2Unite Cognitivo-Comportementale, Alzheimer's Disease center, Gerontopole, Purpan University Hospital, Toulouse, France
So, Alzheimer's diseases and dementia became a stake in public health. In November 2007, the French government develops the plan Alzheimer (2008-2012) to organize and federate a global care for the AD-patients and his caregivers [4].
During the Alzhzeimer's diseases, crises can appear and can be translated by the appearance or the exacerbation of psychological and behavioral symptoms. The severity can become very disturbing for the patient, his family or the nursing home residents. The origin is multifactorial: exhaustion of helping person, acute diseases, break of the coverage care. In this situation, the resort is a necessary hospitalization; it constitutes very often the only answer. The cognitive and behavioral units (CBU) are adapted units which allow to ensure programs of specific care and to improve the quality of life [7].
The concept of the cognitive and behavioral units (CBU), inspired by the psycho-geriatric units, is created within the framework of the plan Alzheimer on 2008-2012 (measure 17) [4].
The measure 17 of the plan Alzheimer allows the creation of 120 specialized units which have the same characteristics: organization, budget, type of care, human resource, equipment. Cognitive and behavioral units (CBU) contain on average 11 beds, identified in units of following and readaptation care. Architectural and material considerations have to be in adequacy with the welcomed population. A specific project for each patient is established and contains different aspects: medical project,care project, ethical aspect. The professionals have skills and specific training. A structured and adapted program of activities is suggested in an objective limiting the expression of the behavior disorders and if possible to decrease the use of the sedative psychotropic and the setting. At the same time, the objectives in units of following and readaptation care are maintained. Nonmedical practices are proposed to these patients: psychomotricity, ergo therapy, orthophony, art-therapy... [8-11].
The general clinical context is taken into account because symptoms associated as pains, discomfort, under nutrition, dehydration; infections can deteriorate behavioral disorders in dementia. Although they can affect the quality of life of elderly with dementia, the oral health is often neglected and the oral care is considered complicated. Indeed, the behavior disorders (agitation, aggression), the lack of cooperation even the opposition, the loss of autonomy, the disturbance of the physical marks are so many brakes in the access to healthcare dental [12- 25].
The Pole Geriatrics-Gerontology of the Toulouse University Hospital became aware of this fact and the oral health is a part of the global care of the hospitalized patients.
Considering the cognitive diseases, the consent was not able to be collected. The general, geriatric data were raised on computerized medical record. The oral status is systematically realized within the framework of a global health check-up.
The most frequent motives for hospitalization were the behavior disorders (92.4%) associated with denutrition (24.4%), cognitive evaluation (9%), loss of autonomy (13.5%) or others (12%). In the entry, most of the patients (88%) walked. The average stay was in average of 32.8 days (range 17-41, median 25). The ADL (/6) was in average of 3.3 ± 1.8 (range 1.75-5, median 3.75). The behavioral disorders and the frequency were collected from the npi-nh (table 3).
The dentate patients had in average 7, 9 maxillary teeth, 9,4mandibulary teeth and 2 roots (Table 5).
92 patients had at least a tooth on every arch. 25 patients had at least 25 healthy teeth (11 women, 14 men) and only 4 patients
Variables |
Description |
Quantitative dental |
Number of maxillary or mandibular teeth Number of roots Presence of removable dentures (partial or complete) |
Functional dental |
Functional units (FU): Number of opposing natural or prosthetic tooth pairs which are going to be in contact during the chewing and during the swallowing [30]. The maxillomandibular wedging is assured by the presence of natural or prosthetic anterior functional units (incisive or canines) and\or by the presence of natural or prosthetic posterior functional units (premolars or molars). If the patients have a complete dentition, they have 8 posterior functional units and a good maxillomandibular wedging, but if they are complete edentulous, they have no functional unit, no wedging. Teeth and/or prosthetic wear |
Gingival and mucosa status |
The modified sulcus bleeding index follows the periodontal inflammation (score 0 = no bleeding, score 1 = bleeding on probing, score 2 = tendency to spontaneous bleeding) |
Dental and/or prosthetic hygiene |
1: adequate, no visible plaque |
|
Median (years) |
Range (years) |
n |
Total |
79,5 |
47-100 |
138 |
Women |
81,8 |
61-100 |
84 |
Men |
76 |
47-96 |
54 |
Multiple decays and demineralizations were observed at 15 patients (11 women and 4 men).
Fixed prostheses (of the crown in the complete bridge) were present at 49 dentate patients (26 women and 23 men). Among 108 dentate patients, 32 patients (23 women and 9 men) wore removable dentures (17 patients wore one removable denture, 15 patients wore 2 removable dentures) (Table5).
46 patients (30 women and 16 men) were edentulous at least an arch (Table 6).
Patients who were upper edentulous had in average 6 mandibular teeth and 1,3 roots for the women and 8,8 mandibular teeth and 3,1 roots for the men.
|
Age (years) |
n (%) |
Dentate (%) |
Edentulous (%) |
Total |
|
138 |
108 (78) |
30 (22) |
Women |
-60 |
- |
- |
- |
60-70 |
6 |
5 |
1 |
|
70-80 |
27 |
24 |
3 |
|
80-90 |
37 |
29 |
8 |
|
90+ |
14 |
6 |
8 |
|
|
|
84 (60) |
64 (46) |
20 (14) |
Men |
-60 |
5 |
5 |
- |
60-70 |
10 |
10 |
- |
|
70-80 |
11 |
11 |
- |
|
80-90 |
27 |
18 |
9 |
|
90+ |
1 |
- |
1 |
|
|
|
54 (40) |
44 (32) |
10 (8) |
60 patients had at least 6 posterior functional units (41 patients thanks to their natural teeth, 19 thanks to their natural and prosthetic teeth).
Among the 32 worn removable dentures, 23 were functional and adapted. 9 patients wore unsuitable, unstable prosthesis.
Facets of wear on the whole set of teeth was found at 51 patient's (24 women, 27 men).
Complete dentures were worn by 22 patients (15 women and 7 men). 6 women showed a good adaptation and a good wedging with their complete denture, 5 women wore only upper denture, 4 women had one of their complete denture which was inadequate. Among 7 men who wore complete denture, 4 men had a good adaptation and a good wedging with their complete denture, 3 men had one of their complete denture which was inadequate.
9 women and 8 men wore complete denture with facets of wear.
The mucosa and the tongue were healthy for 82 patientsi.e without erythema, plaque, xerostomia. 44 patients had a white tongue associated with a candidosa signs on mucosa and moderate xerostomia. 12 patients had severe xerostomia and erythema. The table 9 showed the mucosa status for dentate and edentulous patients (table 9).
|
Age (years) |
n (%) |
Number of teeth |
Number of roots |
|||||||
|
|
108 |
Maxillary |
Mandibulary |
|
||||||
|
|
|
0-5 |
6 -10 |
+10 |
0-5 |
6 -10 |
+ 10 |
0 |
1-4 |
+7 |
Women |
-60 |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
60-70 |
5 |
2 |
1 |
2 |
1 |
1 |
3 |
3 |
2 |
- |
|
70-80 |
24 |
8 |
7 |
9 |
4 |
10 |
10 |
11 |
10 |
3 |
|
80-90 |
29 |
9 |
10 |
10 |
9 |
8 |
12 |
15 |
11 |
“ |
|
90+ |
6 |
4 |
2 |
- |
1 |
3 |
2 |
1 |
4 |
1 |
|
|
|
64 (60) |
23 |
20 |
21 |
15 |
22 |
27 |
30 |
27 |
7 |
Men |
-60 |
5 |
1 |
2 |
2 |
1 |
- |
4 |
3 |
7 |
- |
60-70 |
10 |
- |
2 |
8 |
- |
2 |
8 |
5 |
4 |
1 |
|
70-80 |
11 |
5 |
1 |
5 |
2 |
2 |
7 |
9 |
1 |
1 |
|
80-90 |
18 |
5 |
5 |
8 |
3 |
4 |
11 |
7 |
5 |
6 |
|
90+ |
- |
- |
- |
- |
- |
- |
- |
- |
- |
- |
|
|
|
44 (40) |
11 |
10 |
23 |
6 |
8 |
30 |
24 |
12 |
8 |
|
Age (years) |
n |
Complete edentulous |
Upper edentulous |
Lower edentulous |
Women |
60-70 |
2 |
1 |
1 |
- |
70-80 |
6 |
3 |
2 |
1 |
|
80-90 |
11 |
8 |
3 |
- |
|
90+ |
11 |
8 |
3 |
- |
|
|
|
30 (22) |
20 |
9 |
1 |
Men |
60-70 |
0 |
- |
- |
- |
70-80 |
3 |
- |
3 |
- |
|
80-90 |
12 |
9 |
3 |
- |
|
90+ |
1 |
1 |
- |
- |
|
|
|
16 (11,5) |
10 |
6 |
0 |
|
n (%) |
Maxillomandibular wedging |
Inadequate or inexistent maxillomandibular wedging |
||||
|
|
Dentate |
Removable denture |
Complete denture |
Dentate |
Removable denture |
Complete denture |
Total |
138 |
51 |
26 |
15 |
31 |
2 |
13 |
Women |
84 (60) |
26 |
17 |
9 |
21 |
2 |
9 |
Men |
54 (40) |
25 |
9 |
6 |
10 |
- |
4 |
|
Age (years) |
n |
Periodontal inflammation |
No periodontal inflammation |
|
|
108 |
42 |
56 |
Women |
-60 |
- |
- |
- |
60-70 |
5 |
3 |
2 |
|
70-80 |
24 |
9 |
15 |
|
80-90 |
29 |
12 |
17 |
|
90+ |
6 |
1 |
5 |
|
|
|
64 (60) |
25 |
39 |
Men |
-60 |
5 |
3 |
2 |
60-70 |
10 |
4 |
6 |
|
70-80 |
8 |
5 |
3 |
|
80-90 |
11 |
5 |
6 |
|
90+ |
- |
- |
- |
|
|
|
54 (40) |
17 |
27 |
|
Age (years) |
n |
Normal mucosa |
Candidosa signs |
Severe xerostomia |
|||
|
|
|
Dentate |
Edentulous |
Dentate |
Edentulous |
Dentate |
Edentulous |
|
|
138 |
64 |
18 |
38 |
6 |
6 |
6 |
Women |
-60 |
- |
- |
- |
- |
- |
- |
- |
60-70 |
6 |
2 |
1 |
3 |
- |
- |
- |
|
70-80 |
27 |
12 |
3 |
9 |
- |
3 |
- |
|
80-90 |
37 |
17 |
5 |
12 |
1 |
- |
2 |
|
90+ |
14 |
4 |
5 |
1 |
1 |
1 |
2 |
|
|
|
84 |
35 |
14 |
25 |
2 |
4 |
4 |
Men |
-60 |
5 |
3 |
- |
2 |
- |
- |
- |
60-70 |
10 |
10 |
- |
- |
- |
- |
- |
|
70-80 |
11 |
5 |
- |
6 |
- |
- |
- |
|
80-90 |
27 |
11 |
4 |
5 |
3 |
2 |
2 |
|
90+ |
1 |
- |
- |
- |
1 |
- |
- |
|
|
|
54 |
29 |
4 |
13 |
4 |
2 |
2 |
|
Age (years) |
n |
adequate, no visible plaque |
inadequate, |
||||
|
|
130* |
Teeth |
Teeth + Prosthetic |
Complete |
Teeth |
Teeth + Prosthetic |
Complete |
Women |
-60 |
- |
- |
- |
- |
- |
- |
- |
60-70 |
6 |
- |
- |
1 |
4 |
1 |
- |
|
70-80 |
25 |
6 |
3 |
1 |
10 |
5 |
- |
|
80-90 |
35 |
6 |
4 |
6 |
12 |
7 |
- |
|
90+ |
13 |
1 |
1 |
7 |
2 |
2 |
- |
|
|
|
79 |
13 |
8 |
15 |
28 |
15 |
0 |
Men |
-60 |
5 |
1 |
- |
- |
4 |
- |
|
60-70 |
10 |
3 |
- |
- |
7 |
- |
|
|
70-80 |
11 |
3 |
2 |
- |
4 |
2 |
|
|
80-90 |
24 |
2 |
- |
6 |
11 |
5 |
|
|
90+ |
1 |
- |
- |
1 |
- |
- |
|
|
|
|
51 |
9 |
2 |
7 |
26 |
7 |
0 |
58 % of patients wore satisfactory and good quality prosthesis (fixed partial denture, partial removable denture, coping). A periodic supervision is necessary to keep these prosthesis for a long time.
The men had a better dental status than women. The age group is not correlated with the dental status; the oldest have not a less good oral health [32].
The number of edentulous is less as the institutionalized patients, only 21% patients are edentulous and a majority 73% wear compete denture. Under 34%patients have only one edentulous arch.
The study carried out by Gluhak at al. A similar population (institutionalized old patients with moderate to severe cognitive decline) shows a more damage dental status than the studied population who is younger and has been undergone periodic oral aftercares during their life [15-16].
Under 1/3 of removable dentures and half of complete denture were unfunctional (malajusted, unstable); they needed adjustment or repairing. However, these dentures were worn by the patients without complaint [33-34].
The attrition (generalized dental wear) of the natural and/ or prosthetic teeth was observed among 1/3 of dentate patients. These patients were younger and strolled; the attrition could be explained by a neuromuscular disease due to Alzheimer's decline and not by an occlusal instability. This phenomenon was more common among the men (61%) than the women (37%). The prosthetic wear was observed among 2/3 of edentulous patients wearing complete denture (80% among men and 45% among women). Except the neuromuscular diseases, the prosthetic wear could be explained by the age of the dentures [35].
8 patients had an important risk of infection because they had more than 10 roots and a periodontal inflammation [36-38].
60% of patients had no candidosa signs on the mucosa and the tongue and no xerostomia. In the literature, the prevalence of candidosa for the institutionalized elderly patients is behind 65% [39].
All the patients need hygienic oral care (teeth, mucosa and/ or removable denture) every day to prevent oral damages in the future [18-19, 45]. The Alzheimer's decline would increase for these patients and it would be very difficult to administer safe and efficient oral treatment for the dentists. Daily hygienic oral care is essential. The medical team and the caregivers help the patient hospitalized in the CBU with appropriate protocols. It is frequent that the patient is aggressive, opposing, refuses to open the mouth. The correct installation of the patient and the caregiver is one of keys of the success of the care. The patient is installed in side position of 3/4, head tilted near the nurse. The caregiver (right-hander) is next to the patient (in his right), her arm (left) props up the head of the patient and her hand (left) supports the mandible of the patient. Such an installation is going to contribute to reassure the patient, to assure the nurse's care and to avoid any fit. Reassuring words will accompany the patient during all the care, this is essential for the most opposing or distressed patients. The caregiver slides his index by the lip's corner even if the mouth remains closed. He comes to mass above the gumline. Indeed, when the mouth is big open, lips and cheeks are firmly stuck to the external faces of teeth. This “forced” position can establish a fatigue even or an aggression for the patient. When the mouth is closed, cheeks and lips are supple and allow the access to the external face of the dental arches, the tongue does not hamper anyway. The massage was pulled a relaxation of the joint, then the patient half-opens the mouth without strain and the oral care can start [46-47].
The needs for avulsion, scaling and restoring carious lesions are necessary to prevent infectious risk. The dentists can use the techniques of sedation (oxygen/ nitrous oxide) to facilitate dental care. The stabilization and the adjustment of prosthesis allow restoring adequate mastication and swallowing.
For this population, the infectious risks were identified for 21% of patients, the mastication and swallowing difficulties were identified for 22% of patients and the both problems were identified for 15 % of patients. But, it is uneasy to do a global treatment for all. Before starting an appropriate oral care, the dentist must evaluate with the medical staff the cognitive ability, the drug regimen, other medical conditions (valvular heart disease for example), the nutrition conditions and the disease prognosis.
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