Dental management of patients with Alzheimer'sdisease and other dementias

Ronald L KttingerDepartment nf Prosthodnntit. Dows Institute lur Dental Research. University of Iowa, USA

Key W()rd.\: alzhcimer's disease, diagnosis oral problems, decision making dental care.

IntroductionDementia is not a sign or a symptom, it is not adisease but a variety of syndromes. There are anumber of types of dementia, which includevascular changes such as multi-infarct dementia,Alzheimer's disease, Lewy body dementia,Parkinson's disease and dementia associated withchronic alcoholism'. Alzheimer's disease accountsfor 50-609r of the diagnosed dementias'. Diagnosis

Table 1. Causes of reversible and irreversible dementias

of dementia of the Alzheimer's type (AD) usuallyoccurs over a period of time after reversible ortreatable causes of dementia (Table 1) have beeneliminated\ The clinical diagnostic criteria for ADas developed by the American PsychiatricAssociation, in the Diagnostic and StatisticalManual for Mental Disorders (DSM-IV)* areshown in Table 2.

Reversible or treatable dementia

D - Drugs, alcoholE - Emotions, e. g., depressionM -Metabolic, e. g., pernicious anemia, NiacinE - Endocrine, e. g. hypothyroidism, hyperthyroidism,

hypopituitarismN - Nutrition, e. g., folic acid deficiency, thiaminT - Brain tumors, traumaI - Infections, e. g.. Tuberculosis, Syphilis, AIDSA - Arteriosclerosis (Cerebral)

Irreversible dementia

Alzheimer's diseaseMulti-infarct dementiaLewy Body diseaseDementia Pugilistica

Creutzfeldt-Jackob diseasePick's diseaseParkinson's diseaseHuntington's diseaseBrain tumor

Modified from: Besdine R W. In: Rowe J W, Besdine R W (eds)."Health and Disease in Old Age". Little, Brown & Co. Boston, 1982 (p 104-105)3

Table 2. DSM-IV criteria for dementia of the Alzheimer's type

A. The development of multiple cognitive deficits manifested by both:1) Memory impairment2) One or more of the following:

AphasiaApraxiaAgnosiaDisturbance in executive function

B The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioningand represent a significant decline from a previous level of functioning

C. The course is characterized by gradual onset and continuing cognitive declineD. The cognitive deficits in Criteria A1 and A2 are not due to any of the following:

1) Other central nervous system conditions2) Systemic conditions known to cause dementia3) Substance inducted conditions

E. The deficits do not occur exclusively during the course of a deliriumF. The disturbance is not better accounted for by another Axis 1 disorder

From: Diagnostic and Statistical Manual of Mental Disorders" (4th ed., pp. 142-143). Washington, DC: AmericanPsychiatric Association, 19944

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Denial management of patients with Alzheimer's diseuse and other dcmcndas 9

In the USA there are over 4 million personsaffected with Alzheimer's disease, the prevalence"varies from: 2.8% - 3.5% of those aged 65-74 years;9,0% -19.0% of those at 75-84 years; and 28.0% -47.0% of those at 85+ years. Advanced age seemsto be a major risk factor.

Apart from age*, various other risk factors havebeen identified, such as a first degree relative withthe disorder'"", Trisomy 21, and a previous historyof head trauma'l It has been shown that 40% ofpersons diagnosed with early onset AD have a closerelative who also had the disease. Early-onsetfamilial Alzheimer's disease has been shown tobe associated with mutations in at least 4 genes.They can be expressed as autosomal dominantgenes on chromosomes 1, 14, 19 and 21'^ '^ Forinstance, it has been shown that all personsdiagnosed with Down Syndrome (trisomy 21) whosurvive beyond age 50 will get AD'\

Currently there is no biological test capable ofconfirming the clinical diagnosis of AD. The onlydefinitive diagnosis is by post-mortem evaluationof the brain by a neuropathologist, who identifiesspecific cerebral changes characteristic of thiscondition - that is intraneuronal neurofibrillarytangles and neuritic plaques. There are someadjunctive tests which are being evaluated. Theseinclude cerebrospinal fluid protein markers,positron emission tomography (PST), magneticresonance imaging (MRI) and apolipoprotein E-rV'^ . Other common clinical diagnostic instrumentsbeing used are the clock drawing test and the Mini-Mental State Examination of Folstein' 'I

The progression of AD is gradual and continuousand the average patient can expect to live for 8 to10 years after the onset of symptoms. This is achronic disease and patients require care over acontinuum. The progression of the disease has been

Table 3. Reisberg's global deterioration scale

described by Reisberg ct al^"* as having sevenrecognizable stages (Table 3). However, for thepurposes of dental treatment, the seven stages canbe collapsed into three stages which can bedescribed as early/mild, middle/moderate, or late/severe disease'^ '.

Cballenges for tbe dentistWhen a person becomes eognitively impaired, thedentist faces the dilemma of making a treatmentdecision for such an individual without knowingthe real benefits of that treatment. Gordon et aPhas highlighted some of these dilemmas in decisionmaking for eognitively impaired dental patients:1. How can the clinician determine when a dental

condition requires intervention when the patientis so eognitively impaired that he is unable todescribe the symptoms?

2. How will the clinician know if sensory input ina eognitively impaired patient has declined tothe point that pain perception has been sosignificantly changed that the patient may nolonger perceive pain or be able to describe it?

3. What percentage of seemingly asymptomaticoral conditions in an older patient can bepredicted to become symptomatic in the absenceof treatment?Other significant problems that create dilemmasfor dentists when caring for a patient with ADare his or her:

4. progressive decline in ability to perform oralself-care.

5. progressive decline in ability to tolerate dentalinterventions.

6. progressive decline in the ability to understanddental treatment and his/her concomitantinability to give informed consent.

Stage Clinical phase Clinical characteristics

1 Normal None2 Forgetfulness Subjective forgetfulness but normal physical examination3 Early confusion Difficulty at work, in speech, when traveling in unfamiliar areas, detectable by family; subtle

memory deficit on examination4 Late confusion Decreased ability to travel, count, remember current events5 Early dementia Needs assistance in choosing clothes; disorientation as to time or place; decreased recall of

names of grandchildren6 Middle dementia Needs supervision for eating and toileting; may be incontinent; disoriented as to time, place and

possibly to person7 Late dementia Severe speech loss; incontinence and motor stiffness

Modified from: Reisberg B, Ferris S H, DeLeon O R et al. The Global Deterioration Scale for Assessment of PrimaryDegenerative Dementia. Am J Psychiatry, 1982 139:1136-39.19

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7. oral side ellects irDiii those medications used totreat the symptoms of disease, especiallyhallucinations, agitations, delusions, feiufulness,mood swings, suspiciousness, wandering, sleepchanges, and violent acts. The oral consequencesof this symptomatic treatment are summarizedin Table 4.

Oral infection controlIf oral infection control is not maintained by dailyoral hygiene, the patient is at risk for rampant cariesand severe periodontal disease, which can lead tooral discomfort or pain. Oral discomfort or paincan manifest itself as changes in behaviour suchas:

Increased restlessness Impaired sleep Moaning or shouting Refusal to eat favorite foods or refusal to eat hard

foods/cold foods Refusal to cooperate

Aggressive behaviour towards their caretakers

Therefore, the goals of dental treatment should beto:

Prevent further oral disease Restore and maintain health Make oral health care a normal part of the

patient's life, so that he/she does not find itconfusing or threatening.

Evaluation of the patientBefore an individualized treatment plan can bedeveloped, the dentist needs to carry out an in-depth evaluation of the patient with AD. Thefollowing are issues which must be taken intoaccount and which are not usually examinedwithout cognitive problems.

1. The level of the patient's cognitive impairment.This will require consultation with the patient'sphysician and caretakers. However, Niessen andJones" developed an Index to Dental treatment.

Table 4. Oral consequences of medications used to treat the symptoms of Alzheimer's disease

Category of medication Dental concern/problem Preventive precautions

Anticholinesterases (TacrineDonepezil, Metrifonate)

May decrease function of localanesthetics and vice versaGlossitis, dry mouth

Caution with administrating localanesthetics

Antidepressants (Tricyclicsand Serotonin UptakeInhibitors)

Interaction with epinephrine in the localanesthetic. Also Xerostomia, posturalhypotension, and extrapyramidalsymptoms)

Epinephrine should be used withcaution. Use small amounts andaspirate. Contraindicated withnor-epinephrine

Antipsychotics(Butyrophenones andPhenothiazines

Xerostomia causing detrimental oraleffects such as root caries, periodontaldisease, mucositis, etc. PosturalHypotension or Tardive DyskinesiaExtrapyramidal Symptoms

If possible, ask physician tochange to alternative drug withless xerostomic effects. Usefluorides & salivary substitutes,when possible. Risk of falls dueto Postural Hypotension

Antianxiety or Agitation. FearSleeplessness(Benzodiazepines Oxazepam)

Xerostomia, drowzinessOrthostatic Hypotension

Use fluorides & salivarysubstitutes, when possible.Recognize nsk of orthostatichypotension and prevent falls bysitting the patient up for 5-6minutes prior to release.

AnticonvulsantsPhenytoinsValproic Acid

Gingival overgrowthOral ulcerationsTaste lossErythema multiformeIncreased bleeding

Stress reduction to prevent aconvulsive episode

References:Sommerman M, Dental Implications of Pharmacological Management of the Alzheimerfs Patient. Gerodontology 6:59-66,1987Henry R G. Providing Dental Care for Patients Diagnosed with Alzheimer's Disease Dent Ctins N Am 41:915-942, 1997Gage T W, Picket! R A. Mosby Dental Drug Reference, 4th Edition. Mosby-Year Book, Inc., St. Louis, 1999

The Gerodontology Association 2000Gerodontology

Rental management of patients with Alzheimer's disease and other dementias

Management (Table 5) which is extremely usefulin determining the patient's ability to receive orbenefit from treatment. The most important signfor a dentist who sees a patient for the first timeis how much the individual's capacity for oralself care has deteriorated. That is, can the patientremember how to brush his/her teeth or denturesor how to place dentures in his/her mouth? Theother important factor, which was discussedearlier, is whether the patient's perception ofdiscomfort or pain is so distorted that he/she canno longer can respond to the dentist's diagnostictools such as an electric pulp tester or to cold,palpation or percussion.

2. The level of the patient's activities of daily living.This information can be gained from thepatient's caregiver. What is important to evaluateis whether the patient can feed him/herself andwhether he/she is continent with regard to urineand faeces. The ability to eat will determine theneed for dentition, because the ability to eatunaided is strongly correlated to cognitive status

and the choice of food consistency is correlatedto dental status". The ability to use the toiletcan determine if treatment can be carried out ina dental office or must be carried out in the placeof residence of the patient.

3. Levet of social functioning. This information isdetermined by interacting with the patient andthe caregiver. It will determine if the patient isphysically or verbally abusive and if there is aneed for physical restraint or chemical restraint.The guidelines" for the use of physical restraintare summarized in Table 6.A variety of behavioural managementtechniques should be tried before chemicalrestraint is used. These include always havingthe caretaker visible to the patient duringtreatment, having the caretaker help you byholding the patient's hand, talking to him/her,singing to the patient, removing all visual noise,or distracting the patient by giving him/her aterry cloth towel or soft toy to hold duringtreatment.

Table 5. Index to dental management for a patient with Alzheimer's disease

Can patient brush teeth or clean dentures?

Can patient verbalize chief complaint?

Can patient follow simpleinstructions (sit in chair)?Can patient hold radiograph in mouth withbite-block or snap a x-ray holder?

Is patient assaultive (bites, hits)?

Total score

From: Niessen L, Jones J A, Zocchi M, et al.Dental Care for the Patient with Alzheimer's Disease.J Am Dent Assoc 1985; 110:207-209.23

Yes

(0)Yes(0)Yes(0)Yes(0)No(0)

Needs someassistance

(1)To limited Degree

(1)Occasionally Complies

(1)Sometimes

(1)Sometimes

(1)

Needs completeassistance

(2)No(2)

Cannot follow(2)

Never(2)

Always(2)

Scoring 0-3 Mild disease (no change in treatment)4-7 Moderate disease (modify treatment plan)8-11 Severe disease (emergency treatment only)

Table 6. Guidelines for physical restraint use*

Restraint is necessary for safe, effective treatment Restraint is not for punishment of the patient or the convenience of the staff The least restrictive alternative should be used Restraint should cause no physical trauma and minimal psychological trauma Reasonable benefits are expected as a result of the treatment There is consent for the dental treatment There is consent for the use of the restraint The type of restraint is specifically selected based on the planned treatment Dental staff are trained in the safe use of the restraint Restraint use is clearly documented, including type, duration, and reason for use.

Modified from: Shuman S, Bebeau M. Ethical Issues in Nursing Home Care: Practice Guidelines for DifficultSituations. Spec Care Dent 1996; 16:170-176.25

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If the patient is extremely uncooperative and/or roughly where the person is in their disease andphysically violent, then conscious sedation orgeneral anesthesia may be necessary even tolook in the patient s mouth. If the patient needsto be taken to an operating room for treatment,then the value of the dentition needs to beseriously questioned unless the violentbehaviour was in response to oral pain. This kindof a decision must be made on an individualbasis after discussion with the patient'scaretakers and their physician.

4. Condition of the dentition. The condition of theremaining teeth must be carefully evaluated.What number of remaining teeth are there andhow many chewing pairs of teeth exist? Whatis the level of oral hygiene and how much oraldebris is present? What is the status of theremaining teeth with regard to caries andbreakage? What is the periodontal status and isit possible to make periapical radiographs so asto evaluate bone levels and thus the periapicalhealth of the teeth\* What level of restorativecare can be provided?

If the patient is in the early/mild stage of AD,which usually lasts 2-4 years, all restorative andrehabilitative care is possible. The philosophy ofcare for all stages of AD has been very effectivelydescribed by Niessen and Jones'' (Table 7).

The average life span of persons suffering withAD is about 8-10 years with a range of 3-20 years.Because AD is progressive, knowing when thedisease was diagnosed helps the dentist determine

helps the dental professional to predict the abilityof the patient to carry out oral self-care. In theearliest stage of the disease, the dentist should lookat the remaining dentition and determine the healthof key teeth, such as canines and molars, andaggressively prevent further disease and restore thedentition. As the disease progresses, the focus ofdental treatment changes from restoration andrehabilitation to maintenance. The middle ormoderate stage of the disease, when the patient isrelatively physically healthy, but has lost cognitiveskills and can be physically and verbally abusive,is the most difficult. This stage of the disease canlast 2-10 years. At the later stage of the disease,when major losses have occurred, the patient maybe uncooperative but not violent, with care one canagain approach them without fear of being hurt orhurting them.

Developing an individualized treatment planIn developing a treatment plan, the issues for thedentist are: When do you extract teeth rather than restore

them? When should you replace teeth? Are teeth being replaced for function? Are teeth being replaced for aesthetics? Are teeth being replaced to please the family? When are complete dentures indicated? What do you do if the family wants dentures for

the patient but he/she cannot tolerate them?Table 7. Dental index score and dental treatment considerations

Treatment planningApproacb

General considerations

Specific

DentalMild disease

0-3

Minimal changesin dental practice

Aggressive preventionUse of topical fluoridesDaily oral hygiene;Oral health educationof caregivers

Design treatment plananticipating decline

Restore to function asquickly as possible

Index ScoreModerate disease

4-7

Sedation may be necessary

Short appointments

More frequent recall visits

Aggressive prevention; Use of topical fluorides;

Daily oral hygiene;Oral health educationof caregivers

Design treatment planwith minimal changes(reline dentures rather thanremake if possible)

Severe disease8-10

Sedation may be necessary

Short appointments

More frequent recall visits

Aggressive preventionUse of topical fluorides;Daily oral hygiene;Oral health educationof caregivers

Design treatment ofdentition

Emergency care

From: Niessen L, Jones J A, Zocchi M, et al. Dental Care for the Patient with Alzheimer's Disease. JAm Dent Assoc1985; 110:207-209.23

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LMital management ol [laiients with Al/hcimr IMM- and olhcr di-irii-iilias 13

DECISION MAKING FOR ACOGNITIVELY IMPAIRED PATIENI

Principles of TreatmentI I

CONSCIOUS COMATOSE1. Keep lips moist and lubricated2. Clean mouth and tongue regularly3. Emergency treatment only

DENTATE PATIENT

IPatient Seeks Care

\Family/Care giver

seeks care for patientI

IEDENTULOUS

1. Evaluation of oral health, e.g. candidiasis2. Dehydration -- use of salivary substitutes3. Treatment

Reline or RemakeI

PALLIATIVE CARETissue Conditioner

Pivots

DENTAL PROBLEMSII

AsymptomaticI

Symptomatic

ASSESSMENT OF DEPENDENCY

Functionallyindependent

Frail Functionallydependent

I

LEVEL OFCOGNITIVE IMPAIRMENT

IAble to benefitfrom treatment

I

Unable to benefittreatment

LEVEL OF COOPERATIONNo

restraintPhysical or chemical

restraint requiredGA

LEVEL OFPHYSICAL IMPAIRMENT

IAble to maintain hygiene

independently or with help

None

NoTreatment

}Unable to maintain hygiene1. Are teeth of any value?2. Can patient use dentures?

RISK / BENEFIT OF TREATMENT

Possible(patient)

INFORMED CONSENT

Possible(significant other)

Not Possible NoTreatment

RATIONAL DENTAL CARE

Rehabilitative andReconstructive

(ComprehensiveCare)

Maintenance andMonitoring

(Limited Treatment)

IEmergency Care(Pain & Infection

Only)

NoTreatment

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14 Konald I lUtingcr

What do you do it the patient needs urgenttreatment, eannot give informed consent, andthe family does not give permission?

How do you obtain consent for a patient in along-term cure facility who has no closerelatives.'

To answer these questions the dentist needs tothoroughly evaluate the patient's medicalproblems. cogniti\ e skills, ability to cooperate, therequired treatment setting, the patient's ability topay for the required care, and most importantly,the expectation of the spouse/relative/caregiver.This significant other will decide how much dental/oral work you will provide. In fact, they will either:(a) advocate for car; (b) remain neutral; or (c) insome cases be resistive to dental treatment. Thereis no panacea. As a dentist you must decide whatyou are going to do based upon a clinical judgmentw hich can be expressed as a decision tree and madein conjunction with the patient and their family orcaregiver (Fig. 1).

This flow diagram of decision-making (Fig. 1)can be used for any patient but highlights areas ofdecision-making which are important whenplanning treatment for a patient with AD. Theoverriding principal is that the treatment renderedmust benefit the patient and do no harm. Therefore,the primary responsibility of the dentist is toeliminate pain, control infection and prevent newdisease. In patients with AD, pain thresholds andtolerance can vary greatly; differential diagnosesin these dentate individuals can be very difficultto make as described earlier.

The first issue is: Is the patient conscious orcomatose' If the patient is unresponsive, it isadvised that the mouth be cleaned regularly andthe lips be kept moist and lubricated. Vitamin A &D ointment works very well for this purpose.

If the patient is conscious and responsive thenthe first issue encountered by the dentist will bewhether the patient is coming for treatment of his/her own free will or whether somebody is bringingthem. If they are not acting independently, theymay not comply with home preventive behaviours.

If the patient has no dental problems, noimmediate treatment is required except to focuson oral hygiene to prevent disease. If the patienthas oral problems, he/she may be symptomatic orasymptomatic. Many older patients are taking largedoses of aspirin or non-steroidal anti-inflammatoryagents so that acute dental infection, such asperiapical infections, can occur without pain orfever-^ .^ Because the sensation of pain is extremelysubjective, the dentist is dependent upon the

patient's description of the site, intensity, durationand quality of the pain. It is known that the intensityand duration of pain varies greatly betweenindividuals, depending on a variety of social,ethnic, cultural, emotional and medical factors".Once the extent of the dental problem has beendetermined and a possible treatment plan exists inthe dentist's mind, a series of assessments need tobe made. An assessment of the functionalcapabilities of the patient will help to determinewhere the treatment needs to be carried out(mobility, cognitive status and continence) and howmuch treatment the patient can cope with. Theseassessments are based entirely upon experience andare judgements made by the dentist from observingthe patient, talking to the patient, his or herphysician and significant others. It takes a cliniciantime, experience and skill to sort through the bodylanguage and implied questions of the family ofpersons with AD, some of whom may still beinfluenced by strong cultural behaviours associatedwith their ethnic origins.

As mentioned previously, one of the moreimportant decisions relates to the patient'scognitive level. Will the patient benefit fromtreatment or is his/her level of impairment suchthat he or she will have difficulty cooperating withthe dentist? This decision-making is greatlyinfiuenced by the training of the dentist and his/her past experience with older persons who hadsimilar problems, although the Niessen et al Index"is very helpful.

It has been shown that the patient's perceivedneed for dental care and his/her ability tosuccessfully tolerate dental procedures may beassociated with their dental status'*. Deterioratingoral health may signal important changes in thepatient's ability to maintain adequate home care,which also may be associated with a treatablesystemic condition such as depression, or may bethe first sign of declining cognitive function, suchas undiagnosed Alzheimer's disease. There are noadequate research-based measures that cansubstitute for the dentist's experience to make thesejudgements. However, the primary responsibilityof any dentist is to ensure the oral comfort of thepatient. In many instances, this follows naturallywith the elimination of pain and infection. Forpatients wearing dentures, oral comfort often canbe enhanced by using tissue conditioners, and indentate patients by using desensitizing agents onexposed root surfaces, as well as zinc oxide andeugenol cements in carious teeth. WTien the patientis pain-free and comfortable, the dentist canevaluate the patient and the dentition with regard

The Gerodontology Association 2000Gerodontology

cntal management of patients with Alzheimer's disease and other demcnti.is I *)

to the possibilities for improvement of functionthrough reconstruction of the dentition orocclusion.If the dentist is to go beyond the control of pain

and infection, it is important to evaluate thepatient's ability to cooperate. This decision isusually based upon experience and experience isoften gained by trial and error. However, if anyrestraint (physical or chemical) is required, usingit requires informed consent from the patient if he/she is capable of giving it, or from the legallyresponsible party who is often a relative but whocan also be an institution or a court-appointedperson. Before making the fmal assessment as towhat level of treatment is possible, the ability ofan individual to maintain oral hygiene should beassessed.

Many older adults have never been taught howto clean their dentition adequately. Most caretakershave never been shown how to care for anotherperson's oral health. Older adults often do notunderstand that the primary function oftoothbrushing is to reduce plaque levels in themouth. Some have their mouth professionallycleaned infrequently.

Sheiham^' asked three questions which have noeasy answers at this time: Is it essential for a person to be plaque-free? Should all calculus be removed irrespective of

the periodontal status? Is there a need to surgically treat all deep

periodontal pockets?Interestingly, one of the few studies30 which

evaluated the relationship between the frequencyof oral hygiene treatment with periodontal statusfound confusing relationships. The analysis oflapsed time between dental visits and periodontalstatus found that frequent visits were associatedwith less calculus and fewer pockets deeper than6 mm, but with no differences in gingival bleedingor pockets measuring 3-6 mm. In spite of thesedata, the value of home care still seems to beimportant even in the presence of calculus. Gaareetal31 in a study of young military recruits showedthat it was possible to improve gingival health, asmeasured by bleeding index, in persons with largeamounts of calculus. The question that should beasked is whether this goal of gingival health isapplicable to older people, specifically personswho are eognitively impaired.

When all of these issues have been evaluated, arational treatment plan will evolve, whichunfortunately, will still be based upon clinicalexperience rather than on research". Thesetreatment plans will either be:

No treatment possible. Emergency care, which will include pain and

infection control only, and preventive care wherepossible.

Maintenance and monitoring care, which willinclude management of chronic infection,restoration of carious lesion, plaque control andpreventive measures.

Comprehensive care, which will include surgicaland prosthodontic reconstruction of function andaesthetics.

ConclusionTo maintain the quality of life Alzheimer'spatients, dentists have a specific role: to keep themfree of oral infection, restore their dentition sopatients can enjoy eating, and maintain speech andesthetics as long as possible.

As the disease progresses, maintaining oralhealth and dental treatment become more difficultand challenging both for the patient and for thedentist. A dental needs assessment should becompleted when the patient is diagnosed withAlzheimer's disease. The assessment results willallow the development of an individualized patientcare plan, which will accommodate the physicaland cognitive status changes that will occur as thedisease progresses.

References1. Gauthier S, Panisset M. Current diagnosticmethods and outcome variables for clinicalinvestigation of Alzheimer's disease. J NeuralTransmission (Supplement) 1998; 53: 251-254.2. Fratiglioni L, Gnit M, Forsell Y, etal. Prevalenceof Alzheimer's disease and other dementias in anelderly urban population: Relation with age, sex andeducation. Neurology 1991; 41:1886-1892.

3. Besdine R W. Dementia. In: Health and Diseasein Old Age, eds. Rowe, J W, Besdine, R W. Boston:Little, Brown & Co., 1982.

4. Diagnostic and Statistical Manual of MentalDisorders (4th ed.). Washington, D.C: AmericanPsychiatric Association, 1994.

5. Jorm A F, Korten A E, Henderson A S. Theprevalence of dementia: A quantitative integration ofthe literature. Acta Psychiatr Scand 1987; 76: 465-479.

6. Evans D A, Funkenstain H H, Albert M S, et al.Prevalence of Alzheimer's disease in a communitypopulation of older persons. J Am Med Assoc 1989;262:2551-2556.

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7. Hofman A, Rocca W A, Brayne C, et al. Theprevalence ol dementia in Europe: A collaborativestudy of 1980-1990 fiiulings. Int J Epidemiol 1991;240:218-222.

iS. Evans D. Estimated prevalence of Alzheimer'sdisease in the United States. Milbank Q 1990; 68:267-

9. Wernicke T F, Reichies F M. Prevalence ofdementia in old age: Clinical diagnoses in subjects95 years and older. Neurology 1994; 44: 250-253.

10. Bird T D, Lampe T H, Nemens R M, et al.Familial Alzheimer's disease in American descendentsof the Volga Germans: Probable genetic founder effect.Ann Neurol \99S\ 23: 25-^\.

11. Breitner J C, Silverman J M, Mohs R C, et al.Familial aggregation in Alzheimer's disease:Comparison of risk among relatives of early-and late-onset cases, and among male and female relatives insuccessive generations. Neurology 1988; 38:207-212.

12. Gauthier S. Update on diagnostic methods,natural history and outcome variables in Alzheimer'sdisease. Dement Geriatr Cogn Disord 1998; 9 (Suppl3): 2-7.13. Schellenberg G D, Bird T D, Wijsman E M, etal. Genetic linkage evidence for a familial Alzheimer'sdisease locus on chromosome 14. Science 1992; 258:668-671.

14. Corder E H, Saunders A M, Strittmatter W J,et al. Gene Dose of Apolipoprotein E Type 4 and therisk of Alzheimer's disease in late onset families.Science 1993; 261:921-923.

15. Schellenberg G D. Progress in Alzheimer'sdisease genetics. Current Opinion in Neurology 1995;8: 262-267.

16. Rogaeva E, Premkumar S, Song Y, et al.Evidence for an Alzheimer disease susceptibility locuson chromosome 12 and for further locus heterogeneity.JAm Med Assoc 1998; 280: 614-618.

17. St George-Hyslop P H., Tanzi R E, Polinsky RJ, et al. The genetic defect causing familialAlzheimer's disease maps on chromosome 21. Science1987; 235: 885-890.

18. Folstein M F, Folstein S E, McHugh P R. MiniMental State: A practical method for grading thecognitive state of patients for the clinician.J Psychiatry Res 1975; 12: 189-198.

19. Reisberg B, Ferris S H, DeLeon M J, et al. TheGlobal Deterioration Scale for assessment of primarydegenerative dementia. Am J Psychiatry 1994; 44:2203-2206.

20. Saxe S, Henry R, Wehstein W. Keeping the OlderPerson's Mouth Healthy: A Workshop for FamilyCaregivers: Caregivers Handbook. Lexington, KY.College of Dentistry, University of Kentucky, 1988,

21. Henry R. Neurological disorders in dentistry:Managing patients with Alzheimer's disease. IndianaDent Assoc. J. 1997-1998, 76: 51-57.

22. Gordon S. Argument in favor of providing dentalcare for the severely eognitively impaired patient.Gerodontics 1988; 4: 170-171.

23. Niessen L C, Jones J A, Zocchi M, et al. Dentalcare for the patient with Alzheimer's disease. J AmDent Assoc 1985; 110: 207-209.

24. Nordenram G, Ryd-Kjeilen E, Johansson G,etal. Alzheimer's disease, oral function and nutritionalstatus. Gerodontology 1996; 13: 9-16.

25. Shuman S, Bebeau M. Ethical issues in nursinghome care: Practice guidelines for difficult situations.Spec Care Dent 1996; 16: 170-176.

26. Banting D, Oudshoorn W. The clinicalmanagement of the aging patient: Treatment conceptsand procedures. Ont Dent 1979; 56: 19-24.

27. Rhodes R A, Jahnigen D W, Rhodes P J, et al.Management of dental pain in the elderly. Gerodontics1985; 1: 264-273.

28. Berkey D B. Clinical decision-making for thegeriatric dental patient. Gerodontics 1988; 4:321-326.

29. Sheiham A. Dentistry for an aging population:Responsibilities and future trends. Dent Update 1990;17: 70-76.

30. Beck J, Lainson P, Field H, et al. Risk factorsfor various levels of periodontal disease and treatmentneeds in Iowa. Comm Dent Oral Epidemiol 1984; 12:17-22.

31. Gaare D, Rolla G, Aryadi F J, et al.Improvement of gingival health by toothbrushing inindividuals with large amounts of calculus. J ClinPeriodontol 1990; 17: 38-41.

32. Henry R G, Wekstein D R. Providing dentalcare for patients diagnosed with Alzheimer's disease.Dent Clin NAm 1997; 41: 915-942.

Address for correspondence:

Professor Ronald L Ettinger,Department of Prosthodontics and DowsInstitute for Dental Research,University of Iowa City IA 52242, USATel: 001319 335 7378Fax: 001319 335 8895e-mail: ronald-ettinger@uiowa.edu

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