Received: 11 February 2019 Revised: 14 March 2019 Accepted: 24 March 2019

DOI: 10.1111/scd.12375

ARTICLE

Oral health care for patients with Alzheimer's disease: An update

Leonardo Marchini DDS, MSD, PhD1
Thomas Caprio MD3 Adina Jucan DDS, MEHP, FSCD4
1 Department of Preventive and Community
Dentistry, The University of Iowa College of
Dentistry and Dental Clinics, Iowa City, Iowa
2 Department of Prosthodontics, The
University of Iowa College of Dentistry and
Dental Clinics, Iowa City, Iowa
3 Departments
of Medicine, Public Health
Science and Nursing, University of Rochester
Medical Center, Rochester, New York
4 Departments of Dentistry and Medicine,
University of Rochester Medical Center,
Rochester, New York
Correspondence
Leonardo Marchini, DDS, MSD, PhD, 337-1
Dental Science N, Iowa City, IA 52242.
Email: leonardo-marchini@uiowa.edu
Ronald Ettinger BDS, MDS, DDSc, DDSc(hc)2
Abstract
Alzheimer's disease and related disorders (ADRD) are among the age-associated
chronic conditions that are most challenging to health care systems around the globe,
as patients with dementia require full-time, intensive care for multiple years. Oral
health care is negatively impacted by cognitive decline, and consequently poor oral
health is common among people with ADRD. Poor oral health status is linked with
many undesirable consequences for the well-being of people with ADRD, from excru-
ciating local pain to life-threatening conditions, as aspiration pneumonia. In this paper,
the authors provide an update on the most current concepts about Alzheimer's dis-
ease epidemiology, etiology, and management, current oral health care for patients
with Alzheimer's disease, oral health promotion strategies for this population, as well
as current research and future direction for improving oral health care for patients
with Alzheimer's disease. It concludes that oral health care should be included in the
patient's routine health care as early as possible in the progression of Alzheimer's dis-
ease for preventing rapid oral health deterioration. Establishing oral hygiene routines
and providing dental treatment that is customized to the patients’ individual needs and
disease stage are important to achieve good oral health outcomes and prevent quality
of life decline.

KEYWORDS
Alzheimer's disease, dementia, dental care for aged, dental care for disabled, geriatric dentistry, oral health

1 I N T RO D U C T I O N be made a global priority.” The prevalence of dementia glob-

The aging of the population has become a worldwide
phenomenon.1,2 This population shift has implications for
health care systems around the globe. However, these changes
are predictable and societies can prepare themselves for it.1
One of the most urgent changes needed is a shift of health sys-
tems designed to deal with acute conditions to those designed
to deal with more chronic conditions that are prevalent among
the aging cohort.1,3 Dementia is among the chronic condi-
tions associated with aging that challenges the health care
systems of many countries, as these persons require intensive
care around the clock for many years.3
Therefore, it is considered one of the challenges of the cur-
rent century, and the G8 stated in 2016 that “dementia should
ally is currently estimated at about 40 million people, most of
whom are 60 years or older, and this number is projected to
double every 20 years until 2050.4
Alzheimer's disease is the most frequent cause of
dementia.4 In the United States, Alzheimer's disease
and related disorders (ADRD) affect 8.24% of the adult
population.5 ADRD is a term that encompasses neurocogni-
tive impairments due to multiple etiologies, like Alzheimer's
disease, Lewy's body disease, vascular dementia, traumatic
brain injury (TBI), and others.5 Among ADRD population,
around 80% of the people have Alzheimer's disease.5,6 The
estimated cost of health care for people with ADRD in the
US alone was $236 billion in 2016, with higher out-of-pocket
expenses for people with ADRD than those without ADRD.5

© 2019 Special Care Dentistry Association and Wiley Periodicals, Inc.

Spec Care Dentist. 2019;1–12. wileyonlinelibrary.com/journal/scd 1

2 MARCHINI ET AL.
Due to its neurodegenerative nature, Alzheimer's disease
causes progressive loss of mental and behavioral functions,
thus leading to a functional decline that affects all aspects of
patients’ lives,6 and oral health care is no exception.7
Many mechanisms have been implicated on how oral health
care is impacted by cognitive decline. For instance, impaired
prospective memory can reduce the person's ability to per-
form oral hygiene routines, which are important for maintain-
ing good oral health. Impaired executive function can reduce
the person's ability to effectively execute tooth brushing and
flossing. When the person needs help from others for daily
routines, oral care simply does not become a priority from the
caregiver's perspective. It is not that caregivers do not care.
Particularly in the late stages of the disease, the dependence on
others, resistance to care, refusal to open mouth, and the pri-
oritization when issues like behavioral problems and inconti-
nence are occurring, the concerns of oral health care are seen
as low priority by both family caregivers and many medical
clinicians. Other consequences of cognitive decline can also
impact dental treatment delivery and outcomes. For example,
altered pain interpretation can negatively influence the per-
son's ability to actively seek oral health care. Altered cogni-
tion and language impairment can impact the person's ability
to provide informed consent and following up with a main-
tenance plan.8 As a consequence of the negative impact of
cognitive impairment on oral health, many reports9–13 have
showed poor oral health outcomes among people with ADRD.
The evidence suggests that the conventional oral health
care delivery system has systematically failed to address the
specific needs of the people with ADRD. This failure is
associated with a multitude of barriers for providing oral
health care for patients with Alzheimer's disease. These bar-
riers are related to different levels, for example, the per-
sonal level (patients with dementia can become resistant
and aggressive),7 the population level (the number of older
patients with dementia is increasing at a faster pace than the
number of trained oral health care professionals),14 the pro-
fessional level (many dentists do not feel comfortable treat-
ing patients with dementia or going to a nursing home),15 the
institutional level (many nursing homes do not provide appro-
priate oral care routines),16 and also the health system level
(reimbursement rates for domiciliary care are low or non-
existent).15
Therefore, poor oral health status can have a negative
impact on systemic health and well-being of patients with
Alzheimer's disease. Poor oral health can cause local pain and
infection that may go unnoticed, as people with dementia are
poor reporters of pain,17,18 and unaddressed pain can cause
deterioration of patient behavior. Plaque accumulation and
deteriorated periodontal status have also been linked to aspi-
ration pneumonia, one of the leading causes of death among
frail older adults, especially at the severe stage of dementia.19
Hematogenous spreading of oral bacteria can also cause other
significant diseases, as infective endocarditis, acute bacterial
myocarditis, and cavernous sinus thrombosis. For other con-
ditions, like cardiovascular disease, cerebrovascular disease,
and diabetes mellitus with poor glycemic control, periodontal
inflammation is considered as a risk factor.20
Therefore, considering the negative impact that poor oral
health can have on people with Alzheimer's disease and the
current failure of providing appropriate health care for this
population, it is necessary to modify the way oral health care
is delivered. In this paper, the authors provide an update on
the most current concepts about Alzheimer's disease epidemi-
ology, etiology, and management, current oral health care
for patients with Alzheimer's disease, oral health promotion
strategies for this population, as well as current research and
future direction for improving oral health care for patients
with Alzheimer's disease.
2 A L Z H E I M E R's D IS EAS E
OV E RV I E W
2.1 Epidemiology
In 2011, the global prevalence of dementia was estimated
at 24 million, with an estimated cost of $172 billion in the
United States alone.21,22 In 2016, the global prevalence was
40 million,4 and the cost estimated for the United States
alone was around $236 billion.5 The prevalence is projected
to increase twice fold every 20 years until 2050.4
When comparing a group of European countries and U.S.
populations, which have available data, Alzheimer's disease
ranged from 2.86% in France to 6.8% in the United States. For
all available studies, Alzheimer's disease prevalence increased
with age.23 Prevalence of dementia is expected to increase
more, proportionally, for industrializing countries with rela-
tively younger populations as compared to Western Europe,
Japan, and the United States. Interestingly, several cohorts of
patients in European countries have presented a decline in
age-specific incidence of dementia. Similar trends have been
noticed also in the United States, thus raising expectations of
possible preventive interventions.4
Annual total direct plus indirect costs due to Alzheimer's
disease varied by country and study methodology, and were
as high as $189,843 per person per year in the Netherlands.
Caregiver burden measured in hours per week ranged from
70 h in the United States to 97 h in Germany.23
2.2 Etiology
Neuropathologists define Alzheimer's disease by the com-
bined presence of amyloid plaques and neurofibrillary tan-
gles. Research has showed that amyloid plaques are extra-
cellular deposits of abnormally folded beta amyloid (A𝛽),
and neurofibrillary tangles are composed of paired helical
MARCHINI ET AL.
filaments with hyperphosphorylated tau proteins.4,6 There is
good evidence that tau and A𝛽 provide parallel pathways
causing Alzheimer's disease.24 Through different molecular
pathways, these protein abnormalities cause synaptic failure,
depletion of neurotrophin and neurotransmitters, mitochon-
drial dysfunction, disruption of insulin-signaling pathways in
the brain, vascular injury, and parenchymal inflammation,25
among other brain malfunctions.26
Although age is the most important risk factor,27 genetic
risk factors have also been described.28 Single genes com-
monly associated with Alzheimer's disease and believed to
be causative (early onset) include chromosome 21 APP, chro-
mosome 14 PSEN1, and chromosome 1 PSEN2.28 Other
genes that have been described as increasing susceptibility
to Alzheimer's disease include chromosome 19 APOE,29 and
multiple markers on chromosome 12,25 which is linked to late
onset, and chromosome 17,30 which is linked to familial and
atypical dementia.
Other risk factors are head traumas. The centers for dis-
ease control and prevention (CDC) has identified 2.5 mil-
lion people with TBI. The current prevalence in veterans is
15.2% or 320,000 troops. The prevalence in World Trade Cen-
ter responders is 12.8% or 33,000 persons who are at risk for
dementia as they age. CDC has estimated that across the lifes-
pan 5.3 million older Americans are living with TBI.31
Furthermore, lifestyle-related risk factors for Alzheimer's
disease (diabetes, hypertension, obesity, physical inactivity,
depression, smoking, and low educational attainment) have
also been implicated.32 These are modifiable risk factors that
might account for about a third of patients with Alzheimer's
disease worldwide, thus there is hope for a substantial reduc-
tion in patients with dementia if these factors can be reduced
or eliminated.33
Recently, a study suggested that Porphyromonas gingi-
valis infection and consequence release of its virulence fac-
tors, such as gingipains, may also be involved in the etiology
of Alzheimer's disease. The pathogenic mechanism linking
gingipains to Alzheimer disease development is still unclear,
but it seems to be related to compensatory tau formation in
response to the proteolytic activity of gingipains over tau.34
2.3 Diagnosis and common symptoms
Common symptoms of Alzheimer's disease include but are
not restricted to memory loss that disrupt daily life, confu-
sion with time and place, decreased or poor judgment, chal-
lenges in planning and solving problems, difficult completing
familiar tasks, changes in mood, and increased agitation, anx-
iety, and sleep disturbances.35 As the disease progresses, the
patients need help with activities of daily living (ADL), such
as, oral hygiene, eating, dressing, or using the restroom. In
more advanced stages, patients lose their capacity of recog-
nizing loved ones and become dependent on 24/7 care.35,36
3
There is no single test to diagnose Alzheimer's disease,
and the diagnosis is usually made using a variety of differ-
ent approaches that may include health history (particularly
regarding mental health and history of behavioral and cogni-
tive changes), cognitive tests, physical examinations, neuro-
logic examinations, blood tests, and brain images.35
2.4 Stages
Alzheimer's disease is a progressive neurodegenerative dis-
ease, and its progression has different disease stages that
present with different patient characteristics. It may have a
long prodromal phase (20 years)37 and an average survival of
7–10 years after diagnosis.36 The older the patient, the shorter
the life expectancy after diagnosis of Alzheimer's disease, for
patients in their 90s it may be as short as 3 years.36
There are three major stages of the disease: mild, mod-
erate, and severe. Each stage presents with different behav-
ioral and psychological symptoms accompanied by continu-
ous physical decline, and requires different types of health
care-related services.36 For instance, less intensive domicil-
iary care is needed for the patient at the mild stage, as the
patient is still able to perform most of the ADLs. As the dis-
ease progresses to the moderate stage, much more intensive
domiciliary care is necessary, as patients present with more
intense behavioral changes. 36 At this stage, usually domicil-
iary care become too overwhelming for the family, as well as
too expensive, as the patient needs daily care or they are now
referred to a long-term care institution. At the severe stage,
patients need help for all ADL, have reduced mobility, and
less aggressive behavior. The mean duration of each stage is
about 5.5 years for the initial (mild) phase, the moderate stage
is 3.5 years, and the severe stage is 3.2 years.36
It is important to notice that the whole concept of staging is
now being revised particularly from a research standpoint,37
in which authors are looking at preclinical stage as well as
including mild cognitive impairment and referring to major
and minor neurocognitive disorders.
2.5 Management
Since there is no cure for the disease, the most important com-
ponent of the treatment for Alzheimer's disease patients is the
supportive care for the patients and their families.4 Simple to
write, difficult to do. The management involves a rather com-
plex interaction among health care providers, patients, family,
caregivers, and the health care system.37
Family and other caregivers need to learn about the pro-
gressive nature of the disease, and how to prepare them-
selves to obtain the necessary resources for providing care that
focuses on maintaining the patients’ quality of life and pre-
serving the caregiver's wellbeing.4 There are multiple areas
of resources that need to be acquired: educational resources,
financial resources, health insurance, access to specialized
4 MARCHINI ET AL.
health care facilities, access to specialized health care profes-
sionals, access to skilled direct care workers, and emotional
resources. This is no simple task, and families need profes-
sional help and counseling to accomplish it.
Pharmacotherapy for Alzheimer's disease includes cogni-
tion enhancing drugs, and other drugs used for controlling
challenging behavior and other systemic diseases or compli-
cations of Alzheimer's disease. Cognitive enhancing drugs
include cholinesterase inhibitors, like donepezil, rivastigmine,
and galantamine; and the N-methyl-D-aspartate antagonist,
memantine.4,37 A combination therapy with a cholinesterase
inhibitor and memantine is common and can provide addi-
tional benefits in the early stage of the disease.37 The clinical
response to the treatment is limited and the cost/benefit ratio
has been subject of much debate.38
Other therapeutic approaches have been suggested, as med-
ical foods (omega-3 fatty acids, fractioned coconut oil, and
others) and nutritional supplements (vitamin E, and B com-
plex vitamins). However there is little or contradictory evi-
dence to support these approaches.37
Challenging behavior commonly observed in Alzheimer's
disease includes agitation and/or psychosis with delusions
and hallucinations, depression, apathy, and sleep distur-
bances. These conditions reduce quality of life for both
patient and caregivers, increase functional dependence,
and may trigger institutionalization. Medication used to
treat agitation and/or psychosis are antipsychotic agents
(ie, risperidone, quetiapine). Depression is usually treated
with selective serotonin reuptake inhibitors and serotonin
and norepinephrine reuptake inhibitors (ie, citalopram), and
severe apathy is treated with central nervous system stimu-
lants (ie, methylphenidate). Sleep disturbances are usually
treated with non-benzodiazepine hypnotics (ie, zolpidem)
or an antidepressive agent (ie, trazodone).37 However, no
single effective therapy has been identified to either modify
or reduce the behavioral and psychological symptoms of
dementia, in fact medication long used to address these
symptoms such as antipsychotics have block box warnings
due to increased risk of death in patients with dementia.39
Other sedative/hypnotic medications may increase the risk of
falls40 or even worsen symptoms in some patients.
2.6 Social repercussions
Societal cost of Alzheimer's disease is enormous. As for 2016,
one person develops Alzheimer's disease every 66 s, and by
mid-century one person will develop Alzheimer's disease
every 33 s.35 Alzheimer disease rose from being the 25th most
burdensome disease in the United States in 1990 to being the
12th in 2010. Alzheimer disease also rose from ranking 32nd
in terms of years of life lost to rank 9th. No other disease pre-
sented such large increases.35 In 2015, an estimated amount
of 15 million family members and other unpaid caregivers
delivered about 18.1 billion hours of care for people with
dementia, a contribution to society worth more than US$221
billion.35 The global cost of dementia is estimated to be US$
818 billion, and expected to increase in the coming decades.41
Mortality is also very high. While deaths resulting from
cardiovascular diseases and some types of cancer have
declined, Alzheimer's disease related deaths increased 71%
between 2000 and 2013. In 2013, Alzheimer disease was the
sixth cause of death in the United States.35
3 O RAL H EALTH STATUS AM ONG
PATIENTS WITH ALZHEIMER 's
DIS EAS E
3.1 Epidemiology
Older adults with dementia currently still present with poor
oral health conditions in epidemiologic studies.9,10,42,43 When
comparing dental hard tissues related problems between
older adults with and without dementia, a recent systematic
review13 demonstrated that available data suggest that total
edentulism is similar between the two groups, as well as num-
ber of teeth and decayed/missing/filled teeth index (DMFT)
index. However, older adults with dementia presented with
more coronal and root caries, as well as more retained root
tips.13
In a systematic review about oral soft tissues related
problems,12 it was reported that most patients with demen-
tia presented gingival bleeding or inflammation. Community
periodontal index of treatment needs were higher in older
adults with dementia than without dementia. However, both
gingivitis and periodontitis presented a contradictory result,
where some studies found a higher prevalence among patients
with dementia and others found similar prevalence between
the groups.12 A systematic review and meta-analysis44 inves-
tigating five different periodontal measurements (ie, bleed-
ing on probing, periodontal probing depth, gingival bleeding
index, clinical attachment level, and plaque index) reported
that patients with dementia had significantly higher values.
Oral lesions, like candidiasis,9,12 angular cheilitis,9 and
others,10 such as ulcerations and stomatitis, have also been
reported as being more frequently observed in older adults
with dementia when compared to older adults without demen-
tia. The same trend applies to xerostomia.9,12
Few studies have focused on orofacial pain among older
adults with dementia, and its prevalence was reported to range
between 7.4 and 25.7%.13,42 As for self-perceived oral health,
recent studies have reported that older adults with demen-
tia reported similar Geriatric Oral Health Assessment Index
(GOHAI) scores than the patients without dementia, although
patients with dementia presented with poorer oral health.10,45
For both orofacial pain and GOHAI scores, the ability of
MARCHINI ET AL.
the cognitively impaired patients to reliably report should be
questioned when interpreting these results.
3.2 Risk factors for rapid oral health
deterioration (ROHD)
Recently, a teaching tool was developed to help clinicians
establish the risk for ROHD among older adults.46 As older
adults are retaining their teeth into advanced age and they
might become frailer and functionally dependent, their risk
for ROHD is increased. Thus, it is very important for dentists
to be able to identify what are the risk factors for ROHD, in
what stage of ROHD the patient is and what are the best treat-
ment alternatives considering ROHD risk factors and disease
progression.46 ROHD risk factors are related to three main
groups, that is, general health conditions, social support, and
oral health conditions.46
Among the ROHD risk factors related to general health,
neurodegenerative conditions and dementia are considered
as significant risk factors and treatment plan modifiers,7,11
as well as conditions that often accompany dementia, like
depression47 and polypharmacy.48,49 Older adults with cogni-
tive impairment have many functional losses that can impair
their ability to keep their oral hygiene routines. For instance,
memory and executive function losses can compromise their
ability to perform oral hygiene in a regular and appropriate
fashion.8 Depression may influence oral health through bio-
logical pathways such as disruption of the immune system
and hyposalivation linked to antidepressants; or nonbiolog-
ical pathways, such as reduced self-care and reduced usage
of dental services due to depressive symptoms.47 Cognitive
enhancing drugs like cholinesterase inhibitors and meman-
tine, used to treat Alzheimer's disease, have not been shown
to have significant oral side effects. However, some medi-
cations used to help with challenging behaviors commonly
observed in Alzheimer's disease have dry mouth as a common
side effect, such as the antidepressant citalopram.
Regarding social support, such as being dependent on a
caregiver has been reported as an important barrier to receiv-
ing proper oral hygiene care50 ; also being institutionalized,51
as many reports have shown that nursing home residents
receive inadequate oral hygiene and oral health care.16,51,52
Both dependency and institutionalization are common among
patients with Alzheimer's disease, and educating caregivers
to provide appropriate oral health care has been an enduring
challenge, with no clear resolution in sight.16,53 Finances and
other socioeconomic factors were also reported as barriers for
older adults to access appropriate oral health care.54 Among
older adults with Alzheimer's disease, financial burden can
be even more intense, as they have more out-of-pocket health
expenses when compared to older adults with no dementia.5
Oral health conditions related to ROHD risk factors
include but are not limited to the presence of multiple
large restorations,55 removable partial dentures (RPDs),10,56
5
periodontitis,57 and xerostomia.55 These conditions are com-
mon among older adults in general and, consequently among
older adults with Alzheimer's disease, who present with these
oral health conditions even before the onset of Alzheimer's
disease. Poor oral hygiene, mainly due to the above mentioned
general health and social support factors, is also a common
oral health-related ROHD risk factor among older adults with
Alzheimer's disease.9
3.3 Access to oral health care: Barriers
and enablers
There are many barriers for older adults with Alzheimer dis-
ease to access appropriate oral health care. At a societal level,
the lack of adequate reimbursement for dentists and dental
hygienists to provide domiciliary oral health care has been
cited as an important barrier.15 Lack of enforcement of appro-
priate regulations regarding oral hygiene routines in long-term
care institutions has been cited as another barrier, as well
as lack of caregiver education, caregiver overload, and high
turnover among nursing home caregivers.16 More research
dollars are also needed to establish evidence-based protocols
for oral health care of patients with Alzheimer's disease.58
At the dental professional level, although 92.8% of U.S.
dental schools teach geriatric dentistry as a compulsory
course, and 84.9% of those teach the topic “Restorative
management of persons with Alzheimer's disease and other
dementias,”59 only 57.1% had some compulsory clinical edu-
cation in geriatric dentistry60 and it is unsure how much of
this clinical training involves patients with dementia. A small
number of dentists have received advanced training in geri-
atric dentistry in the United States, and there is a shortage of
current fellowship programs.61
At the patient level, aggressiveness of the patients has been
consistently reported as a barrier for providing appropriate
oral hygiene care, and many techniques have been reported to
overcome this barrier.7 Patient inability to communicate oral
pain or discomfort has also been reported as a barrier to pro-
viding adequate oral health care.7,8 As the disease progresses
from mild to the severe stage, aggressiveness and communi-
cation deficits become more common, it is important to pro-
vide early interventions and establish an adequate level of oral
hygiene as soon as possible.7,11
4 P RO M OT ING ORAL H EALTH
CARE FOR PAT IENTS WITH
ALZHEIMER
4.1 Oral health diagnosis and early
intervention
Clinical reports emphasize that patients with Alzheimer
disease should receive oral diagnosis and treatment as early
6 MARCHINI ET AL.

as possible in the course of the disease.7,11,62 Early inter-

TABLE 1 Alzheimer's disease stages characteristics and
vention is important because patients in the mild stage are recommended dental care
able to perform most of their ADLs,36 including oral hygiene
Alzheimer's
routines. Table 1 presents dental care recommendations for
disease
each stage of Alzheimer's disease. stages Characteristics Recommended dental care
When the patient is diagnosed with dementia, the fam-
Mild Duration: 2–3 years Early intervention, risk factors
ily and/or caregivers should be encouraged to schedule an Memory for ROHD are present
appointment with the dentist. It would be very useful if the impairment, Comprehensive examination,
physicians providing the diagnosis could include this item difficulty to including radiographs,
in the family/caregivers initial checklist. The dentist should perform complex formulation of a dental
then proceed with a comprehensive examination, oral diagno- tasks and learning treatment plan, and an oral
sis and treatment plan that considers the irreversible and pro- new facts, time hygiene maintenance plan
and space Treatment is similar to regular
gressive nature of the disease. The maintenance plan should
disorientation treatment, can usually be
include careful assessment of the patient's oral hygiene rou- Patient can still do done in the dental office
tines (number of times a day, supplies used, appropriateness most of ADLs Treatment is time limited and
of the procedure, need for help, etc.) and dietary habits, which independently urgent as the patient's ability
can be done with a family member/caregiver per the dentists to cooperate will deteriorate
request and using a checklist provided by the dentist (Table 2). Moderate Duration: 2–10 years If early intervention was
At the mild stage, it is recommended to encourage patient's Language deficits, provided, then the focus
autonomy, keeping the patient in charge of his/her own oral aphasia, apraxia, should be on maintenance, if
hygiene routines, with some supervision. Supervision comes agnosia, possible.
hallucinations, If no early intervention was
by providing reminders and cues to remember to perform oral
delusion, provided, ROHD may be
care, checking for adequacy of oral hygiene routines at least
insomnia, happening or have happened,
once a day, checking if dentures are being removed at night, executive and extensive treatment may
and if dentures are clean. At this stage it would be also ideal functioning is be necessary
to start using a high-concentration fluoride (5000 ppm) tooth- impaired Treatment may be done in the
paste twice a day to help prevent caries, as well as schedul- Patient needs help dental office, with or without
ing the patient for a shorter recall schedule (at least every six with most ADLs oral sedation
months or less, depending on each patient's needs). Patient behavior At risk teeth should be
will deteriorate extracted or crowned at this
As a patient progresses toward a more advanced stage of
and may become stage
dementia, it becomes more difficult for the patient to per- aggressive
form his/her own oral hygiene independently, and more help Sundowning is
is needed from family members/caregivers.11 At the moder- common
ate stage, patients will need assistance from caregivers to per- Severe Duration 2–5 years If early intervention was
form oral hygiene and could become more combative. Estab- Severe language and provided, then the focus
lishing oral hygiene routines early can help reduce resistance, cognitive deficits, should be on maintenance, if
and autonomy should be encouraged for as long as possi- cannot recognize possible.
ble using techniques like task breakdown (breaking down the loved ones, and If no early intervention was
may not be able to provided, ROHD may have
activity into small steps), hand over hand (the patient holds
respond to simple happened, and extensive
the toothbrush and caregiver places his/her hand over the
commands treatment may be necessary
patient's hand and guides brushing), chaining (the caregiver Patients are totally If possible, treatment needs to
starts brushing and lets the patient finish it), and bridging dependent on be provided at patient
(the patient holds the toothbrush and caregiver brushes with caregivers home/institution, or under
another toothbrush). At the severe stage, usually oral hygiene Patients tend to deep sedation or general
can only be cared out by caregivers as the patients are not become passive anesthesia
capable. If the patient is resistant, techniques such as rescu- If general anesthesia is
required, the value of the
ing (a second caregiver enters and delivers care as the first
natural dentition should be
caregiver leaves) and distraction (the patient can be distracted assessed
by singing, or holding a preferred item) can be used. Much
ADL, activities of dialing living; ROHD, rapid oral health deterioration.
more information regarding overcoming barriers to care can
be found in the “Resources for families/caregivers” document
in the Supporting Information of this article.
MARCHINI ET AL.
T A B L E 2 Checklist for family members/caregivers assessment of
current oral hygiene routines and dietary habits with recommended
goals
Family
members/caregivers
assessment of oral
hygiene routines and
dietary habits Recommended goals
Toothbrushing routine Brushing at least two times a day, for at
least 2 min, covering all teeth and teeth
surfaces. No visible plaque should be
noticeable.
As the disease progresses, the patient will
need help with brushing.
Flossing routine Flossing once a day, covering all areas
between the teeth. This is usually not
possible in the later stages.
Denture cleaning routine Dentures should be brushed with a
denture brush at least once a day,
covering all denture surfaces. No
visible plaque should be noticeable.
Dentures can also be soaked in a denture
cleanser overnight.
Fluoride toothpaste Non-prescription fluoride toothpaste
should be used to brush patient's teeth
at all times, unless a
high-concentration fluoride toothpaste
is prescribed.
Prescription oral health If a prescription product is being used,
products make sure to adhere to the prescription
(high-fluoride directions. If directions are not
toothpaste, oral available, contact the dentist or the
rinses, etc.) pharmacy.
Non-prescription oral If the patient is using non-prescription
health products oral health products, check with the
(denture cleaning and dentists if they are still appropriate and
adhesives, oral rinses, get information on how is the best way
etc.) to use it.
Sugar intake and If possible, reduce the amount and
frequency frequency of sugary food and
beverages. Substituting sugar with
no-calories sweeteners can be helpful.
Acidic food and Reduce the amount and frequency of
beverage intake and acidic foods and beverages. Substitute
frequency with non-acidic items can be helpful
Dental care routines Six months or shorter dental visits, if
(periodic exams and possible.
cleanings)
Unfortunately, a recent study63 showed that oral hygiene
care is not routinely evaluated for patients with early stage
dementia, and one can assume that this is one of the reasons
poor oral health has been reported so often12,13 for patients
with Alzheimer's disease.
7
4.2 Establishing and maintaining oral
hygiene routines: Domiciliary and institutions
Having a supportive family is best gift for a person with
Alzheimer's disease. A motivated family will seek the
resources to provide the best possible care for its loved ones,
and there are a lot of good resources as illustrated in the
Supporting Information. However, as mentioned above, the
physician who diagnosis dementia and the dentist have a very
important role in stimulating the patient's families interest
in domiciliary oral hygiene care and educating the families
about how to provide appropriate daily oral hygiene care.64
Clinical experience has shown that motivated and educated
families can provide excellent care for their loved ones with
Alzheimer's disease. However, there is a moment, usually in
the moderate stage of dementia,36 that behavioral problems
become overwhelming for the caregivers and the patients are
then referred to a long-term care institution.
Oral health care in long-term care institutions is usually
poor,50,51,65 and seeking answers for how to fix it has stim-
ulated much research and debate,66–69 but no resolution has
been achieved.16 A recent study16 suggested that an effective
training program for caregivers to provide oral hygiene for res-
idents should include more than a couple hours of lectures,
and needs the training of oral health “champions”—caregivers
who would be responsible for training their peers and super-
vising oral hygiene in a nursing home. It is important to have
more administrative support to enforce oral hygiene protocols,
meaning that oral health outcomes should be part of the over-
all therapeutic goal for each resident. Considering the high
turnover among direct care workers in nursing homes, ongo-
ing educational materials-–like mobile phone apps and online
courses-–are important to help train new staff members. Some
of the available ongoing educational materials are also pre-
sented in the Supporting Information.
4.3 Dental treatment
The ROHD assessment teaching tool uses a 10-question guide
for assessing the risk for ROHD.46 This tool is intended to
guide the thought process of the oral health care provider
through the complexities of data gathering, risk assessment,
and treatment planning for patients with multiple complicat-
ing factors, such as patients with Alzheimer's disease. The 10
questions of the tool are presented below along with the most
common items to be identified for patients with Alzheimer's
disease.
The first question, Do we have all the data?, is really split in
three, as dentists should check if all the data regarding patient
has been gathered, such as (a) general health conditions, (b)
social support, and (b) oral health conditions.
General health conditions data involves not only a revision
of systemic diseases and medication, but also an assessment
8 MARCHINI ET AL.
of patient's disabilities as it relates to the disease stage, and
how it impacts patient's autonomy, also the patient's ability to
communicate oral health problems and the patient's capacity
to tolerate possible treatment and maintenance plans.
Social support involves knowing who is the legal guardian,
how the patient will be transported to appointments, who
is responsible for supervising/performing oral hygiene care,
what is the institutionalization status and institution policies,
if they have any, for oral hygiene care, if there is dental insur-
ance, and the expectations and attitudes about dental treatment
of the patient, caregivers, family members, and other members
of the health care team.
Oral health conditions should be recorded through a com-
prehensive examination including radiographs. The earlier the
examination occurs defining the stage of disease progression,
the earlier preventive strategies can be implemented to reduce
the risk of ROHD, by establishing oral hygiene routines. As
patients are keeping their teeth for longer, more complex oral
conditions are now seen among older adults, with and with-
out dementia.70 The examination should include the condition
of each and every tooth, their periodontal status, daily oral
hygiene practices, condition of the oral mucosa, salivary flow
rates, denture status, denture hygiene practices, and temporo-
mandibular dysfunction signs and symptoms.
The fourth question is What data is the most relevant
for ROHD and/or treatment planning?, that is, from all the
data that has been gathered, dentists should decide which
factors are critical on defining disease progression in this
patient and what is required for treatment. The stage of dis-
ease progression, oral hygiene care (or its absence), the care-
givers willingness to provide support, the degree of ROHD
development, and the severity of xerostomia are critical
data to be considered for in many patients with Alzheimer
disease.
The fifth question is What will happen if we do nothing?,
that is, dentist should be able to predict what can happen with
regard to disease progression if no intervention takes place.
This step is important mainly as the patient approaches the
severe stage of disease progression, and providing care at reg-
ular intervals becomes more difficult, if not impossible. Then
decisions should be made about treating or not treating, and
knowing what can happen if no treatment is performed as it
becomes an important part of the family/legal guardian deci-
sion making process.
The sixth question is What is the patient's risk for rapid oral
health deterioration?, and the risk categories are: (a) There
are no risk factors present, (b) The patient is at risk of ROHD,
but not currently experiencing ROHD, (c) The patient is cur-
rently experiencing ROHD, and (d) ROHD has happened to
the patient. Classifying the patient regarding the presence of
risk factors and oral disease progression helps inform the den-
tist in asking the next series of questions, which are related to
treatment planning and decision making.
The seventh question is What treatment alternatives are
available?, that is, dentists should present viable treatment
alternatives considering the risk factors gathered from first
and fourth questions, as well as patient risk for ROHD.
Usually the most important difference among treatments is
whether the treatment should be more conservative or more
invasive, which also involves more or less visits. The patient's
disease stage is an important factor to be considered here. The
earlier the stage, the more treatment the patient can usually
tolerate. However, dentists should always consider the irre-
versible and progressive nature of the disease, and consider
that less than ideal oral hygiene will be provided in the future.
Complex fixed prosthesis, although possible to provide in the
mild stage, are much harder to maintain in the moderate and
severe stages.
Fortunately, dentists have a range of preventive and restora-
tive products that can be used for the most aggressive
caries progression, such as high-fluoride toothpastes,71 sil-
ver diamine fluoride,72 and glass-ionomer cements.73 If used
early in disease progression, high-fluoride toothpastes can
help prevent caries; and if used in the more advanced stages,
it can help slow ROHD progression.71 Silver diamine fluo-
ride can also be used for preventing and arresting caries; it is
cheap and easy to use, but needs to be applied by an oral health
care provider. The negative side effect is the black staining of
the affected dentin.71 Root surface caries and coronal caries
which are in areas that are difficult to access, are more com-
mon among older adults with Alzheimer's disease.13 Glass-
ionomers have been the preferred restorative material, when
using partial caries removal technique, as long as it has been
able to establish sound cavity margins, to allow for an appro-
priate seal of the restoration.73
The provision of dentures should also be done with cau-
tion. Adding RPDs without a corresponding improvement in
oral hygiene may lead to an increased risk for ROHD.56 If the
patient has enough chewing pairs to provide appropriate func-
tion, according to the principles of the shortened dental arch,
then no RPD is the best treatment alternative.70,74
The eight question is What is the best treatment alterna-
tive for this patient and what is its justification? This is a
follow-up question from the previous one. The dentist should
present the alternative that best fits this patient's needs and
be prepared to justify the treatment plan. When considering
treatment alternatives and choosing a specific intervention,
dentists should also take into account the concepts of ratio-
nal treatment planning,70,74 which states that it is a process of
decision making, which takes into account all the modifying
factors and develops a treatment plan that is in the best interest
of the patient. This treatment plan could use the most sophis-
ticated dental techniques available or its many modifications,
including no treatment at all.
The patient, their family/legal guardian and caregivers’ per-
spectives and expectations need to be considered when devel-
MARCHINI ET AL.
oping this treatment plan. For the patient at the moderate
and/or severe stages of the disease, treatment choice should
also consider the patients’ ability to tolerate the proposed
treatment. The use of sedation at different levels, as well
as general anesthesia, may be required.70 In considering the
patient's comfort and safety, as well as taking into account the
dentist's skills, a decision about where to provide oral health
care must be made, which can then be provided in the dental
office, the patient's home or in a long-term care institution.
The ninth question is How will the treatment and mainte-
nance plan be communicated to the patients and/or their care-
givers? The dentist should be able to present the details of
the treatment plan in a way that considers the patient's abil-
ity to understand, as well as other necessary third parties,
such as caregivers, family members, and legal guardians for
health and/or finances. Communication should include treat-
ment alternatives, the rationale for the chosen treatment plan,
and other issues such as number of appointments required,
discussion of responsibility for daily oral hygiene, and limi-
tations of the treatment. When providing all this information
to the different audiences, the dentist should consider using
appropriate language and provide supporting materials to help
people understand what they are supposed to do and how they
are expected to do it.
The 10th question is related to Self-assessment by the den-
tist, and includes evaluating if there is any missing data, and
the effectiveness of the communication plan. Self-assessment
after each patient will help the dentists to continuously
improve the quality of any future treatments.
5 RESEARCH AND FUTURE
DIRECTIONS
5.1 What are the most promising strategies?
The latest research has confirmed that amyloid plaques
and neurofibrillary tangles are causally related to
neurodegeneration.4,6 However, it has also showed that this
causality is not linear, being rather more complex and involv-
ing multiple causes.4,75 Recent advances on the understanding
of Alzheimer's disease genetics and molecular pathways have
helped identifying novel cerebrospinal fluid and blood
biomarkers,4,37,76 as well as the development of promising
new therapies that are currently being tested.31,66 Among the
promising therapies, are those which target A𝛽 production,
direct targeting of A𝛽 and tau, and immunotherapy.37,76 Tra-
ditional preventive therapies, which improve brain circulation
are still used to target Alzheimer's disease.76
With regard to the clinical management of Alzheimer's dis-
ease, only minor progress has been reported to improve the
quality of life for patients with Alzheimer's disease and their
caregivers.76 Caring for someone with Alzheimer's disease
9
is a complex, dynamic process that involves acquiring a lot
of information and developing skills. It also requires exter-
nal support, mainly from health care providers and services.77
Caregiver training has been shown to improve their quality
of life,77,78 and comprehensive support and counselling have
been shown to postpone institutionalization.77 Many older
adults would prefer to age in their homes, and programs
like PACE (Program of all-inclusive care), which allow nurs-
ing home eligible older adults to stay in their communities,
are increasing.79,80 Since its inception, PACE programs have
included full health care for the participants, including oral
health care. The inclusion of oral health care in PACE pro-
grams provides an opportunity for dentistry to develop an effi-
cient model for oral health care delivery in multidisciplinary
programs, which is an improvement to the current ineffec-
tive oral health care model that exists in most long-term care
institutions.
Recently, some reports have focused on possible associ-
ation among oral health-related factors, such as periodontal
disease and tooth loss, and Alzheimer's disease progression.81
Although some clinical and molecular studies have reported
on these statistical associations,82,83 causative relationships
have not been demonstrated.81,83 A recent study, however,
have done an initial step toward proving causative rela-
tionship between P. gingivalis infection and Alzheimer's
disease, as stated earlier in the Etiology section of the present
manuscript.34
6 CONC LU SI ON S
Oral health among patients with ADRD is poor, as they are
exposed to multiple risk factors for ROHD. To prevent ROHD
from happening, oral health care should be included in the
patient's routine health care as early as possible in the progres-
sion of Alzheimer's disease. Primary care providers can play a
key role on referring early diagnosed patients to an oral health
care provider. Establishing oral hygiene routines and provid-
ing dental treatment that is customized to the patient's individ-
ual needs and disease stage is important to achieve good out-
comes. Future basic sciences research might bring new, more
effective therapies to Alzheimer's disease. While it does not
happen, improving care management is essential for the qual-
ity of life of patients with Alzheimer's disease, and this should
certainly include oral health care.
CO N F L I C T O F I N T E R E ST
The authors declare no conflict of interest.
O RC I D
Leonardo Marchini DDS, MSD, PhD
https://orcid.org/0000-0003-1291-6684
10
Ronald Ettinger BDS, MDS, DDSc, DDSc(hc)
https://orcid.org/0000-0001-6902-5263
REFERENCES
1. WHO. World Report on Ageing and Health. Geneva, Switzerland:
World Health Organization; 2015.
2. U.S. Census Bureau. Older Americans Month: May 2017. 2017.
https://www.census.gov/content/dam/Census/newsroom/facts-for-
features/2017/cb17-ff08.pdf. Accessed October 31, 2017.
3. Prince MJ, Wu F, Guo Y, et al. The burden of disease in older
people and implications for health policy and practice. Lancet.
2015;385(9967):549-562.
4. Scheltens P, Blennow K, Breteler MM, et al. Alzheimer's disease.
Lancet. 2016;388(10043):505-517.
5. Dwibedi N, Findley PA, Wiener RC, Shen C, Sambamoorthi U.
Alzheimer disease and related disorders and out-of-pocket health
care spending and burden among elderly medicare beneficiaries.
Med Care. 2018;56(3):240-246.
6. Kumar A, Singh A. Ekavali. A review on Alzheimer's disease
pathophysiology and its management: an update. Pharmacol Rep.
2015;67(2):195-203.
7. Brennan LJ, Strauss J. Cognitive impairment in older adults and oral
health considerations: treatment and management. Dent Clin North
Am. 2014;58(4):815-828.
8. Chen X, Zimmerman S, Potter GG, Sloane PD, Cohen LW, Reed
D. Assessment of dentally related function in individuals with cog-
nitive impairment: the dental activities test. J Am Geriatr Soc.
2017;65(3):580-585.
9. Aragon F, Zea-Sevilla MA, Montero J, et al. Oral health in
Alzheimer's disease: a multicenter case-control study. Clin Oral
Investig. 2018;22(9):3061-3070.
10. Ribeiro GR, Costa JL, Ambrosano GM, Garcia RC. Oral health
of the elderly with Alzheimer's disease. Oral Surg Oral Med Oral
Pathol Oral Radiol. 2012;114(3):338-343.
11. Machado MC, Lopes GH, Marchini L. Oral health of Alzheimer's
patients in Sao Jose dos Campos, Brazil. Geriatr Gerontol Int.
2012;12(2):265-270.
12. Delwel S, Binnekade TT, Perez R, Hertogh C, Scherder EJA,
Lobbezoo F. Oral hygiene and oral health in older people with
dementia: a comprehensive review with focus on oral soft tissues.
Clin Oral Investig. 2018;22(1):93-108.
13. Delwel S, Binnekade TT, Perez RS, Hertogh CM, Scherder EJ,
Lobbezoo F. Oral health and orofacial pain in older people with
dementia: a systematic review with focus on dental hard tissues.
Clin Oral Investig. 2017;21(1):17-32.
14. Marchini L, Ettinger R, Chen X, et al. Geriatric dentistry education
and context in a selection of countries in 5 continents. Spec Care
Dentist. 2018;38(3):123-132.
15. Nunez B, Chalmers J, Warren J, Ettinger RL, Qian F. Opinions on
the provision of dental care in Iowa nursing homes. Spec Care Den-
tist. 2011;31(1):33-40.
16. Marchini L, Recker E, Hartshorn J, et al. Iowa nursing facil-
ity oral hygiene (INFOH) intervention: a clinical and microbi-
ological pilot randomized trial. Spec Care Dentist. 2018;38(6):
345-355.
MARCHINI ET AL.
17. van de Rijt LJM, Weijenberg RAF, Feast AR, Vickerstaff V, Lobbe-
zoo F, Sampson EL. Oral health and orofacial pain in people with
dementia admitted to acute hospital wards: observational cohort
study. BMC Geriatr. 2018;18(1):121.
18. Sampson EL, White N, Lord K, et al. Pain, agitation, and
behavioural problems in people with dementia admitted to general
hospital wards: a longitudinal cohort study. Pain. 2015;156(4):675-
683.
19. van der Maarel-Wierink CD, Vanobbergen JN, Bronkhorst EM,
Schols JM, de Baat C. Oral health care and aspiration pneumonia
in frail older people: a systematic literature review. Gerodontology.
2013;30(1):3-9.
20. Beikler T, Flemmig TF. Oral biofilm-associated diseases: trends
and implications for quality of life, systemic health and expendi-
tures. Periodontol 2000. 2011;55(1):87-103.
21. Reitz C, Brayne C, Mayeux R. Epidemiology of Alzheimer disease.
Nat Rev Neurol. 2011;7:137.
22. Reitz C, Mayeux R. Alzheimer disease: epidemiology, diagnos-
tic criteria, risk factors and biomarkers. Biochem Pharmacol.
2014;88(4):640-651.
23. Takizawa C, Thompson PL, van Walsem A, Faure C, Maier WC.
Epidemiological and economic burden of Alzheimer's disease: a
systematic literature review of data across Europe and the United
States of America. J Alzheimers Dis. 2015;43(4):1271-1284.
24. Small SA, Duff K. Linking Abeta and tau in late-onset Alzheimer's
disease: a dual pathway hypothesis. Neuron. 2008;60(4):534-542.
25. D'Introno A, Solfrizzi V, Colacicco AM, et al. Current knowledge
of chromosome 12 susceptibility genes for late-onset Alzheimer's
disease. Neurobiol Aging. 2006;27(11):1537-1553.
26. Querfurth HW, LaFerla FM. Alzheimer's disease. N Engl J Med.
2010;362(4):329-344.
27. Xia X, Jiang Q, McDermott J, Han JJ. Aging and Alzheimer's dis-
ease: comparison and associations from molecular to system level.
Aging Cell. 2018;17(5):e12802.
28. Karch CM, Cruchaga C, Goate AM. Alzheimer's disease genetics:
from the bench to the clinic. Neuron. 2014;83(1):11-26.
29. Moreno-Grau S, Hernandez I, Heilmann-Heimbach S, et al.
Genome-wide significant risk factors on chromosome 19 and the
APOE locus. Oncotarget. 2018;9(37):24590-24600.
30. Bird TD, Wijsman EM, Nochlin D, et al. Chromosome 17 and
hereditary dementia: linkage studies in three non-Alzheimer fami-
lies and kindreds with late-onset FAD. Neurology. 1997;48(4):949-
954.
31. Peters ME. Traumatic brain injury (TBI) in older adults: aging
with a TBI versus incident TBI in the aged. Int Psychogeriatr.
2016;28(12):1931-1934.
32. Norton S, Matthews FE, Barnes DE, Yaffe K, Brayne C. Poten-
tial for primary prevention of Alzheimer's disease: an analysis of
population-based data. Lancet Neurol. 2014;13(8):788-794.
33. de Bruijn RF, Bos MJ, Portegies ML, et al. The potential for preven-
tion of dementia across two decades: the prospective, population-
based Rotterdam Study. BMC Med. 2015;13:132.
34. Dominy SS, Lynch C, Ermini F, et al. Porphyromonas gingivalis in
Alzheimer's disease brains: evidence for disease causation and treat-
ment with small-molecule inhibitors. Sci Adv. 2019;5(1):eaau3333.
MARCHINI ET AL.
35. Alzheimer's Association. Alzheimer's disease facts and figures.
Alzheimers Dement. 2016 2016;12(4):459-509.
36. Kua EH, Ho E, Tan HH, Tsoi C, Thng C, Mahendran R. The natural
history of dementia. Psychogeriatrics. 2014;14(3):196-201.
37. Masters CL, Bateman R, Blennow K, Rowe CC, Sperling RA, Cum-
mings JL. Alzheimer's disease. Nat Rev Dis Primers. 2015;1:15056.
38. Krolak-Salmon P, Dubois B, Sellal F, et al. France will no more
reimburse available symptomatic drugs against Alzheimer's dis-
ease. J Alzheimers Dis. 2018;66(2):425-427.
39. Zhai Y, Yin S, Zhang D. Association between Antipsychotic drugs
and mortality in older persons with Alzheimer's disease: a system-
atic review and meta-analysis. J Alzheimers Dis. 2016;52(2):631-
639.
40. Shaw FE. Falls in cognitive impairment and dementia. Clin Geriatr
Med. 2002;18(2):159-173.
41. Shah H, Albanese E, Duggan C, et al. Research priorities to
reduce the global burden of dementia by 2025. Lancet Neurol.
2016;15(12):1285-1294.
42. Delwel S, Scherder EJA, de Baat C, et al. Orofacial pain and its
potential oral causes in older people with mild cognitive impairment
or dementia. J Oral Rehabil. 2018;46(1):23-32.
43. Chen X, Shuman SK, Hodges JS, Gatewood LC, Xu J. Patterns
of tooth loss in older adults with and without dementia: a retro-
spective study based on a Minnesota cohort. J Am Geriatr Soc.
2010;58(12):2300-2307.
44. Maldonado A, Laugisch O, Burgin W, Sculean A, Eick S. Clin-
ical periodontal variables in patients with and without dementia-
a systematic review and meta-analysis. Clin Oral Investig.
2018;22(7):2463-2474.
45. Klotz AL, Hassel AJ, Schroder J, Rammelsberg P, Zenthofer A. Oral
health-related quality of life and prosthetic status of nursing home
residents with or without dementia. Clin Interv Aging. 2017;12:659-
665.
46. Marchini L, Hartshorn JE, Cowen H, Dawson DV, Johnsen DC.
A teaching tool for establishing risk of oral health deterioration in
elderly patients: development, implementation, and evaluation at a
U.S. dental school. J Dent Educ. 2017;81(11):1283-1290.
47. Hybels CF, Bennett JM, Landerman LR, Liang J, Plassman BL, Wu
B. Trajectories of depressive symptoms and oral health outcomes
in a community sample of older adults. Int J Geriatr Psychiatry.
2016;31(1):83-91.
48. de Deco CP, Reis MRVS, Marchini AMPS, da Rocha RF, dos San-
tos MBF, Marchini L. Taste alteration, mouth dryness and teeth
staining as side effects of medications taken by elderly. Braz J Oral
Sci. 2014;13(4):257-260.
49. Singh ML, Papas A. Oral implications of polypharmacy in the
elderly. Dent Clin North Am. 2014;58(4):783-796.
50. Marchini L, Vieira PC, Bossan TP, Montenegro FL, Cunha VP.
Self-reported oral hygiene habits among institutionalised elderly
and their relationship to the condition of oral tissues in Taubaté,
Brazil. Gerodontology. 2006;23(1):33-37.
51. De Visschere LM, Grooten L, Theuniers G, Vanobbergen JN. Oral
hygiene of elderly people in long-term care institutions—a cross-
sectional study. Gerodontology. 2006;23(4):195-204.
11
52. Kelly MC, Caplan DJ, Bern-Klug M, et al. Preventive dental care
among Medicaid-enrolled senior adults: from community to nursing
facility residence. J Public Health Dent. 2017;78(1):86-92.
53. de Lugt-Lustig KH, Vanobbergen JN, van der Putten GJ, De Viss-
chere LM, Schols JM, de Baat C. Effect of oral healthcare education
on knowledge, attitude and skills of care home nurses: a systematic
literature review. Community Dent Oral Epidemiol. 2014;42(1):88-
96.
54. Manski RJ, Cohen LA, Brown E, Carper KV, Vargas C, Macek MD.
Dental service mix among older adults aged 65 and over, United
States, 1999 and 2009. J Public Health Dent. 2014;74(3):219-226.
55. Jablonski RY, Barber MW. Restorative dentistry for the older
patient cohort. Br Dent J. 2015;218(6):337-342.
56. Mengatto CM, Marchini L, Bernardes LADS, Gomes SC, Silva
AM, Rizzatti-Barbosa CM. Partial denture metal framework
may harbor potentially pathogenic bacteria. J Adv Prosthodont.
2015;7(6):468-474.
57. Eke PI, Thornton-Evans GO, Wei L, Borgnakke WS, Dye BA,
Genco RJ. Periodontitis in US adults: National Health and
Nutrition Examination Survey 2009–2014. J Am Dent Assoc.
2018;149(7):576-588.e576.
58. Ettinger RL. Geriatric dentistry in the USA: looking back 30 years.
Gerodontology. 2014;31(3):161-165.
59. Ettinger RL, Goettsche ZS, Qian F. Curriculum content in geriatric
dentistry in USA dental schools. Gerodontology. 2018;35(1):11-17.
60. Ettinger RL, Goettsche ZS, Qian F. Predoctoral teaching of geriatric
dentistry in U.S. dental schools. J Dent Educ. 2017;81(8):921-928.
61. Ettinger RL, Goettsche ZS, Qian F. Postdoctoral teaching
of geriatric dentistry in U.S. dental schools. J Dent Educ.
2017;81(10):1220-1226.
62. Rozas NS, Sadowsky JM, Jeter CB. Strategies to improve dental
health in elderly patients with cognitive impairment: a systematic
review. J Am Dent Assoc. 2017;148(4):236-245.e233.
63. Emanuel R, Sorensen A. A study of oral health prevention
behaviours for patients with early stage dementia. Br Dent J.
2018;224(1):38-42.
64. Kossioni AE, Hajto-Bryk J, Janssens B, et al. Practical guidelines
for physicians in promoting oral health in frail older adults. J Am
Med Dir Assoc. 2018;19(12):1039-1046.
65. Katsoulis J, Schimmel M, Avrampou M, Stuck AE, Mericske-Stern
R. Oral and general health status in patients treated in a dental con-
sultation clinic of a geriatric ward in Bern, Switzerland. Gerodon-
tology. 2012;29(2):e602-e610.
66. De Visschere LM, van der Putten GJ, Vanobbergen JN, Schols JM,
de Baat C. Dutch Association of Nursing Home Physicians. An oral
health care guideline for institutionalised older people. Gerodontol-
ogy. 2011;28(4):307-310.
67. De Visschere L, de Baat C, Schols JM, Deschepper E, Vanobbergen
J. Evaluation of the implementation of an ‘oral hygiene protocol’ in
nursing homes: a 5-year longitudinal study. Community Dent Oral
Epidemiol. 2011;39(5):416-425.
68. De Visschere L, de Baat C, De Meyer L, et al. The integration of
oral health care into day-to-day care in nursing homes: a qualitative
study. Gerodontology. 2013;32(2):115-122.
12
69. Weening-Verbree L, Huisman-de Waal G, van Dusseldorp L, van
Achterberg T, Schoonhoven L. Oral health care in older people in
long term care facilities: a systematic review of implementation
strategies. Int J Nurs Stud. 2013;50(4):569-582.
70. Geddis-Regan A, Walton G. A guide to treatment planning in com-
plex older adults. Br Dent J. 2018;225(5):395-399.
71. Gluzman R, Katz RV, Frey BJ, McGowan R. Prevention of root
caries: a literature review of primary and secondary preventive
agents. Spec Care Dentist. 2013;33(3):133-140.
72. Oliveira BH, Cunha-Cruz J, Rajendra A, Niederman R. Control-
ling caries in exposed root surfaces with silver diamine fluo-
ride: a systematic review with meta-analysis. J Am Dent Assoc.
2018;149(8):671-679.
73. Walsh LJ. Minimal intervention management of the older patient.
Br Dent J. 2017;223(3):151-161.
74. Ettinger RL. Treatment planning concepts for the ageing patient.
Aust Dent J. 2015;60(Suppl 1):71-85.
75. Robinson M, Lee BY, Hane FT. Recent progress in Alzheimer's dis-
ease research, part 2: genetics and epidemiology. J Alzheimers Dis.
2017;57(2):317-330.
76. Hane FT, Robinson M, Lee BY, Bai O, Leonenko Z, Albert MS.
Recent progress in Alzheimer's disease research, part 3: diagnosis
and treatment. J Alzheimers Dis. 2017;57(3):645-665.
77. Prorok JC, Horgan S, Seitz DP. Health care experiences of people
with dementia and their caregivers: a meta-ethnographic analysis of
qualitative studies. CMAJ. 2013;185(14):E669-E680.
78. Barbosa CS, Marchini AM, Marchini L. General and oral health-
related quality of life among caregivers of Parkinson's disease
patients. Geriatr Gerontol Int. 2013;13(2):429-436.
MARCHINI ET AL.
79. Mui AC. The Program of All-Inclusive Care for the Elderly (PACE):
an innovative long-term care model in the United States. J Aging Soc
Policy. 2001;13(2-3):53-67.
80. Shaw L. Program of All-Inclusive Care for the Elderly: a compre-
hensive, cost-effective alternative for frail elderly individuals. N C
Med J. 2014;75(5):344-345.
81. Singhrao SK, Harding A, Simmons T, Robinson S, Kesavalu L,
Crean S. Oral inflammation, tooth loss, risk factors, and associ-
ation with progression of Alzheimer's disease. J Alzheimers Dis.
2014;42(3):723-737.
82. Ide M, Harris M, Stevens A, et al. Periodontitis and cognitive
decline in Alzheimer's disease. PLoS One. 2016;11(3):e0151081.
83. Holmer J, Eriksdotter M, Schultzberg M, Pussinen PJ, Buhlin K.
Association between periodontitis and risk of Alzheimer's disease,
mild cognitive impairment and subjective cognitive decline: a case-
control study. J Clin Periodontol. 2018;45(11):1287-1298.
S U P P O RT I NG IN FO R M AT I O N
Additional supporting information may be found online in the
Supporting Information section at the end of the article.
How to cite this article: Marchini L, Ettinger R,
Caprio T, Jucan A. Oral health care for patients with
Alzheimer's disease: An update. Spec Care Dentist.
2019;1-12. https://doi.org/10.1111/scd.12375