*Anna Haładyj, Tomasz Kaczyński
Oral health assessment in patients with Alzheimer’s disease – a pilot study
Ocena stanu zdrowia jamy ustnej pacjentów z chorobą Alzheimera – badanie pilotażowe
Department of Periodontology and Oral Diseases, Medical University of Warsaw
Head of Department: Professor Renata Górska, MD, PhD
Wstęp. Wyniki najnowszych badań sugerują, że zły stan zdrowia jamy ustnej może mieć wpływ na rozwój choroby Alzheimera oraz wskazują na istniejącą korelację pomiędzy zapalną chorobą przyzębia a chorobą Alzheimera.
Cel pracy. Ocena stanu zdrowia jamy ustnej u pacjentów z chorobą Alzheimera oraz określenie stomatologicznych potrzeb leczniczych tej grupy chorych.
Materiał i metody. Badaniem objęto 35 chorych z chorobą Alzheimera przebywających na oddziale Centrum Alzheimera w Warszawie. Badanie periodontologiczne oraz stomatologiczne przeprowadzono przy łóżkach chorych z wykorzystaniem lampy czołowej, sondy periodontologicznej oraz lusterka stomatologicznego. W badaniu oceniano: liczbę zębów, głębokość kieszonek dziąsłowych, obecność kamienia nazębnego i płytki nazębnej (API, PI), uzupełnia protetyczne, wypełnienia stomatologiczne oraz zmiany na błonach śluzowych.
Wyniki. Wśród badanych tylko 18 osób posiadało szczątkowe uzębienie. U tych pacjentów rozpoznano przewlekłe zapalenie przyzębia oraz stwierdzono potrzebę profesjonalnej opieki periodontologicznej. Liczba osób bezzębnych wynosiła 17, a średnia liczba zębów 5,63. Średnie wartości PWUZ, PI oraz API wynosiły odpowiednio 24,91, 79,0 oraz 82,1%. Patologiczne zmiany na błonie śluzowej zaobserwowano u 34 chorych.
Wnioski. Stan zdrowia przyzębia i całej jamy ustnej u pacjentów z chorobą Alzheimera wymaga szczególnej uwagi ze strony personelu medycznego. Ze względu na zaburzenia poznawcze, utrzymanie właściwej higieny jamy ustnej oraz ruchomych uzupełnień protetycznych może wymagać dodatkowej pomocy. Z tych względów pacjentów z chorobą Alzheimera należy objąć szczególną opieką stomatologiczną oraz zwiększyć świadomość w tym zakresie wśród personelu opiekującego się chorymi.
Introduction. Recent data have shown a possible correlation between periodontitis and Alzheimer’s disease and suggested that poor oral condition may contribute to the clinical onset and progression of Alzheimer’s disease.
Aim. To evaluate the oral health of patients with Alzheimer’s disease and establish a proper dental and periodontal management strategy in this patient population.
Material and methods. The study included 35 subjects diagnosed with Alzheimer’s disease and hospitalised in Alzheimer’s Centre in Warsaw. Bedside periodontal and dental examination was performed in all patients using a periodontal probe, a mirror and a headlamp. Number of teeth, pocket depth, the presence of dental plaque, calculus, PI, API, DMFT, lesions of oral mucosa, as well as conservative and prosthodontic restorations were assessed.
Results. Only 18 patients had residual dentition that allowed to evaluate the periodontal status. All these patients had periodontitis and were in need of professional treatment. The number of edentulous patients was 17, and mean number of present teeth was 5.63. Mean values of DMFT, PI and API were 24.91, 79.0 and 82.1% respectively. Oral mucosa lesions were observed in 34 subjects.
Conclusions. Oral and periodontal health status of patients with Alzheimer’s disease should raise a concern of care providers. Due to cognitive impairment, proper oral hygiene and denture care could not be maintained without additional assistance. Thus these patients should be provided with special dental care. Additionally, the awareness of caretakers about the importance of oral hygiene maintenance should be raised.
Alzheimer’s disease is a chronic, progressive neurodegenerative disorder characterised by cognitive impairment, psycho-behavioural symptoms and verbal disability (1). It is the most common dementia, accounting for 50% of cases (2). In Poland, the number of patients with dementia is approximately 400,000, including about 250,000 AD patients (3). The incidence of this disease increases with age, from 4% in 65-74 age group to 19% in 85-89 years age group (4). Higher incidence of AD in women, who account for two-thirds of all patients, is also observed (5). Current demographic processes in developed countries result in an increase in the elderly population and are thus associated with a growing population affected by age-related diseases. In 2007 in Poland, the proportion of people aged at least 65 years was 13.5% and it is expected to reach 23.2% in 2035 (6). Demographic prognoses regarding population aged 85 years or more assume a three-fold increase in 2035 (3.1%) compared to 2007 (1.1%) (6). It is estimated that by 2020 there will be a four-fold increase in the number of AD patients in Poland, giving about one million affected people (3).
Due to both, the increasing awareness of patients as well as the increase in the level of dental care, the proportion of elderly edentate individuals is systematically decreasing. This contributes to the growing demand for dental care in longer-living patients, who are increasingly less likely to exclusively use complete dentures. Unfortunately, the manual skills of patients deteriorate with age, especially if accompanied by dementia (7). Demographic data indicate that the number of elderly people will continue to increase significantly throughout the world, resulting in the growth in the incidence of dementia, Alzheimer’s disease and other comorbidities, such as diabetes and periodontitis. Oral health affects not only the quality of life in the elderly, but can also impact the overall health. Studies indicate a relationship between chronic periodontitis and multiple systemic diseases, i.e. cardiovascular diseases, respiratory diseases, diabetes, osteoporosis (8), preterm birth and low birth weight (9), pancreatic cancer (10), metabolic syndrome (11), chronic renal failure (12) and rheumatoid arthritis (13). Furthermore, there are reports on the relationship between periodontitis and dementia, including AD (14). Considering the direction of demographic changes in developed countries, special attention should be paid to general health status as well as dental needs in the growing elderly population, with a particular focus on the potential effects of periodontal diseases and caries on general health.
The aim of the study was a clinical assessment of oral hygiene and health in patients with Alzheimer’s disease as well as an attempt to identify dental needs in this patient population.
Material and methods
The study included 35 randomly selected patients diagnosed with Alzheimer’s disease and staying under the care of Alzheimer’s Centre in Warsaw. The study group included 12 males and 23 females aged 57 to 91 years (mean age 80.23 years).
Written informed consent was obtained from all subjects or legal guardians of incapacitated persons prior to study.
Clinical evaluation was performed in the rooms of patients using dental mirrors, WHO 632 periodontal probe and a headlamp. Caries assessment was based on the WHO guidelines for epidemiological research (15) and the number of decayed, filled and missing teeth was recorded. Based on these data, DMFT and care index, assessing the efficacy of caries treatment, were used. Oral hygiene was assessed based on the presence of dental plaque on the four surfaces of each tooth (mesial, distal, lingual and vestibular), and thus O’Leary plaque index (PI) and Lange approximal plaque index (API) were obtained (17). For the purpose of periodontal assessment, the presence of bleeding upon probing, mineralised calculus, pockets with a depth of 3.5 up to 5.5 mm and pockets with a depth of more than 6 mm was evaluated. The presence of oral mucosal lesions and removable dentures was also recorded.
Arithmetic mean and standard deviation were calculated in order to characterise the average values of the evaluated continuous items and their variability. The obtained results were analysed and converted into percentage using Excel.
A total of 35 patients, residing permanently in Alzheimer’s Centre in Warsaw, participated in the study. A total of 26 patients (74.3%) were diagnosed with dementia, almost half had hypertension, and 22% of subjects suffered from coronary artery disease. Only one patient was a habitual smoker. An assessment of periodontal and dental health as well as selected periodontal indices was possible only in 16 (45.7%) patients. Bleeding upon probing, dental plaque and calculus were found in all subjects. Gingival pockets deeper than 6 mm were found in 8 patients. All patients required professional tooth cleaning. O’Leary PI and API were used to assess oral hygiene. PI ranged between 25 and 100% (mean 79 ± 31.18%). The approximal plaque index ranged from 33.33 up to 100% (mean 83.22 ± 25.75%). For the analysis of caries medical history, DMFT comprising a sum of decayed, missing and filled teeth, was used. The DMFT ranged between 11 and 29 (mean 24.91 ± 5.09) in the study group. A detailed analysis of DMFT revealed that missing teeth were dominant (783), followed by decayed (54) and filled (35).
An evaluation of individual DMFT components showed that the number of carious teeth ranged between 0 and 8 (mean 1.54 ± 2.38), the number of missing teeth was 6 to 28 (mean 22.37 ± 7.37), and the number of filled teeth ranged between 0 and 9 (mean 1.0 ± 1.96).
The care index is defined as the ratio of filled teeth to the sum of filled and decayed teeth. It ranged between 0 and 0.8 (mean 0.35 ± 0.32) among subjects.
Clinical assessment of oral health allowed to determine the mean number of teeth, which was 5.63 ± 7.37. There were 16 (45.7%) edentate patients in the study group. Only 10 (28.6%) patients used removable dentures. Type 2 stomatopathy was found in half of the patients.
Clinical assessment revealed that the most common oral mucosal lesions included: exfoliative cheilitis (42.9%), fissured tongue (37.1%), haemangiomas (37.1%), inflammation of the corner of the mouth (31.4%), coated tongue (28.6%) and traumatic lesions (17.1).
Alzheimer’s disease (AD) is a degenerative disorder of the brain characterised by progressive loss of memory and irreversible mental degradation. Cognitive and motor impairment in AD patients as well as multiple medications they receive result in poor oral hygiene, reduced salivation and ineffective control of dental plaque, which renders these patients more susceptible to inflammatory periodontal diseases. The fact that the deteriorating oral health in ageing population can also influence the development or exacerbation of systemic diseases is alarming. Therefore, the potential correlation between Alzheimer’s disease and periodontal diseases, which represent an important public health issue due to their growing incidence, has become the focus of much scientific attention. Recent reports indicate that Alzheimer’s disease is correlated with poor oral hygiene and health, increased incidence of inflammatory periodontal diseases and increased severity of dental caries (18-20). Individuals with dementia were found to show poor oral hygiene (21) and attaching less importance to own health, which is associated with higher incidence of inflammatory periodontal diseases (22). It should be noted that the interpretation of the above findings is limited by difficulty determining whether oral conditions occur prior to dementia or Alzheimer’s disease or are related to advanced age and risk factor accumulation in this group of patients.
The analysis of periodontal indices performed during clinical evaluation revealed very poor oral health. The study group of patients with Alzheimer’s disease showed high needs of dental care, periodontal and prosthetic treatment in particular. More than half of subjects lost their teeth due to inflammatory periodontal disease. A total of 50% patients with dentition had chronic, advanced periodontitis and required comprehensive periodontal treatment. Gingival pockets with a depth between 3.5 and 5.5 mm were found in 25% of subjects. The whole group of patients with dentition required a considerable improvement in oral hygiene as well as professional tooth cleaning to remove hard and soft dental deposits.
High O’Leary’s plaque index (mean 79%) and API (mean 83.2%) indicate poor oral hygiene, increased risk of inflammatory periodontal diseases and caries in patients with Alzheimer’s disease. Furthermore, the mean DMFT calculated for the Warsaw sample (24.91) was also comparable to the mean DMFT values obtained by Hatipoglu et al. (23) and Ribeiro et al. (24). The results are associated with the limited ability of patients to manually remove dental plaque due to their advanced age and mobility impairment caused by Alzheimer’s disease. Unfortunately, they also indicate poor awareness and involvement of caregivers in daily oral hygiene procedures of their patients. The above findings correspond with the conclusions drawn by Hatipoglu et al. (23) and Ribeiro et al. (24). It should be emphasised that a comparison between our patients and a peer group of healthy individuals would allow to determine whether Alzheimer’s disease had a direct impact on oral health. Our research on oral health in AD patients is a preliminary, pilot study due to small sample size. Therefore, our findings on the effects of AD on oral health in the study group should be interpreted with some limitation. Nevertheless, they clearly point to poor oral health and hygiene.
Attention should be paid to the fact that all subjects required new removable dentures. Only 28.6% of patients used full dentures. Unfortunately, it should be noted that all dentures were in very poor condition and required replacement – both patients and their caregivers tended to forget about their cleaning or removing before going to sleep at night, which resulted in a continuous accumulation of food and plaque within dentures and the remaining teeth.
There are studies indicating that patients with Alzheimer’s disease show poor oral hygiene compared to healthy individuals and that the stage of AD can have an impact on oral health (25, 26). According to literature, Alzheimer’s disease, which causes a number of psycho-behavioural changes and disability, can accelerate tooth loss. In our study, the U-factor was the highest for the DMFT, and the lowest for filled teeth, which may suggest that the complications of caries and inflammatory periodontal disease leading to tooth extraction were more common in our study group. Untreated caries is a major cause of pulpal complications and leads to odontogenic infections, which are particularly dangerous for chronically ill patients. A number of studies indicate that the incidence of caries in AD patients is significantly higher compared to healthy individuals (25-28). Therefore, this group of patients require special dental care and prophylaxis programme.
Summing up the analysis of oral health in patients with Alzheimer’s disease, it can be sadly concluded that the oral health in these patients is very poor. We have found in the study that neglected oral hygiene, the presence of untreated caries, as well as the periodontal and prosthetic needs indicate that this group of patients require special dental care, while their caregivers should be provided with appropriate health education. It also highlights the need for effective cooperation between dentists and physicians dealing with AD patients as it likely that these patients are at increased risk of caries and periodontitis.
1. The study has found an alarmingly poor condition of oral health in patients with Alzheimer’s disease as well as identified the need to provide these patients with dental care.
2. The knowledge and awareness of caregivers and doctors of AD patients are insufficient. Special attention should be paid to the importance of maintaining good oral health in these patients.
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