368 Current Alzheimer Research, 2010, 7, 368-373

Oral Health in Alzheimer’s Disease: A Review

M. Mancini, M. Mancini, I. Grappasonni, S. Scuri and F. Amenta*

Centro di Ricerche Cliniche, Dipartimento di Medicina Sperimentale e Sanità Pubblica, Università di Camerino, 62032
Camerino, Italy

Abstract: The main data on oral health and dental pathologies affecting Alzheimer’s disease (AD) patients were re-
viewed. Oral health declines and dental pathologies increase with progression of AD. Poor oral hygiene, difficulty in
wearing dentures, and the inability to self-care, including carrying out oral hygiene procedures are the most probable
cause of impaired oral health in AD. Collection of information on oral/dental conditions from AD patients or their care-
givers/relatives is often difficult and scientific literature on the topic is sparse . The majority of data on the subject consist
in retrospective studies affected to some extent by subjective views of dental professionals involved. Appropriate dental
interventions in adult-onset dementia disorders will decrease pain and oral pathology and consequently could contribute to
maintain enough oral and nutritional health in these patients. Dental treatment in early stages of the disease are important
and should be finalized at producing a stable oral condition. This could improve the quality of life and contribute to de-
crease worsening of oral situations in the later stages of the disease when dental treatment may be difficult. The problem
of awareness of good oral health for keeping quality of life more acceptable in adult-onset dementia disorders is dis-
cussed.
Keywords: Alzheimer’s disease, oral health, dental caries, periodontal disease, dental management, preventive measures.

1. INTRODUCTION vanced stages of neurodegenerative disorders. Poor oral

Adult-onset dementia disorders and Alzheimer's disease
(AD), the most common of it, represent a growing concern in
Western world because of the rapid increase of elderly popu-
lation and the augmented incidence of old people affected by
neurodegenerative disorders. It is expected that the number
of AD patients may double or triple in the next 40 years [1].
Oral health declines and dental pathologies increase as AD
progresses. Dysfunction of salivary glands [2], reduced sa-
liva flow as a side effect of pharmacological treatments [3],
difficulty in wearing dentures, and the inability to self-care,
including carrying out properly oral hygiene procedures, are
the most probable causes of impaired oral health in AD [4].
Weight loss which is thought could precede the development
of overt dementia, may be regarded as an indirect effect of
poor oral health inducing nutritional deficits [5-10].
This paper has reviewed the main data on oral health and
dental pathology in AD, based on papers published between
1985 and 2008 and containing in the title the words mouth or
oral health or oral disease(s) or oral hygiene and Alzheimer’s
disease. Papers were retrieved by Medline analysis from 1
January 1985 to 31 December 2008.
2. ORAL HEALTH AND HYGIENE
The term oral health includes different subcategories,
which should be considered individually to understand the
complexity of oral physiologic and pathologic environment.
Oral health is related to general health and comfort in ad-
*Address correspondence to this author at the Dipartimento di Medicina
Sperimentale e Sanità Pubblica, Via Madonna delle Carceri, 62032 Cameri-
no, Italy; Fax: +39-0737-403325;
E-mail: francesco.amenta@unicam.it
health can impact on diet and nutrition, and consequently on
well being comfort, behavior, quality of life and life expec-
tancy [11-13]. For instance, the risk of aspiration pneumonia
is significantly increased by oral factors such as decayed
teeth, periodontal disease and loss of bactericide power of
saliva [14].
Oral health declines as AD progresses. The impact of the
disorder, especially in the latter stages, leads to poor oral
hygiene with increased periodontal disease, higher levels of
decay (both coronal and cervical) and greater incidence of
other dental/oral problems. They include difficulty wearing
dentures, inability to comply with oral care and to carry out
adequate oral hygiene procedures [2, 4, 15-18]. Poor oral
care and an increase in oral disease can lead to the develop-
ment of painful symptoms or discomfort, changes in swal-
lowing habits, compromised aesthetics with consequent
problems in self-esteem [19].
Factors influencing oral health, the ability to self care,
routine access to, and provision of oral care were extensively
studied [20]. Because of the difficulty in carrying out longi-
tudinal studies, the topic of oral health in adult-onset demen-
tia disorders has been analyzed only sparsely by investiga-
tions of such a type [17, 21].
It is commonly accepted that demented individuals have
poorer oral hygiene compared to the general population. This
leads to an increase in oral diseases [4, 16]. Inadequate oral
hygiene may depend by the cognitive and motor impairment
common in advanced stages of dementia and the consequent
reduced ability of self-care, including oral hygiene procedures
[2, 22]. The maintenance of oral hygiene has been found to
be more difficult for people with dementia. These conclu-
sions were drawn from a study investigating 116 dentate

1567-2050/10 $55.00+.00 © 2010 Bentham Science Publishers Ltd.

Oral Health in Alzheimer’s Disease: A Review
community-living older adults with dementia and a compa-
rable group of 116 adults without dementia [23] Obvious
differences in oral maintenance were reported only in ad-
vanced stages of the disease in a population of 230 hospital
geriatric clinic patients [22]. Reliance on caregivers who
may not have knowledge, motivation, skills or training nec-
essary for carrying out oral care has a further adverse impact
on oral hygiene, with augmented caries occurrence [18]. This
is probably the reason why demented people show often an
already compromised oral health status when admitted to
long-term care homes [23].
3. PERIODONTAL DISEASE
Periodontal disease is an important determinant of nutri-
tional status in older people. The largest study on the topic
has examined and interviewed 1929 (87%) of the 2220 resi-
dents in 29 of the 30 institutions for the elderly in a Japanese
city, from October 1988 to February 1989 [24]. Gingivitis is
more prevalent in people with dementia than in age-matched
non-cognitively compromised individuals [18, 22]. Cogni-
tive impairment, motor restlessness and apraxia may con-
tribute to the increase of periodontal disease as plaque con-
trol and appropriate oral care require adequate cognitive and
motor skills. Some studies did report in demented individu-
als significantly higher plaque scores, increased proportion
of gingival bleeding sites and more calculus than in age-
matched control subjects. Other investigations did not find
statistically significant differences in periodontal health be-
tween control and dementia groups [2, 17].
Periodontal pathology has been found to be associated
with cardiovascular disease and stroke. Chronic recurrent
infections and inflammations resulting from periodontal dis-
ease may be responsible of this association. A relationship
between periodontal disease and raised circulating cytokine
levels has been reported [25]. Particular pathogens are
probably important in mediating associations with systemic
diseases [26]. It cannot be excluded that some specific in-
flammatory features of periodontal disease may represent a
risk factor of AD as documented by neuropathological and
epidemiological studies. These studies have found a relation-
ship between cardiovascular diseases and dementia disor-
ders. The association between dementia and high-sensitivity
C-reactive protein, which represents a non-specific marker of
inflammation was evaluated in a 25-year follow up. This
analysis has shown that inflammatory markers may reflect
not only peripheral disease, but also central neurodegenera-
tive processes related to dementia. It has also been stated that
these markers are already measurable before the appearance
of overt dementia [27, 28].
4. DENTAL CARIES
The majority of investigations on the prevalence of caries
in people with dementia included non-medicated individuals
in the early to moderate stage of the disease. This may have
caused an underestimation of the problem of dental caries in
dementia disorders due to the exclusion of individuals on
symptomatological treatment for cognitive dysfunction and
behavioural problems.
Coronal (crown) and cervical (root) caries increments are
significantly higher in demented patients. Male gender, de-
Current Alzheimer Research, 2010, Vol. 7, No. 4 369
mentia severity, high caregiver burden, oral hygiene difficul-
ties, use of antipsychotics which cause dry mouth and previ-
ous caries experience, are considered as risk factors for den-
tal decay [18]. Oral health problems, including dental caries
have been reported to increase parallel with worsening of
dementia [22]. Clinical trials have found decreased salivary
flow rates, poorer oral hygiene and increased prevalence of
caries (both coronal and cervical) in demented subjects, al-
though statistical significance of differences between non-
demented individuals is difficult to be demonstrated [4, 17,
21]. This is probably due to the exclusion from these studies
of people with advanced AD which were unable to give in-
formed consent and in the problems of gaining co-operation
and/or compliance from these patients when included. Indi-
viduals with a poor level of cooperation are those most likely
at risk of increased oral disease [4, 17, 19, 21, 22].
In a Swedish population of 159 individuals aged 80 years
and over, both coronal and cervical caries increase parallel to
the cognitive impairment. People with poor cognitive func-
tion have a four times higher risk of not using dental services
regularly [29]. It has been shown that demented individuals
living in care homes have more oral problems, especially if
suffering from moderate to severe dementia, than individuals
without dementia [30], as shown in residents (n=135) in four
nursing homes in Cheshire who were recruited and matched
in two cohorts. One cohort's subjects were deemed to have
no or mild dementia, whereas the other cohort's subjects
were affected by moderate to severe dementia [31]. To sum
up, studies on this area concluded that severity of cognitive
impairment rather than diagnosis of dementia is a key factor
in caries experience [4, 17, 19, 21, 22, 30, 31].
5. PHARMACOTHERAPY AND ORAL MUCOSA
Common medications used in AD (Table 1) [32] can
cause xerostomia (dry mouth) and as a complication of it
plaque accumulation, periodontal disease, denture wearing
problems and dental caries.
If medications are syrup-based the potential for the de-
velopment of caries is increased. With AD progression indi-
viduals are less able to remember and to carry out daily liv-
ing activities such as tooth brushing. Hence, AD patients
need support in this task. On the other hand, these patients
become unable to express their needs or wishes, and to un-
derstand and explain a key dental symptom such as pain
[33].
The spectrum of side effects/adverse reactions of drugs
used for countering symptoms of AD may affect oral health
of patients as well. Sialorrhea is common in patients treated
with cholinesterase inhibitors (ChEIs). ChEIs besides to their
cerebral activity display several systemic effects typical of
enhanced cholinergic function such as salivation, peristalsis,
and vascular smooth muscle relaxation. This may cause nau-
sea, vomiting, abdominal pain, and diarrhea. Increased sali-
vation may make more difficult to maintain a dry field dur-
ing dental treatment, enhances choking sensation and may
cause problems for the patient to maintain a removable pros-
thesis [34-36]. The occurrence of glossitis as an adverse re-
action accompanying the use of ChEIs was reported [33, 37].
Besides to drugs licensed for symptomatic treatment of
AD, people with dementia may receive different medications
370 Current Alzheimer Research, 2010, Vol. 7, No. 4 Mancini et al.

Table 1. Common Oral Dosing for Drugs Used in the Treat- to treat problems such as anxiety, depression, psychosis,
ment of Alzheimer Disease insomnia and/or other systemic diseases common in the eld-
erly. It has been reported that submandibular gland but not
parotid salivary flow rate is reduced in early AD compared
First-Line Medications Oral Dosing
to control individuals [16]. Xerostomia is often associated
with the use of antidepressants, benzodiazepines, and antip-
Cholinesterase inhibitors*
sychotics, mainly due to their anti-cholinergic activity. Hypo
Donepezil 5-10 mg daily salivation reduces lubrication of mucosal tissues, resulting in
increased dryness of oral mucosa and lips. This increases the
Galantamine °ER 8-24 mg daily potential for mucosal abrasions and ulcerations as well as
°IR 4-12 mg twice daily increases the difficulty to retain removable prosthetics [34,
Rivastigmine 1.5-6 mg twice daily 38]. Reduction in salivary flow alters normal oral flora, de-
creases tissue flushing, and impairs buffering capacity of this
N-methyl-D-aspartate receptor an- fluid. This can create a favorable environment for increasing
tagonists plaque formation and for the development of gingivitis,
periodontal disease, dental caries, and of retrograde infec-
Memantine 5-10 mg twice daily
tions causing sialadenitis [34, 35, 38-41].
Adjunctive/symptomatic medications
Neuroleptic medication increases susceptibility to caries
Tricyclic antidepressants [18]. These drugs can also cause mucositis, gingival hyper-
plasia, oral ulceration, erythema multiforme [36-37]. Loss of
Desipramine 10-150 mg daily taste has been reported in individuals treated with anticon-
Nortriptyline 10-40 mg daily vulsants [2, 35-37, 42]. No differences in mucosal pathology
(including candidiasis) were reported in spite of the tendency
Amitriptyline 10-50 mg daily of demented individuals to have dry and cracked lips [2, 37,
Selective serotonin reuptake inhibitor antidepressants
42]. Dry mouth has serious consequences for cognitively
impaired subjects who may be unaware or unable to express
Citalopram 10-20 mg daily their difficulties [4, 16, 34, 41, 42].
Fluoxetine 10-20 mg daily
6. DENTAL MANAGEMENT
Paroxetine 10-40 mg daily
Oral care, treatment planning, and behavioural manage-
Sertraline 25-100 mg daily ment in demented individuals must be designed with consid-
eration of the severity of disease and should involve family
Typical antipsychotics members and caregivers [2, 43]. AD patients asking for den-
Haloperidol 0.25-5 mg every 6 h tal advice rarely are diagnosed as demented or are aware of
their conditions. The same is true for their families that in
Atypical antipsychotics general may incorrectly attribute symptoms of their relatives
Risperidone 0.25-2 mg daily
to age-related slowing of brain functions. An index of dental
management based on an assessment of observed behavior
Olanzapine 2.5-10 mg daily and ability has been proposed [43]. This may offer an useful
guidance for planning treatment.
Quetiapine 12.5-200 mg daily
The “Guidelines for the Development of Local Standards
Anxyolitics of Oral Health Care For People with Dementia” set out an
Lorazepam 1-2 mg daily algorithmic approach to decision making and treatment plan-
ning for patients with cognitive impairment that provides
Oxazepam 10-60 mg daily clinical guidance [20]. They can help clinicians in assessing
Temazepam 7.5-30 mg daily
realistic treatment options based also on consultations with
families, caregivers and multi-disciplinary teams. It is impor-
Hypnotics tant for dental profession to treat, rather than ignore, any oral
health problems as people in the late stage of AD are often
Zolpidem 5-10 mg daily
unable to communicate dental symptoms [44], which cause
Triazolam 0.125-0.25 mg daily behavioral changes or worsening of them [2, 33].
Typically, dosing of these drugs is titrated up slowly to limit side effects. As with any During early dementia, routine dental care must be per-
drug, especially in an older population with a number of comorbidities (e.g., decreased formed to eliminate potential sources of pain, disease, and
liver and kidney function), the lowest dose should be identified that produces the infection and to restore dentition, dentures, or both to opti-
desirable effects without intolerable side effects. mal function. It is critical to anticipate future oral decline
°ER, extended release; °IR, immediate release. planning preventive treatments and measures, such as the use
*Often combined with N-methyl-D-aspartate receptor antagonist in advanced stages of of topical fluoride, chlorhexidine, or both. The practice of
dementia.
frequent recall visits and daily oral hygiene measures will be
Modified from [32]
certainly useful. Caregivers and family members must be
instructed on assisting the patient with daily oral and denture
Oral Health in Alzheimer’s Disease: A Review
hygiene. Clinicians should maintain updated medical and
medication records of these patients to avoid possible com-
plications, such as postural hypotension, adverse interactions
with epinephrine contained in dental anesthetics, the poten-
tial for over sedation, and medication-induced salivary gland
dysfunction. Treatment performed for adults with moderate
dementia will require specific modifications because of un-
cooperative behavior [20]. Caution is to be recommended in
case sedatives or anxiolytics are required. Older patients may
experience a greater duration and depth of sedation with sub-
sequent cognitive, behavioural, and motor disturbances and
therefore must be supervised closely after administration of
sedatives. Short-acting benzodiazepines (e.g. triazolam, ox-
azepam, or lorazepam) administered before dental treatment
to manage behavioral problems should be preferred as much
as possible [36, 38, 45]. Intravenous sedation or general an-
esthesia can be considered for necessary dental care, prefera-
bly after careful evaluation of patient’s condition by multi-
disciplinary teams [36, 38, 45].
Even using oral sedatives, it may not be possible to per-
form a thorough extra oral, intraoral, and radiologic exami-
nation. Frequent recall and aggressive preventive measures
must be avoided. Short appointments and lighter maneuvers
can be less stressful. The role of caregivers becomes critical
in providing symptomatic and objective information, as well
in performing daily oral hygiene. Treatment plans should be
designed with minimal changes to the oral cavity and should
not involve complete rehabilitation. Adaptation to new pros-
theses may be difficult for these patients. Relines for ill-
fitting dentures may be preferable [20]. Complex and time-
consuming dental treatment should be avoided in severe de-
mentia. It is important to keep patients free of pain and able
to maintain adequate nutritional intake, particularly if they
are no longer able or willing to wear their dentures [20, 38].
7. DISCUSSION
In modern societies adults are more aware than in the
past about the importance of oral health for a better quality
of life. To maintain lifelong good oral health, elderly needs
regular dental care. Definition of proper treatment level for
AD patients is a complex task. A high degree of awareness is
necessary to obtain a compromise between patient mental
impairment and needs of dental treatment. Extensive guide-
lines and treatment schemas for the management of oral pa-
thologies in cognitively intact people are available. Although
there is consensus on the need of keeping adequate oral
health in AD, it is difficult to provide appropriate dental
treatment without a consultation involving patient’s care-
giver, physician, dentist and neurologist.
Important information useful for planning appropriate
dental treatment include the disease stage, the patient’s cog-
nitive ability to provide consent for treatment, the disease
prognosis, the drug regimen and the identification of other
medical conditions (e.g. valvular heart disease) that may
influence dental treatment [20]. Treatment-planning must
take into account the patient needs and the caregiver attitude
and awareness. Patient physical and mental status and the
predictive benefit of treatment to the quality of its life, are
key aspects also in terms of success of measures undertaken
[46, 47].
Current Alzheimer Research, 2010, Vol. 7, No. 4 371
Patients with AD can become frustrated and irritable in
unfamiliar circumstances, environments or with questions,
instructions or information that they do not understand [48].
The dentist should capture the patient’s wandering attention.
This can be accomplished by minimizing office noise and the
overall level of activity. Dentist and team members should
be alert to the patient’s needs, communicating acceptance
and reassurance and providing the sense of safety of the en-
vironment. With these precautions, most routine treatment
can be provided. A specific preparation of dentists in psy-
chological, neurological and behavioural correlates of adult-
onset dementia disorders is desirable to improve the quality
of any approach to oral problems of these frail patients.
Dividing the progression of the AD into stages/therapy
goals would be not sufficient to face with the actual patient’s
oral problems. Some people are comfortable with a visit to
the dentist, while others find the whole experience distress-
ing. The ability to comply with oral hygiene procedures,
dental care and visit in dental offices is often influenced by
past dental behavior and experiences [49]. Of course, poor
co-operation of people in the late stage of dementia is not
necessarily because of the nature of the illness but may de-
pend on past negative dental experiences [50, 51]. Informa-
tion on past dental care and previous attitudes towards oral
care from relatives and/or caregivers could be important in
predicting the behavior and willingness to receive dental
care. People familiar with regular dental treatment often re-
member what they are expected to do and have little diffi-
culty in co-operating with simple procedures until dementia
is advanced. For other people the journey to the surgery, the
strange environment and the unfamiliar faces of the dental
team can exacerbate their confusion, making treatment diffi-
cult or impossible. In these circumstances domiciliary dental
care should be considered, as seeing the person in their fa-
miliar and ‘safe’ environment can enhance cooperation.
Independently from the AD stage, dental treatment
should focus on the removal of non-restorable teeth and on
the maintenance of dentition and existing dentures with fre-
quent oral hygiene measures. To reduce pain and pathology
and to maintain the dignity and quality of life of a person
with AD, dentists will be increasingly challenged with pre-
serving oral and nutritional health of their patients. Oral hy-
giene, medicaments such as fluoride and anti-bacterial pastes
and mouth-rinse, and in general, all available prophylaxis a-
traumatic procedures should be preferred than the true dental
treatment.
Dental treatment in early stages of the disease should be
aimed as far as possible at producing a stable oral condition
that gives the sufferer minimal trouble when, in the later
stages of the disease, dental treatment may be extremely dif-
ficult or impossible. To sum up, dentists may have a specific
role in maintaining the quality of life of AD patients. They
should keep patients free of oral infection, restore their denti-
tion allowing effective eating, and maintain speech and aes-
thetics as long as possible. For reaching these goals, the de-
velopment of an individualized patient care plan, taking into
account physical and cognitive status changes that will occur
as the disease progresses is of great importance. Oral health
care providers should also be sensitive to the needs of patient
family and caregivers. An essential part of any successful
372 Current Alzheimer Research, 2010, Vol. 7, No. 4
strategy to optimize the quality of life for patients with AD is
familiarity with and access to available resources.
Clinician must remember that when treating AD patients,
he should exercise empathy, congruence, and a positive re-
gard. Dementia may become a barrier to the delivery of rea-
sonable oral health care, both from a personal and profes-
sional point of view. The development of specific preven-
tion/treatment programs devoted to mental/oral care of adult
demented and on evaluation of their follow-up will help to
place proper approaches for maintaining reasonable quality
of life of these individuals as longest as possible.
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Received: July 02, 2009 Revised: October 27, 2009 Accepted: November 01, 2009
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