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CHAPTER 2

Tips and Tricks for
Optimal Oral Care

It is often very challenging to maintain good standards of oral care with people living with dementia or a mental health challenge. For this reason, it is necessary to be creative and think outside the box.

I had a patient who, for the sake of confidentiality, I will refer to as Max. He was 26 years old with a diagnosis of young onset Alzheimer’s disease. Throughout his life, Max had neglected his teeth, choosing to brush them rarely and never visiting a dentist. When I met him, he had a severe case of halitosis, his teeth were badly discoloured from nicotine and coffee and it was clear there was much more gum and tooth disease that required attention.

The model I follow when implementing an intervention that requires blue sky thinking (thinking outside the box of normal, everyday clinical practice) is based on four key factors as identified in Figure 2.1.

Figure 2.1: Blue sky thinking

In the case of Max, this model proved useful in achieving the aim of encouraging and supporting him to see a dentist. It is a process that any caregiver, formal or informal, can implement with equal success.

Spotlighting

This is a technique I use when I am working with a patient to identify the underlying problem that has brought them to see me. With Max, it was imperative that I uncovered why he had avoided visiting the dentist throughout his 26 years of life.

I start by establishing a therapeutic relationship, and with Max it was based around our mutual liking for music and sport, both boxing and rugby. He was very nervous, anxious and driven by fear, typical of someone living with dementia.

Once Max felt safe with me, I was able to explore the reasons for his fear of going to the dentist. As a young boy, his father had pulled one of Max’s loose teeth with his fingers. It had hurt so badly he would never allow anyone to touch his teeth again.

Strategy

The next step in this model is to develop a strategy, with the patient being at the very core of any game plan created. At this stage, it was imperative that Max took the lead, made the decisions and controlled everything moving forward.

Action

Once we knew the cause of Max’s anxiety around visiting the dentist, we were able to empower him in developing a strategy that put him in the driving seat of finding a resolution. It transpired that Max’s favourite band was Queen, with Freddie Mercury being his rock idol. That was somewhat fortuitous because the dentist I referred him to was also a huge fan of Freddie and Queen! Together we agreed the following action:

• I would arrange for Max to go and see Dr Jones for a dental examination.

• Prior to Max’s wife taking him to the dental office, she would play his favourite album, A Kind of Magic, both at home and in the car (it transpired that they both rocked out to this album as they made their way to see the dentist!).

• Dr Jones would play a Queen song in his office while working with Max.

Outcome

Max and his wife had an amazing surprise when they arrived at the dental office. In reception were numerous photos of Queen playing venues such as Wembley stadium. Dr Jones had also put some magazines and other memorabilia on the tables, which distracted Max from worrying about the examination, thus decreasing his anxiety levels.

Once he was in the office and in the dentist’s chair, Max became engrossed in a conversation with Dr Jones about Queen. When it was time for the examination, there were no issues and a further appointment was made where Max agreed to have his teeth and gums treated.

It is essential that we think outside the box and work collaboratively to support people to live as well as possible through their unique journey of dementia.

I will now consider some tricks and tips used in the dental office that can lead to optimal oral care. These strategies require a team effort involving the patient, professionals and family members and/or friends.

TIP NUMBER 1: GETTING TO KNOW YOU

Get to know the patient – this refers to the entire dental practice team, from the receptionist to the most senior dentist.

One way of doing this is to hold a monthly ‘Getting to know you. Getting to know us’ event specifically aimed at families or individuals currently on their journey through cognitive change. This could be in an early evening or on a Saturday.

Provide some snacks and beverages and have all the team available. Prepare some flyers containing basic information on how the team work with people who have additional complex needs and demonstrate that every member of the team has received extra training in supporting people living with various forms of cognitive challenge.

You could also do an informal presentation and hold a Q and A session.

TIP NUMBER 2: LIFE STORY

Ensure that you have an entire history of the patient. Not only is medical information and history important, but life history too. The following page of Five things I like/Five things I don’t like/Five things I like to do/Five things I don’t like to do is sufficient and can be completed with the involvement of everyone:

Five things I like	Five things I don’t like
1 2 3 4 5	1 2 3 4 5
Five things I like to do	Five things I don’t like to do
1 2 3 4 5	1 2 3 4 5
Knowing a person makes a huge difference to their sense of personhood. When referring to personhood, I include things such as sense of purpose and being, likes and dislikes, choices, individuality, personality and character. All the things that make up a person are the things that lead to personhood. The aim is always to avoid malignant social psychology, or negative care strategies, approaches and interventions that diminish an individual.

TIP NUMBER 3: POINTS OF CONVERSATION

Ensure that you have three points of conversation based on the individual’s life history. I suggest the following:

1. Past or previous occupation: We spend our lives in various roles. We may be a father or mother, an auntie or uncle, a son or a daughter. We behave differently in each of these roles due to the responsibilities bestowed on us. However, one of the things that most of us hold dear and cherish is our occupation. It is often during that role that we meet people, including our future spouse, and it is where we achieve as much as we can and perform to our highest ability. Engaging in these types of conversations reminds people of their value and self-worth and has a very positive impact on their personhood.

2. Sport/leisure interest: Most people have interests outside work and this is one of the things we all cherish as part of work–life balance. Again, people often achieve things during their pursuits – being able to talk about the day Fred won the golf tournament or when Sandra won the final of the pool competition brings up fantastic memories and puts people in a really good place as far as their mental health is concerned.

3. Family (if there is no family, choose another topic such as fashion – something based on what you have learned from the individual’s life story and ‘Getting to know you’ event): If you ask most people, family is, and always was, their major priority throughout life. There is so much that can be discussed here, and very often, as healthcare professionals, we can relate to many of the same experiences and stories. All parents face similar experiences when bringing up children and can often speak with pride about their accomplishments. Holiday destinations and times such as Easter and Christmas are always fun to talk about.

You must be motivated to instigate the conversation and ask questions that are clear, concise and basic. We do not expect the individual to process complex information, and very often they will focus on topics and events that are based on history. Remember: the only time period that matters to someone living through cognitive change is the present. Whatever happened five minutes ago is irrelevant. Whatever is about to happen in five minutes’ time has no impact right now. This very second, the second you are engaging with the patient, is the only action that matters. It is easy to fall into the trap of talking about upcoming events or further treatment if in the dental chair.

TIP NUMBER 4: ACTIVITIES

The reception area of a dental office can be a negative place to be. People waiting to see the dentist are often very nervous, highly anxious and afraid. These are natural feelings and emotions that most people feel when visiting a dentist or doctor of any type. Usually, there are a few magazines scattered around and perhaps a few toys for children to entertain themselves with.

Let us think about some of the day-to-day challenges faced by those experiencing their journey through dementia:

• Increased anxiety in unfamiliar surroundings

• Restlessness due to decreased ability to concentrate

• Agitation due to inability to comprehend certain experiences

• Frustration due to forgetfulness.

Challenges are likely to be unique to each individual; however, these four highlighted above are common experiences.

There are a number of ways in which we can ensure available activities in the reception area or waiting rooms that are interactive, engaging and stimulating while at the same time being age appropriate and not too challenging, or completely fail free.

First, there is adult colouring, which is a growing activity enjoyed by many throughout the world. There are some books that are relatively basic and quick to complete.

A second activity is recognition cards such as word games. For example, show a card to the person that has ‘That is water under the …’ written on it and they have to find the word that completes the sentence (in this case, the word is bridge). Again, this activity is quick and can be concluded at any time.

Something that many people with neurocognitive and neurological disorders respond to is music. Playing music that the person relates to will contribute to bringing down anxiety levels and improve the person’s mindset.

By talking with the person, their family and friends, and including the questions mentioned in Tip 2, the dental team will be able to identify the most appropriate activities for patients.

TIP NUMBER 5: THINK ABOUT FLOOR AND COLOURS

Two primary colours (yellow and blue) and three secondary colours (orange, green and purple) are the best colours for dental offices and treatment rooms.

Consider that many of those living with dementia will have difficulties with their sight. This will be due to either their condition, the natural aging process or a combination of both. This further enhances feelings of confusion, disorientation and isolation. Consequently, levels of both fear and anxiety will increase.

The use of colours, especially in a contrasting way, makes a huge difference. You can highlight important areas while losing unimportant, unwanted and unneeded areas. Colour can also be used to highlight risks as well as elevate mood.

It is best to avoid the colour red as much as possible – including red clothing such as uniforms and scrubs. It is a colour that can induce rage and is often associated with danger. If we consider a red traffic sign, it means STOP.

For some people living with dementia, in particular those with Lewy Body dementia (the third leading cause of neurocognitive disorder), there is difficulty with spatial awareness. This is due to damage of the brain’s posterior parietal lobe, which means awareness of oneself in space is lost. Someone with this issue struggles to understand the relationship of organized objects in a particular space when there is a positional change. People manage better on an even floor that does not change due to gradient, colour or texture. In other words, try to ensure the floor remains constant and unchanged. This can help reduce falls risk as well as improve the environment, so it is more predictable.