After I had chatted with her for a bit, I found out that her appointment has been made by the care home and she hadn't been told she was going to the dentist until 15 minutes before they left. It wasn't her condition, she was just hacked off and rightly so! She didn't have time to clean her teeth before leaving and she had just had lunch.'

As the FGDP advises, it's a good idea to enlist the help of carers or care home staff to make appointments as stress-free for patients as possible. For example, it is often possible to schedule appointments at a time when the practice is not too busy (to minimise waiting time) or when the patient is typically more alert. There is an optimum time in the day for some people which is worth exploring. Patients with Parkinson's are usually best not long after their medication is taken.

'It's really important for us to look after carers and be supportive,' says Christine. 'Many family members are also patients and will accompany the patient to appointments. This means we can offer them some respite (a sit in the waiting room with a good magazine) and the chance to talk about how things are going. Good communication is really important, from ensuring that carers understand my written treatment plan to advising them on matters such as the patient's diet. For instance, I might suggest they stop buying biscuits (at all) if it seems that the patient cannot keep track of their own consumption.'

On the other hand, dental professionals should be prepared to act if they suspect a vulnerable person is being abused, neglected or subjected to degrading treatment by someone close to them or a care professional. If a patient is living in residential care, concerns should usually be raised with the care home and followed up to check the issue had been properly addressed. If a patient is living at home, Christine recommends seeking advice from the DDU, the patient's GP or the local authority's Multi-Agency Safeguarding Hub.

DDU and BSP periodontal e-learning

Dental practices should also seek out more general information about caring for patients with dementia. Christine suggests getting in touch with a local tutor through the deanery website or contacting the Regional Education Centre. As regional dental tutor for Surrey and West Sussex, Christine has organised evening meetings for local practitioners on different aspects of dementia care, including dento-legal issues such as consent and assessing capacity. Attendees have also heard from dementia care experts and patients themselves.

At one such meeting Christine was struck by a speaker's description of dementia. 'Imagine being on a guided tour of another country and on the last night you all go out for supper together. The next morning you wake up in an alleyway with no phone, money or wallet. You didn't notice the name of the hotel or the address and you cannot communicate with anyone in their language. I use this analogy when training my staff and asked them: wouldn't any of us feel frightened and confused in that situation? Well, that's how it feels when you have dementia.'

Dementia is something that many people fear but dental professionals have an ethical duty to show empathy and compassion towards patients, and as Christine points out, 'there is usually something I can do to make them more comfortable, and let's face it, we all like to have newly polished teeth.'

At the same time, she adds: 'I have a long-term professional relationship with these patients and there is often a lot of laughter.' In other words, caring for patients with dementia and their families is more than an ethical responsibility - it can be an extremely rewarding experience too.

Dento-legal advice

Given the prevalence of dementia and its predicted increase, it makes sense for dental professionals to improve their understanding of the condition and the dento-legal considerations when treating patients.

The following points give an overview, but if you have any specific concerns you can call the DDU helpline on 0800 374 626.

  • Be ready to work with carers in the patient's best interest, but if a patient has capacity you must seek their consent before sharing personal information with others.
  • Understand the process for assessing patients' legal capacity and best interests as set out in the Mental Capacity Act 2005 and its accompanying Code or the Adults With Incapacity (Scotland) Act 2000. Bear in mind that a patient's ability to consent may fluctuate with time and depending on the complexity of the decision.
  • Find out if anyone has legal responsibility for the patient's welfare (someone with lasting power of attorney or an Independent Mental Capacity Advocate) and keep a record of their details.
  • Take extra care to meet patients' specific communication needs and be conscious of your body language. The FGDP's Dementia-Friendly Dentistry includes useful advice, such as always introducing yourself and stating your role, keeping questions simple and trying not to interrupt. There is also Communication Visual Aid in the appendices.
  • Provide written treatment plans, using simple, non-technical language. If appropriate, these can be shared with a carer or someone with legal responsibility.
  • Ensure that you understand your legal duties under the Equality Act 2010 and its statutory Code of Practice. Service providers must make 'reasonable adjustments' to ensure patients are 'provided access to a service as close as it is reasonably possible to get to the standard normally offered to the public at large'. The Dementia Action Alliance has produced a Dementia-Friendly Physical Environments Checklist with useful advice to improve access.
  • If you believe continuing to treat the patient poses a risk to their safety or care, the patient will need to be referred to the community dental service or special care dental service. They can be contacted through your primary care organisation.
  • Find out about local procedures for the protection of vulnerable adults and ensure these contact details are to hand.
  • Make use of available sources of advice and authoritative guidance including the FGDP, the British Society of Gerodontology, charities such as the Alzheimer's Association, Alzheimer's Society or Alzheimer's Research UK and your local deanery.

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This article was correct at publication on 26/04/2018. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

Christine Osborne

BDS (Lon) FFGDP MGDS LDS RCS (Eng)

Christine graduated from Guy's Dental Hospital in 1980. Following two associateships in Surrey she became a practice owner in 1985 in West Byfleet. She relocated the practice for the second time in 2012, and is currently employed by HELASE as dental tutor for Surrey and Sussex and clinical dental adviser.

See more by Christine Osborne