Geriatric Oral Health Clinical Case #2

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Question 1 of 3

1. Question
Mary Perkins is 72 years old and was diagnosed with Alzheimer’s Disease 7 years ago. She requires assistance with bathing, toileting, and dressing. She can feed herself, but she needs to be reminded to do so. She is able to walk quite well. She lives in her home of 50 years with her daughter and granddaughter. An aide is present for 8 hours during the day. Her daughter and granddaughter share evening responsibilities including meal preparation, getting Mrs. Perkins cleaned and ready for bed, and redirecting her back to bed if she roams at night.

Mrs. Perkins medical health has been otherwise good. She has Hypertension, Hyperlipidemia and Hypothyroidism. Her medications include:
- Amlodipine 5 mg once daily
- Hydrochlorothiazide 25 mg once daily
- Levothyroxine 100 mcg once daily
- Pravastatin 20 mg once daily
- Memantine 10 mg twice daily
Mrs. Perkins’ primary care clinician retired last year, and the family had difficulty locating a new source of care. When you finally do see her as a new patient, her oral examination reveals the following:

Robert Henry, DMD, MPH

Which of the following is the most plausible explanation for Mrs. Perkins’ oral appearance?
- Patients with dementia often have poor oral clearance and Mrs. Perkin’s daughter did not have time to help her mother brush after breakfast this morning to remove residual food. While patients with dementia may exhibit impaired oral clearance, what is shown in the photos is not food but instead dense tartar and plaque buildup.
- Mrs. Perkins has not been receiving the ongoing assistance she needs with oral hygiene and plaque and tarter have built up giving rise to periodontitis and gum recession.
- This patient is a victim of elder abuse. Elder abuse is a significant problem in the United States, affecting more than 1 million individuals each year. Poor oral health warrants consideration of elder abuse, especially if coupled with trauma to the head or face, or other signs of neglect and mistreatment. However, in a patient that is otherwise clean, well fed, and cared for, these findings are more likely due to the self-neglect experienced by individuals with advanced dementia. This patient, who needs help with bathing and dressing, certainly could not be expected to manage her oral needs independently.
- Elderly patients can be expected to develop tarter fast due to the drugs they are on and this can accelerate periodontitis and gum recession due to age-related physiologic changes in the mouth. Age alone does not predispose the elderly to periodontitis. However, poor oral hygiene, xerostomia, and smoking all do contribute.
- Elderly patients often crave a fiber rich diet which results in increased food retention in the mouth and may lack nutrients needed leading to periodontitis. Taste changes experienced by the elderly as well as dental disease may predispose this group to prefer soft, high sugar foods. Such diets lack important nutrients that may reduce inflammation, promote healing and reduce the risk of caries.
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Question 2 of 3

2. Question
Mrs. Perkins is referred to a dentist. In three office visits, the plaque and tarter are removed. With root planing, use of oral doxycycline, chlorhexidine rinse, and good oral hygiene her periodontitis comes under control. The dentist and her staff also provide the family with instruction on how to provide effective daily oral care.

How should Mrs. Perkins’ family be instructed to brush her teeth?
- Have her lay in bed and brush the teeth from a standing position above her. This position does not allow for adequate control of the patient’s head nor visualization of the patient’s mouth and teeth in order to provide proper cleaning and prevent trauma in doing so.
- Have her stand facing you. This position does not allow for adequate control of the patient’s head nor visualization of the patient’s mouth and teeth in order to provide proper cleaning and prevent trauma in doing so.
- Have her stand or sit in front of you and brush her teeth from behind.
- Have her sit facing you. This is the optimal position for brushing. It provides more control and safety as well as better visualization.
- Do not recommend use of a brush. Rather, have her rinse with mouthwash daily. Mouthwashes will not remove plaque and debris adequately. Brushing is necessary to maintain good oral hygiene, particularly at the gumline.
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Question 3 of 3

3. Question
Mrs. Perkins declines gradually over the next 4 months. She breaks her arm in a fall and suffers a bout of diverticulitis that requires hospitalization. Caring for her at home in her weakened state has become increasingly difficult for her family, and the decision is made to pursue placement in a nursing home. It is important to the family that she continues to receive good oral care in the nursing home so that she does not lose the benefit of all of the progress they have made.

Which of the following is true concerning the maintenance of good oral health in nursing home residents?
- Attention to the oral needs of nursing home residents has been shown to decrease the incidence of aspiration pneumonia and pneumonia deaths. While this response is correct, there are also other correct responses present.
- Without assistance, up 90% of nursing home residents are not able to meet their own oral health needs. While this response is correct, there are also other correct responses present.
- Nursing homes that have dedicated and trained staff for oral health assessment and care have better oral health outcomes than those that do not. While this response is correct, there are also other correct responses present.
- Patients in nursing homes with dentures require assistance with denture care and routine evaluation of oral structures with dentures removed. While this response is correct, there are also other correct responses present.
- All of the above
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Geriatric Oral Health

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