Update in clinical procedures

Dementia is a condition that alters memory and hinders the individual’s ability to maintain social relations. It generally involves at least one of the following symptoms: language disorders, apraxia, cognitive and motor dysfunction. The time between initial diagnosis and patient death can vary between 8 and 12 years on average, depending on age and general health status[2].

[2] American Psychiatric Association 1994

Dementia: a growing challenge for public health

As life expectancy increases, as does the prevalence of dementia. Patients with dementia are more likely to have caries, periodontal disease and impaired oral hygiene (Syrjälä et al., 2010). Additionally, these patients tend to have a diet with higher levels of sugars, have lower levels of salivation, motor function and swallowing problems, habitual sucking motions, impaired chewing function and difficulties in managing their prostheses (especially implant-supported prostheses).

Furthermore, patients with dementia are less likely to co-operate, may refuse to brush their teeth or let them be brushed for them. This makes it difficult to examine or treat them. It is therefore crucial to follow a treatment plan specific to patients with severe cognitive disorders, emphasising prevention rather than treatment (Niessen et al., 1985).

Peri-implantitis is found more and more in elderly patients

The incidence of peri-implantitis in elderly patients is increasing. This is because implants are now being placed at more advanced ages, and patients who have received implants are living longer. Some studies have shown that the rate of implant loss in patients between the ages of 65 and 80 are similar to that of younger age groups (Srinivasan et al., 2017; Bertl et al., 2019), but the inflammatory response is stronger and less reversible. This points to a crucial question: how do we handle implant-reconstructions after the onset of dementia?

Immunosenescence

The immune system weakens with age, leading to greater susceptibility to infection, neoplasia and autoimmunity (Ebersole 2016). This aging of the immune system, or ‘immunosenescence’, results in a pro-inflammatory status. When this ‘inflamm-ageing’ affects the immune cells in the periodontium, it worsens the biological response to the oral bacterial burden.

Peri-implantitis and patients with dementia

We have only anecdotal clinical experience. However, millions of implants have already been placed, and practitioners and researchers have a responsibility to follow them throughout the patient’s life, and to collect enough clinical data to help patients take care of them when they no longer can.

The ‘back-off’ strategy: de-sophistication of treatments

Dementia causes motor coordination to deteriorate. Patients with dementia usually cannot wear their prostheses over time, as they are less able to put them in or use them. The type of prosthesis should therefore be adapted to the patient’s dexterity, which changes continually as the condition progresses. Prothesis retention should be adjusted to the maximum that patients can handle for themselves. Fixed prostheses should be changed to removable prostheses, and bar overdentures changed to locators, which are easier to clean. These can be changed at a later date to ball attachments and magnets as the patient’s abilities deteriorate. Finally, implants can be made ‘dormant’ by placing healing caps and readjusting the denture base.

The speaker outlined an oral health care plan for dementia:

• Prevent technical failures by properly selecting the components and prothesis design
• Optimise prosthesis self-cleaning morphology, and motivate and instruct caregivers in providing assisted oral hygiene
• Provide adequate retention to facilitate chewing efficiency and to ease handling by the patient (according to the ‘back-off’ strategy)
• Anticipate the patient’s future deterioration and potential changes which may be needed when oral hygiene compliance becomes difficult