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Management of Patients with Chronic Diseases

Course Number: 567

Alzheimer’s Disease

A progressive, degenerative brain disease beginning with mild memory loss and over time possibly leading to loss of the ability to carry on a conversation and respond to the environment.13-15 A brain with Alzheimer’s disease typically has an accumulation of beta-amyloid plaques outside the neuron and tau tangles inside the neuron.14 As the number of damaged neurons increase, signals will no longer be able to carry information through the synapses. Clinical signs and symptoms are summarized in Figure 2.

Figure 2. Clinical Signs and Symptoms of Alzheimer’s Disease.13,16

  • Memory loss disruptive to daily life
  • Changes in planning or solving problems
  • Difficulty handling money or paying bills and completing other familiar tasks
  • Confusion with time or place
  • Decreased or poor judgment
  • Misplacing things and inability to retrace steps to find them
  • Changes in mood, personality, or behaviors13
  • Withdrawal from work or social activities
  • Problems with words when speaking or writing

Epidemiology and Etiology

Alzheimer’s disease is the most common cause of dementia.13,17 In 2020, 5.8 million Americans were diagnosed with this disease. The number of diagnoses are projected to increase to 14 million people by 2060.13 Signs and symptoms typically of Alzheimer’s disease typically develop after age 60 and risk increases with age.13 Although dementia is caused by damage to brain cells, the actual cause of the damage in Alzheimer’s disease is not yet fully known.16 Age, family history, and genetics appear to increase the likelihood of developing the disease.13,16 There is strong evidence that traumatic brain injury, mid-life obesity, and current smoking also increases the risk of developing AD.18,19 Figure 3 provides additional statistics about this disease.

Figure 3. Alzheimer’s Disease Statistics and Risk Factors.

  • 6th leading cause of death among US adults; 5th among those 65 years or older13,16
  • Nearly 2/3rds of Americans with Alzheimer’s disease are women16
  • Older African-Americans are about twice as likely to have Alzheimer's or other dementias as older whites16
  • Hispanics are about one and one-half times as likely to have Alzheimer's or other dementias as older whites16
  • Risk factors for heart disease and stroke (like high blood pressure/high cholesterol) may also increase risk of Alzheimer’s disease13

Patient Management and Oral Health Considerations for Alzheimer’s Disease

Understanding the oral health status of a patient diagnosed with Alzheimer’s disease can be complicated. Individuals in advanced stages may be unable to verbalize oral pain or discomfort. This may lead to refusal to eat, pulling at the face or mouth, refusal to wear dentures, increased restlessness or shouting, disturbed sleep, refusal to participate in activities, and aggressive behavior.20 Care providers must be aware of behavioral changes that may indicate a patient is experiencing dental problems. It is helpful to have a baseline understanding of each patient’s typical behavior in order to identify when these behaviors are atypical.10

Patients diagnosed with Alzheimer’s disease routinely experience problems in the oral cavity such as periodontal disease, caries, tooth loss, tooth mobility, orofacial pain, impaired swallowing, articular abnormalities in temporomandibular joints, difficulty wearing dentures, sores in mouth, cracked lips, coated tongue, and halitosis.11,14,21-26 Patients may forget how to brush their teeth17or be unable to remember the need for oral hygiene, which may contribute to oral cavity problems.20 Additionally, patients may be taking medications, such as antidepressants, antipsychotics, and sedatives, which have oral side effects such as dry mouth, glossitis, mucositis, glossodynia, dysphagia, candidiasis, and involuntary repetitive tongue and jaw movements.31,32 These oral problems can have a negative impact on eating, smiling, laughing, self-esteem, and quality of life.27-29 Dental providers should recommend rigorous preventive measures such as 3-month hygiene recall appointments, to also include fluoride varnish applications.

Patients diagnosed with Alzheimer’s disease will have diminishing decision-making capacity as the disease progresses. This can create problems with obtaining valid informed consent. When given the opportunity, dental providers should discuss informed consent alternatives with the patient prior to the patient reaching this stage.11,15 Unfortunately, this is not always an option. If a patient is unable to provide valid informed consent, and a surrogate has not been identified, treatment procedures should not be initiated. In emergency situations dental providers may legally act in the best interest of the patient without having informed consent.30