# data[].attributes.attachment_caption
(Aging and Oral Health Problems | Artistic Touch Dentistry | %, 2020)

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Regular Dental Check-ups:

Emphasize the importance of routine dental visits for professional cleanings and examinations.

An early detection of issues can lead to the prevention of more significant problems.

Proper Brushing Techniques:

To avoid irritation and damage to sensitive gums, highlight the importance of using a soft-bristled toothbrush.

Instruct on gentle circular or back-and-forth brushing motions, ensuring coverage of all tooth surfaces.

Encourage brushing twice a day for at least two minutes each session.

Managing Xerostomia/ Saliva Substitutions

Recommend sugar-free gum or candies to stimulate saliva production.

In chronic xerostomia cases, suggest using saliva substitutes or artificial saliva to maintain oral moisture.

Denture Care:

Emphasize the importance of removing and cleaning dentures daily to prevent plaque buildup and irritation.

Stress proper storage of dentures in a cleansing solution when not in use.

Orthodontic Considerations:

For individuals with orthodontic appliances, reinforce meticulous cleaning around brackets, wires, and other components.

Regular orthodontic check-ups are crucial to address any issues promptly.

Nutritional Guidance:

Encourage a balanced diet rich in essential nutrients, including calcium and vitamin D, for overall oral and bone health.

Discourage excessive consumption of sugary and acidic foods and beverages.

Oral Cancer Screenings:

Reinforce the importance of regular oral cancer screenings during dental check-ups.

Encourage self-examination for unusual changes in the mouth, lips, or throat.

Adaptation to Physical Limitations:

Consider adaptive tools, such as electric toothbrushes or floss holders, for individuals with physical limitations.

Ensure that dental hygiene practices are adapted to the individual's capabilities.

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Physiological changes that occur in oral health due to aging:

# data[].attributes.subject
Physiological changes that occur in oral health due to aging:

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Enamel Thinning:

Over time, the enamel, the outermost layer of the tooth, may thin due to natural wear and tear.

Thinning enamel makes teeth weaker and more vulnerable to decay, which can result from general aging.

Dentin Changes:

Dentin, the layer beneath the enamel, may experience changes with age.

Dentin naturally thickens over time, leading to the yellowing or darkening of teeth as it becomes more visible through the translucent enamel.

Gum Recession:

The gums tend to recede gradually with age, exposing parts of the tooth root.

Reduced Salivary Flow:

Saliva production tends to decrease as individuals age.

Reduced salivary flow can result in xerostomia, impacting the ability to cleanse the mouth, neutralize acids, and prevent tooth decay.

Tooth Mobility:

Teeth may become more mobile as supporting bone density decreases over time.

Jaw and Muscles:

The support structure for teeth may be affected due to the loss of bone density in the jaw.

Masticatory muscles may experience atrophy, impacting the efficiency of chewing.

These physiological changes are crucial for dental professionals and caregivers to tailor oral health care for older individuals.

# data[].attributes.attachment_caption
(Cognitive Decline in Old Age Could Be a Warning Sign for Issues with Motor Skills, 2020)

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How cognitive decline in aging adults impacts their oral health:

# data[].attributes.subject
How cognitive decline in aging adults impacts their oral health:

# data[].attributes.body
Neglect of Oral Hygiene:

Aging adults experiencing cognitive decline may forget to brush or floss or have trouble with dexterity, they may be less aware of oral health importance.

Dental caries are very common in cognitively impaired patients because of poor oral hygiene due to a lack of support from caregivers and regular dental care.

Possibility of an increased likelihood of infections like thrush due to a decline in oral health care.

Inability to Communicate Pain:

May struggle to report or explain dental discomfort.

Those advancing in age may have difficulties with expressive and receptive communication when speaking about possible oral health issues they may be experiencing.

Resistance to Care:

May resist hygiene or dental visits.

Agitation is a common aspect seen in those with cognitive impairments such as Alzheimer's and dementia, the dental office can be a very sensory-ridden environment that may cause them to be upset

Unhealthy Dietary Habits:

May be more likely to eat sugary or unhealthy foods due to declined awareness of health importance.

Dental Appliances Challenges:

May have difficulty adapting to dentures or bridges.

Memory loss or dexterity issues associated with cognitive decline may cause some denture users to struggle when using dentures

Financial/Organizational Issues:

May have trouble managing dental health-related logistics

# data[].attributes.headline
Modifications to dental hygiene treatment

# data[].attributes.subject
Modifications to dental hygiene treatment

# data[].attributes.body
It's important clients are comfortable when in the dental office. Elderly patients may require some modifications to their appointments.

treatment may have to be done in a wheelchair.

some clients may not tolerate being reclined back much in dental chairs, or reclined at all. This leaves them having to sit completely upright and you as the provider standing for treatment.

support workers or family may be present during appointments depending on client's independence

if client has xerostomia, water breaks may be necessary

mid-day appointments may be more convenient

# data[].attributes.body
Some elderly clients in the dental office may present with some dexterity issues. This could be caused by a few issues such as:

arthritis

grip strength

attention/memory

It's important when teaching oral self-care aids that we as dental hygienists take into consideration the client's dexterity.

Some modifications to help clients with dexterity are

toothbrush handles that are extended may be easier for patients

toothbrush handles with grips on them to increase diameter

electric toothbrushes

floss with toothbrush- like handle

water flossers

Without proper oral self-care this can increase plaque, calculus, risk of caries, and periodontal disease. If oral health isn't being sufficiently taken care of this can increase patients' risk of systemic conditions.

# data[].attributes.attachment_link.readable_text
PURCHASE COURSE
This course was published in the September 2023 issue and expires September 2026. The authors have no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.

AGD Subject Code: 750

EDUCATIONAL OBJECTIVES

After reading this course, the participant should be able to:

1. Identify the demographics and background of patients living with Alzheimer disease/dementia (AD/D).

2. List oral hygiene modifications that can help patients maintain their oral health and sense of independence.

3. Note the importance of the caregiver in supporting oral hygiene.

4. Explain a possible workflow to develop dynamic and consistent review of oral hygiene instruction modifications for patients with AD/D.

The deterioration of cognitive functions, such as executive functioning, working memory, attention, aphasia, and apraxia, complicates the ability to provide dental care to patients with Alzheimer disease/dementia (AD/D). Dementia is a comprehensive term used to describe a significant decline in cognitive abilities that interferes with an individual's ability to carry out daily activities. AD is common among patients with dementia.

The functional changes caused by dementia, such as a decline in hand grip strength and manual dexterity, can make performing oral hygiene challenging. Without appropriate oral hygiene modifications, individuals with AD/D are at greater risk for dental caries, gingivitis, and periodontitis. Periodontitis is associated with a variety of systemic disorders such as type 2 diabetes and cardiovascular disease. Practicing good oral hygiene at home plays a quintessential part in reducing systemic health risks and maintaining good oral health.

Enhancing the oral hygiene and dental health of individuals with AD/D can be achieved through several means, including educating both formal and informal caregivers on proper oral care techniques, utilizing oral hygiene assessment tools, and providing regular professional dental care. Over time, these interventions can be tailored to address specific patient needs. ¹⁻³

In 2022, approximately 6.5 million Americans age 65 and older were diagnosed with AD/D. Almost three quarters of this population are older than 75. By 2050, the number of Americans living with the disease is expected to increase to more than 12 million; worldwide this number is estimated to be 152 million. 1,2 The majority of aid provided to older adults living with AD/D comes from family, friends, or caregivers who provide help with activities of daily living. These may include personal hygiene activities, such as bathing and dressing; transportation; eating; maintenance of medication regimen; and other tasks that directly impact quality of life. Often, caregivers who assist do not receive payment for their work. ¹

Oral Systemic Link

Emerging studies point toward a link between poor oral health and AD/D. Periodontitis may play a role in AD/D progression. ³⁻⁶ Although research has begun to show evidence of a possible connection between periodontitis and the presence of dementia, a concise description of the relationship between the two remains unknown. Currently, there is a lack of well-designed studies that support this connection, but cohort and case-control studies of medium and high quality indicate a lack of daily performance of oral hygiene (eg, toothbrushing) and gingival inflammation are associated with the development of dementia. 3,4

With the direct correlation between poor oral hygiene and dental caries, infection, and tooth loss, oral hygiene is critical in this patient population. Demonstrating modified oral hygiene techniques and recommending supplemental oral hygiene tools can significantly improve patients' oral health and overall health.

If patients with AD/D can no longer effectively brush and floss, modifications should be implemented to improve performance and preserve independence. If patients can no longer execute effective oral hygiene even with modifications, then the caregiver should be given instructions and appropriate modification suggestions to optimize the oral care regimen performed at home.

Oral Care Strategies

A variety of tools are available to help patients improve their oral hygiene regimen. Recommendations should be based on patients' specific limitations. Depending on patients' physical abilities, caregivers may also need instruction to either assist in daily oral hygiene activities or take them over completely.

Prior to the initiation of any examination or treatment, patients must have the consent of their legal guardian if guardianship is in place. In this instance, patients may no longer be able to make decisions about their healthcare, and cannot consent to treatment alone. ¹ Documentation should be presented at the initial appointment, and the guardian should be present or contacted to give consent to any treatment. Documentation should be kept in patients' secured charts/records. If there is ever any doubt of whether a patient is able to make treatment decisions alone, his or her primary care provider should be consulted.

When the problem is poor grip strength, a number of modifications can improve patients' abilities to perform oral hygiene at home. Inexpensive modified silicone or rubber-based grips increase the diameter of the toothbrush handle, making it easier for patients to grasp during brushing. Alternatively, a small hand towel wrapped around the toothbrush handle and secured with rubber bands can also work. If these solutions are not effective, a three-dimensional printed grip can be fabricated from a functional impression of the patient's hand.

If patients have issues with dexterity, it may be difficult for them to execute the fine motor skills needed to properly brush. Introducing an electric toothbrush may help. A modified grip that extends the toothbrush handle so patients do not need to their lift arms into an uncomfortable position for a prolonged period of time is another option.

A three-sided toothbrush can be incorporated into the patients' regimens. Because the buccal, occlusal, and lingual surfaces can be cleansed simultaneously, this brush reduces the amount of motion patients need to execute to achieve proper plaque removal.

A more recent entry in the toothbrush market is the u-shaped toothbrush. It requires a small range of motion to operate, but studies indicate it may not be effective at removing dental plaque. 10,11

Flossing may also become more difficult as manual dexterity diminishes. Without flossing, oral health is difficult to achieve and maintain, increasing the likelihood of caries and periodontal disease progression, especially in the molar areas. ¹² Using a flosser with a toothbrush-like handle allows patients to modify their grip. Patients may find this flosser easier to use than traditional floss. Water flossers can also be used; they have been shown to be as effective as conventional flossing in plaque removal. ⁷⁻⁹

If patients are showing signs of forgetfulness, memory aids can be incorporated into their daily routines. Something as simple as a memory board or gentle, consistent reminders from a caregiver can improve compliance. Do not give patients vague instructions. Use short, simple sentences to guide the patient step-by-step through the procedure, such as brushing or flossing. ¹ Oral hygiene techniques should be modified so patients can independently complete this daily task.

Focus on the Caregivers

If patients can no longer brush and floss due to advanced disease or severe limitations, caregivers become pivotal in maintaining adequate at-home oral care. Speaking with caregivers/guardians via phone, video, or chairside to provide solutions is key.

Oral health professionals need to demonstrate how and when to put in and take out any dental appliances such as partials or dentures, as well as instruction on cleaning and storing these appliances at bedtime. Providing information, training, and tools to help caregivers support patients' oral hygiene greatly improves their chance of maintaining their oral health.

The use of traditional mouthrinse may raise the risk for aspiration among patients with advanced AD/D. 13,14 Mouthrinse strips may enable patients to use this product safely.

Brushing can be a challenge for caregivers, even with instruction. Caregivers have limited vision and often cannot see how effective their brushing technique is in the posterior region. It may also be difficult for caregivers to know how far posteriorly to place the brush head, which could cause discomfort. A three-sided toothbrush may simplify brushing. The brush's head is often smaller and easier to place in posterior areas for more effective plaque removal. 15,16

The use of flossers and interdental brushes with longer toothbrush-like handles eliminates the need for the caregiver to place fingers inside of the patient's mouth, thus preventing any accidental biting during flossing.

Educating caregivers on how to detect potential issues related to patients' oral health is critical. As the disease progresses, patients alone may not be able to identify the need for dental care. Caregivers should contact the dental care provider if they see any obvious dental issues (eg, broken fillings, sores, swelling, pain, discomfort, sensitivity, poorly fitting dental appliances, etc).

Oral Hygiene Pathway

Devising a systematic pathway to evaluate the need for oral hygiene modifications can be instrumental in ensuring that the oral hygiene instruction (OHI) fits the patient's needs (Figure 1). It also allows for consistent review and additional modifications to continually support patients in their quest to maintain good oral health.

As AD/D progresses, the efficacy of the patients' oral hygiene routines may need to be re-evaluated to ensure they are being supported. This also provides an opportunity for dental care providers to identify when caregivers should become more actively involved in the daily oral hygiene care process.

Conclusion

In order for it to work at its highest efficacy, OHI must be modified to fit the needs of the patient. Vigilance is also key, since AD/D is a progressive disease with no known cure. Re-evaluating patients' abilities to perform oral hygiene at regular intervals ensures that modifications are implemented in a timely fashion, reducing the likelihood of prolonged lapses in adequate at-home oral care. When traditional instruction no longer yields oral health, the reason for the change must be identified. A systematic protocol has the potential to provide an environment conducive to maintaining oral health in spite of disease progression in this patient population.

Acknowledgments

The authors would like to thank Claudia Espinal, Stephanie Diaz, and the South East Texas Geriatric Workforce Enhancement Program for their help with this manuscript.

References

1. Alzheimer's Association. Alzheimer's Disease and Dementia. Available at alz.org/alzheimers-dementia/facts-figures. Accessed August 22, 2023.

2. Li X, Feng X, Sun X, Hou N, Han F, Liu Y. Global, regional, and national burden of Alzheimer's disease and other dementias, 1990-2019. Front Aging Neurosci. 2022;14:937486

3. Elwishahy A, Antia K, Bhusari S, Ilechukwu NC, Horstick O, Winkler V. Porphyromonas Gingivalis as a risk factor to alzheimer's disease: a systematic review. J Alzheimers Dis Rep. 2021;5:721-732.

4. Daly B, Thompsell A, Sharpling J, et al. Evidence summary: the relationship between oral health and dementia. Br Dent J. 2017;223:846-853.

5. Noble JM, Scarmeas N, Celenti RS, et al. Serum IgG antibody levels to periodontal microbiota are associated with incident Alzheimer disease. PLoS One. 2014;9:e114959.

6. Sparks Stein P, Steffen M J, Smith C, et al. Serum antibodies to periodontal pathogens are a risk factor for Alzheimer's disease. 2012;8:196-203.

7. Abdellatif H, Alnaeimi N, Alruwais H, Aldajan R, Hebbal MI. Comparison between water flosser and regular floss in the efficacy of plaque removal in patients after single use. Saudi Dent J. 2021;33:256-259.

8. Lyle DM, Goyal CR, Qaqish JG, Schuller R. Comparison of water flosser and interdental brush on plaque removal: a single-use pilot study. J Clin Dent. 2016;27:23-26.

9. Goyal CR, Lyle DM, Qaqish JG, Schuller R. Comparison of water flosser and interdental brush on reduction of gingival bleeding and plaque: a randomized controlled pilot study. J Clin Dent. 2016;27:61-65.

10. Nieri M, Giuntini V, Pagliaro U, Giani M, Franchi L, Franceschi D. Efficacy of a u-shaped automatic electric toothbrush in dental plaque removal: a cross-over randomized controlled trial. Int J Environ Res Public Health. 2020;17:4649.

11. Schnabl D, Wiesmüller V, Hönlinger V, et al. Cleansing efficacy of an auto-cleaning electronic toothbrushing device: a randomized-controlled crossover pilot study. Clin Oral Invest. 2021;25:247-253.

12. Marchesan JT, Byrd KM, Moss K, et al. Flossing is associated with improved oral health in older adults. J Dent Res. 2020;99:1047-1053.

13. Arcand M. End-of-life issues in advanced dementia: Part 2: management of poor nutritional intake, dehydration, and pneumonia. Can Fam Physician. 2015;61:337-341.

14. Mitchell SL, Teno JM, Kiely DK, et al. The clinical course of advanced dementia. N Engl J Med. 2009;361:1529-1538.

15. Al-Omiri MK, Al-Shayyab MH, Alahmari NM, et al. Impacts of the triple bristles three-sided sonic powered toothbrush on tooth shade, plaque control and gingival health. Int J Dent Hyg. 2021;19:382-397.

16. AL‐Omiri MK, Abu‐Awwad M, Bustani M, et al. Oral health status, oral health‐related quality of life and personality factors among users of three‐sided sonic‐powered toothbrush versus conventional manual toothbrush. Int J Dent Hyg. 2023;21:371-381.

Resources for Caregivers
Oral Hygiene for Caregivers and Families With or Without Dementia https://youtu.be/XHpfP_pHTb8
Demonstrating Oral Health Assessment for Nondental Professionals https://youtu.be/wXuYxQNd7gs

From Dimensions in Dental Hygiene. September 2023; 21(8):36-41.

# data[].attributes.attachment_link.title
Modifying Oral Hygiene Techniques to Improve Oral Health - Dimensions of Dental Hygiene | Magazine

# data[].attributes.attachment_link.description
Dimensions of Dental Hygiene is a monthly, peer-reviewed journal that reconnects practicing dental hygienists with the nation's leading educators and researchers. Dimensions is committed to the highest standards of professionalism, accuracy, and integrity in our mission of education supporting oral health professionals and those allied with the dental industry.

# data[].attributes.body
Poor oral hygiene can lead to systemic conditions such as:

• Cardiovascular disease (CVD) and stroke

• Diabetes

• Osteoporosis

• Malnutrition

• Pneumonia

• Gum disease and bad breath

It's important oral health education and oral self-care aids are heavily emphasized at dental hygiene appointments. Elderly patients have a weaker immune system. This puts them at a higher risk of developing systemic conditions.

There is a bilateral connection between oral health and systemic diseases.

As dental hygienists, we can educate our elderly clients on this connection and bring awareness. We can also ensure proper oral self-care is being implemented in their day-to-day lives.

# data[].attributes.body
Aging changes in teeth and gums: MedlinePlus Medical Encyclopedia. (2015). Medlineplus.gov. https://medlineplus.gov/ency/patientinstructions/000951.htm

Borreani, E., Wright, D., Scambler, S., & Gallagher, J. E. (2008). Minimising barriers to dental care in older people. BMC oral health, 8, 7. https://doi.org/10.1186/1472-6831-8-7

Chen, X., Clark, J. J., Chen, H., & Naorungroj, S. (2015). Cognitive impairment, oral self-care function and dental caries severity in community-dwelling older adults. Gerodontology, 32(1), 53–61. https://doi.org/10.1111/ger.12061

Ho, S. Y., Walsh, L. J., Pradhan, A., Yang, J., & Lopez Silva, C. P. (2024). Perspectives of oral health therapists on the barriers to oral care provision in nursing homes in Singapore: A qualitative analysis. Special Care in Dentistry, 44(1), 157–165. https://doi-org.georgian.idm.oclc.org/10.1111/scd.12833

Potts, E., Naderi, R., Hashmani, K., Catic, A., & Kiefer, L. (2023, September 15). Modifying oral hygiene techniques to improve oral health - dimensions of Dental Hygiene: Magazine. Dimensions of Dental Hygiene | Magazine.

https://dimensionsofdentalhygiene.com/article/modifying-oral-hygiene-techniques-to-improve-oral-health/

Raphael, C. (2017). Oral Health and Aging. American Journal of Public Health, 107(S1), S44–S45. https://doi.org/10.2105/ajph.2017.303835

‌

Sano, M., Cummings, J. L., Auer, S., Bergh, S., Fischer, C. E., Gerritsen, D., Grossberg, G., Ismail, Z., Lanctôt, K., Lapid, M. I., Mintzer, J., Palm, R., Rosenberg, P. B., Splaine, M., Zhong, K., & Zhu, C. W. (2023). Agitation in cognitive disorders: Progress in the International Psychogeriatric Association consensus clinical and research definition. Agitation in Cognitive Disorders: Progress in the International Psychogeriatric Association Consensus Clinical and Research Definition, 1–13. Cambridge University Press. https://doi.org/10.1017/s1041610222001041

Sobral, A. I. G. D. P., de Araújo, C. M. T., & Sobral, M. F. F. (2018). Mild cognitive impairment in the elderly Relationship between communication and functional capacity. Dementia & neuropsychologia, 12(2), 165–172. https://doi.org/10.1590/1980-57642018dn12-020009

# data[].attributes.attachment_link.readable_text
PURCHASE COURSE
This course was published in the September 2023 issue and expires September 2026. The authors have no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.

AGD Subject Code: 750

EDUCATIONAL OBJECTIVES

After reading this course, the participant should be able to:

1. Identify the demographics and background of patients living with Alzheimer disease/dementia (AD/D).

2. List oral hygiene modifications that can help patients maintain their oral health and sense of independence.

3. Note the importance of the caregiver in supporting oral hygiene.

4. Explain a possible workflow to develop dynamic and consistent review of oral hygiene instruction modifications for patients with AD/D.

The deterioration of cognitive functions, such as executive functioning, working memory, attention, aphasia, and apraxia, complicates the ability to provide dental care to patients with Alzheimer disease/dementia (AD/D). Dementia is a comprehensive term used to describe a significant decline in cognitive abilities that interferes with an individual's ability to carry out daily activities. AD is common among patients with dementia.

The functional changes caused by dementia, such as a decline in hand grip strength and manual dexterity, can make performing oral hygiene challenging. Without appropriate oral hygiene modifications, individuals with AD/D are at greater risk for dental caries, gingivitis, and periodontitis. Periodontitis is associated with a variety of systemic disorders such as type 2 diabetes and cardiovascular disease. Practicing good oral hygiene at home plays a quintessential part in reducing systemic health risks and maintaining good oral health.

Enhancing the oral hygiene and dental health of individuals with AD/D can be achieved through several means, including educating both formal and informal caregivers on proper oral care techniques, utilizing oral hygiene assessment tools, and providing regular professional dental care. Over time, these interventions can be tailored to address specific patient needs. ¹⁻³

In 2022, approximately 6.5 million Americans age 65 and older were diagnosed with AD/D. Almost three quarters of this population are older than 75. By 2050, the number of Americans living with the disease is expected to increase to more than 12 million; worldwide this number is estimated to be 152 million. 1,2 The majority of aid provided to older adults living with AD/D comes from family, friends, or caregivers who provide help with activities of daily living. These may include personal hygiene activities, such as bathing and dressing; transportation; eating; maintenance of medication regimen; and other tasks that directly impact quality of life. Often, caregivers who assist do not receive payment for their work. ¹

Oral Systemic Link

Emerging studies point toward a link between poor oral health and AD/D. Periodontitis may play a role in AD/D progression. ³⁻⁶ Although research has begun to show evidence of a possible connection between periodontitis and the presence of dementia, a concise description of the relationship between the two remains unknown. Currently, there is a lack of well-designed studies that support this connection, but cohort and case-control studies of medium and high quality indicate a lack of daily performance of oral hygiene (eg, toothbrushing) and gingival inflammation are associated with the development of dementia. 3,4

With the direct correlation between poor oral hygiene and dental caries, infection, and tooth loss, oral hygiene is critical in this patient population. Demonstrating modified oral hygiene techniques and recommending supplemental oral hygiene tools can significantly improve patients' oral health and overall health.

If patients with AD/D can no longer effectively brush and floss, modifications should be implemented to improve performance and preserve independence. If patients can no longer execute effective oral hygiene even with modifications, then the caregiver should be given instructions and appropriate modification suggestions to optimize the oral care regimen performed at home.

Oral Care Strategies

A variety of tools are available to help patients improve their oral hygiene regimen. Recommendations should be based on patients' specific limitations. Depending on patients' physical abilities, caregivers may also need instruction to either assist in daily oral hygiene activities or take them over completely.

Prior to the initiation of any examination or treatment, patients must have the consent of their legal guardian if guardianship is in place. In this instance, patients may no longer be able to make decisions about their healthcare, and cannot consent to treatment alone. ¹ Documentation should be presented at the initial appointment, and the guardian should be present or contacted to give consent to any treatment. Documentation should be kept in patients' secured charts/records. If there is ever any doubt of whether a patient is able to make treatment decisions alone, his or her primary care provider should be consulted.

When the problem is poor grip strength, a number of modifications can improve patients' abilities to perform oral hygiene at home. Inexpensive modified silicone or rubber-based grips increase the diameter of the toothbrush handle, making it easier for patients to grasp during brushing. Alternatively, a small hand towel wrapped around the toothbrush handle and secured with rubber bands can also work. If these solutions are not effective, a three-dimensional printed grip can be fabricated from a functional impression of the patient's hand.

If patients have issues with dexterity, it may be difficult for them to execute the fine motor skills needed to properly brush. Introducing an electric toothbrush may help. A modified grip that extends the toothbrush handle so patients do not need to their lift arms into an uncomfortable position for a prolonged period of time is another option.

A three-sided toothbrush can be incorporated into the patients' regimens. Because the buccal, occlusal, and lingual surfaces can be cleansed simultaneously, this brush reduces the amount of motion patients need to execute to achieve proper plaque removal.

A more recent entry in the toothbrush market is the u-shaped toothbrush. It requires a small range of motion to operate, but studies indicate it may not be effective at removing dental plaque. 10,11

Flossing may also become more difficult as manual dexterity diminishes. Without flossing, oral health is difficult to achieve and maintain, increasing the likelihood of caries and periodontal disease progression, especially in the molar areas. ¹² Using a flosser with a toothbrush-like handle allows patients to modify their grip. Patients may find this flosser easier to use than traditional floss. Water flossers can also be used; they have been shown to be as effective as conventional flossing in plaque removal. ⁷⁻⁹

If patients are showing signs of forgetfulness, memory aids can be incorporated into their daily routines. Something as simple as a memory board or gentle, consistent reminders from a caregiver can improve compliance. Do not give patients vague instructions. Use short, simple sentences to guide the patient step-by-step through the procedure, such as brushing or flossing. ¹ Oral hygiene techniques should be modified so patients can independently complete this daily task.

Focus on the Caregivers

If patients can no longer brush and floss due to advanced disease or severe limitations, caregivers become pivotal in maintaining adequate at-home oral care. Speaking with caregivers/guardians via phone, video, or chairside to provide solutions is key.

Oral health professionals need to demonstrate how and when to put in and take out any dental appliances such as partials or dentures, as well as instruction on cleaning and storing these appliances at bedtime. Providing information, training, and tools to help caregivers support patients' oral hygiene greatly improves their chance of maintaining their oral health.

The use of traditional mouthrinse may raise the risk for aspiration among patients with advanced AD/D. 13,14 Mouthrinse strips may enable patients to use this product safely.

Brushing can be a challenge for caregivers, even with instruction. Caregivers have limited vision and often cannot see how effective their brushing technique is in the posterior region. It may also be difficult for caregivers to know how far posteriorly to place the brush head, which could cause discomfort. A three-sided toothbrush may simplify brushing. The brush's head is often smaller and easier to place in posterior areas for more effective plaque removal. 15,16

The use of flossers and interdental brushes with longer toothbrush-like handles eliminates the need for the caregiver to place fingers inside of the patient's mouth, thus preventing any accidental biting during flossing.

Educating caregivers on how to detect potential issues related to patients' oral health is critical. As the disease progresses, patients alone may not be able to identify the need for dental care. Caregivers should contact the dental care provider if they see any obvious dental issues (eg, broken fillings, sores, swelling, pain, discomfort, sensitivity, poorly fitting dental appliances, etc).

Oral Hygiene Pathway

Devising a systematic pathway to evaluate the need for oral hygiene modifications can be instrumental in ensuring that the oral hygiene instruction (OHI) fits the patient's needs (Figure 1). It also allows for consistent review and additional modifications to continually support patients in their quest to maintain good oral health.

As AD/D progresses, the efficacy of the patients' oral hygiene routines may need to be re-evaluated to ensure they are being supported. This also provides an opportunity for dental care providers to identify when caregivers should become more actively involved in the daily oral hygiene care process.

Conclusion

In order for it to work at its highest efficacy, OHI must be modified to fit the needs of the patient. Vigilance is also key, since AD/D is a progressive disease with no known cure. Re-evaluating patients' abilities to perform oral hygiene at regular intervals ensures that modifications are implemented in a timely fashion, reducing the likelihood of prolonged lapses in adequate at-home oral care. When traditional instruction no longer yields oral health, the reason for the change must be identified. A systematic protocol has the potential to provide an environment conducive to maintaining oral health in spite of disease progression in this patient population.

Acknowledgments

The authors would like to thank Claudia Espinal, Stephanie Diaz, and the South East Texas Geriatric Workforce Enhancement Program for their help with this manuscript.

References

1. Alzheimer's Association. Alzheimer's Disease and Dementia. Available at alz.org/alzheimers-dementia/facts-figures. Accessed August 22, 2023.

2. Li X, Feng X, Sun X, Hou N, Han F, Liu Y. Global, regional, and national burden of Alzheimer's disease and other dementias, 1990-2019. Front Aging Neurosci. 2022;14:937486

3. Elwishahy A, Antia K, Bhusari S, Ilechukwu NC, Horstick O, Winkler V. Porphyromonas Gingivalis as a risk factor to alzheimer's disease: a systematic review. J Alzheimers Dis Rep. 2021;5:721-732.

4. Daly B, Thompsell A, Sharpling J, et al. Evidence summary: the relationship between oral health and dementia. Br Dent J. 2017;223:846-853.

5. Noble JM, Scarmeas N, Celenti RS, et al. Serum IgG antibody levels to periodontal microbiota are associated with incident Alzheimer disease. PLoS One. 2014;9:e114959.

6. Sparks Stein P, Steffen M J, Smith C, et al. Serum antibodies to periodontal pathogens are a risk factor for Alzheimer's disease. 2012;8:196-203.

7. Abdellatif H, Alnaeimi N, Alruwais H, Aldajan R, Hebbal MI. Comparison between water flosser and regular floss in the efficacy of plaque removal in patients after single use. Saudi Dent J. 2021;33:256-259.

8. Lyle DM, Goyal CR, Qaqish JG, Schuller R. Comparison of water flosser and interdental brush on plaque removal: a single-use pilot study. J Clin Dent. 2016;27:23-26.

9. Goyal CR, Lyle DM, Qaqish JG, Schuller R. Comparison of water flosser and interdental brush on reduction of gingival bleeding and plaque: a randomized controlled pilot study. J Clin Dent. 2016;27:61-65.

10. Nieri M, Giuntini V, Pagliaro U, Giani M, Franchi L, Franceschi D. Efficacy of a u-shaped automatic electric toothbrush in dental plaque removal: a cross-over randomized controlled trial. Int J Environ Res Public Health. 2020;17:4649.

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12. Marchesan JT, Byrd KM, Moss K, et al. Flossing is associated with improved oral health in older adults. J Dent Res. 2020;99:1047-1053.

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15. Al-Omiri MK, Al-Shayyab MH, Alahmari NM, et al. Impacts of the triple bristles three-sided sonic powered toothbrush on tooth shade, plaque control and gingival health. Int J Dent Hyg. 2021;19:382-397.

16. AL‐Omiri MK, Abu‐Awwad M, Bustani M, et al. Oral health status, oral health‐related quality of life and personality factors among users of three‐sided sonic‐powered toothbrush versus conventional manual toothbrush. Int J Dent Hyg. 2023;21:371-381.

Resources for Caregivers
Oral Hygiene for Caregivers and Families With or Without Dementia https://youtu.be/XHpfP_pHTb8
Demonstrating Oral Health Assessment for Nondental Professionals https://youtu.be/wXuYxQNd7gs

From Dimensions in Dental Hygiene. September 2023; 21(8):36-41.

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Modifying Oral Hygiene Techniques to Improve Oral Health - Dimensions of Dental Hygiene | Magazine

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Dimensions of Dental Hygiene is a monthly, peer-reviewed journal that reconnects practicing dental hygienists with the nation's leading educators and researchers. Dimensions is committed to the highest standards of professionalism, accuracy, and integrity in our mission of education supporting oral health professionals and those allied with the dental industry.

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Recognize Obstacles in Providing Care for Elderly Clients

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Recognize Obstacles in Providing Care for Elderly Clients

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Access to dental care is essential for maintaining good oral health, especially as individuals age. However, elderly individuals often encounter various barriers that hinder their ability to access dental services effectively. These barriers can have significant implications for their oral health and overall well-being.

Financial Constraints:

One of the primary barriers to dental care for the elderly is financial constraints. Many older adults live on fixed incomes, such as pensions or social security benefits, which may not cover the cost of dental treatments. Traditional Medicare typically does not cover routine dental care, leaving many elderly individuals without insurance coverage for essential dental services. As a result, they may forgo or delay dental visits, leading to untreated oral health issues.

Limited Insurance Coverage:

Even for those with dental insurance, coverage may be limited or inadequate.

Lack of Transportation:

Mobility issues and lack of transportation can pose significant barriers to accessing dental care for elderly individuals, particularly those who no longer drive or have difficulty traveling long distances. Limited access to public transportation or affordable transportation services can make it challenging for older adults to travel to dental appointments, especially if they live in rural or underserved areas with few dental providers.

Physical and Cognitive Impairments:

Elderly individuals with physical or cognitive impairments, such as arthritis, dementia, or Parkinson's disease, may face additional challenges in accessing dental care. Difficulties with mobility, communication, or understanding instructions can make it challenging for them to receive dental treatments safely and effectively.

Fear and Anxiety:

Dental anxiety is common among people of all ages, but it can be particularly pronounced in elderly individuals who may have had negative experiences with dental care in the past. Fear of pain, discomfort, or embarrassment may prevent older adults from seeking dental treatment, even when they are experiencing oral health problems. Without appropriate support and accommodations, dental anxiety can become a significant barrier to accessing care for elderly individuals.