ORAL HEALTH OF PATIENTS WITH
J O N A T H A N A. S H IP , D .M .D .
^ J lz h e im e r ’s disease, an age-
related, progressive and chronic
neurodegenerative disorder, is
the m ost common form of
dem entia am ong th e elderly.1,2
The disease is characterized by
neurological, cognitive and
behavioral sym ptom s with
severe consequences to m any
organ system s.
Incidence of Alzheim er’s
increases dram atically w ith
age, from about 0.1 percent a t
age 60 to 65 to as high as 47
percent a t age 85.3 Intellectual
faculty deterioration m ay be
caused by reduced synaptic
connectivity, partially
attrib u ted to neuronal loss.2
Definitive diagnosis requires
neuropathological confirmation
and, unfortunately, th ere is no
effective tre a tm e n t for the
intellectual and functional
im pairm ent resulting from the
disease.
Recent research advances
allow a better u n d erstanding of
Alzheim er’s b u t little h as been
reported about its oral signs.
Only two studies have
exam ined a component of oral
health in patients w ith the
disease:
"> D entures among th e elderly
w ith early stages of senile
dem entia were older and less
clean compared w ith a control
population, im plying th a t the
ABSTRACT
G e n e r a l ly h e a lth y ,
u n m e d ic a te d p a tie n ts
w i t h A lz h e im e r ’s d is e a s e
h a v e f e w b u t s ig n if i c a n t
c h a n g e s in th e ir o ra l
h e a l t h . S tu d y r e s u l t s
re in fo rc e p re v e n tiv e o ra l
h y g ie n e f o r t h e s e
p a tie n ts .
elderly dem ented have poorer
personal oral hygiene habits.4
■■ S ubm andibular salivary
gland dysfunction in
unm edicated Alzheim er’s
p atients was reported recently,
suggesting th a t neuronal
degeneration also influences
oral physiology.5
Published reports
recom mend preventing oral
disease and m aintaining oral
health and function for patients
as long as possible.618 There is
no available inform ation on the
general oral h ealth of patients
w ith A lzheim er’s, nor have any
specific oral h ealth needs been
identified for th is population,
based on th eir oral condition.
This investigation exam ines
gingival, periodontal, dental,
oral m ucosal and salivary
p aram eters in unm edicated,
essentially healthy p atients
w ith Alzheim er’s.
METHODS
Forty-one comm unity-dwelling
w hites (22 m en and 19 women)
with a clinical diagnosis of
Alzheim er’s disease were
evaluated as p a rt of an ongoing
longitudinal study a t the
N ational In stitu te on Aging
(NIA) a t the Clinical C enter of
the N ational In stitu tes of
H ealth. The average age was
68.2 ± 9.3 years (m ean ± SD)
w ith a range of 48 to 83 years.
A diagnosis of definite,
probable and possible
Alzheim er’s was m ade
according to NINCDS-ADRDA
criteria,19 after patien ts were
screened vigorously to exclude
other medical, neurological or
psychiatric conditions. The
study population included two
definite, 34 probable and five
possible patients.
All patien ts were extensively
evaluated w ith diagnostic radio­
graphs, computed tom ographic
brain scans, m agnetic
resonance imaging, positron
emission tom ography and
neuropsychological and medical
tests.20-23 None was tak in g any
m edication for system ic disease,
nor being treated for other
disorders. Tw enty-three
subjects were included in a
previous study of salivary gland
function in patients w ith
Alzheim er’s disease.5 The Mini-
JADA, Vol. 123, January 1992 53
M ental S tate Exam ination
(MMSE) was adm inistered to
estim ate the severity of
cognitive im pairm ent24; the
average value was 18.2 ± 1.0
(Mean ± SEM) of a m aximum
30 points.
Forty-nine healthy white
people (25 m en and 24 women)
were selected as controls. The
average age was 64.1 ± 8.2
years (m ean ± SD) w ith a range
of 50 to 82. All were volunteer
participants in a norm ative
aging program conducted by the
NIA. All were community-
dwelling individuals who
underw ent rigorous medical,
neurological and laboratory
screening.20,25 Control
individuals were n either being
tre a te d for any systemic disease
nor tak in g prescription
m edications. The average
MMSE value for control
subjects was 29.4 ± 0.7 (m ean ±
SD).
The diagnosis of each patient
was unknow n a t the tim e of the
clinical exam ination. I
interview ed all participants and
perform ed a clinical
exam ination, as follows 26,27:
■“ D ental, periodontal and
m ucosal m easurem ents. The
num ber of tee th (excluding
th ird m olars), decayed-missing-
filled-teeth score, and the
num ber of tee th w ith coronal
and cervical caries and
restorations were recorded.28
The mesiobuccal, midbuccal,
distobuccal, m esiolingual, mid-
lingual and distolingual
surfaces of the six teeth
proposed by Ram fjord29were
exam ined for periodontal
p aram eters,30 according to
NIDR criteria.28
Briefly, the 36 tooth surfaces
were assessed for presence or
absence of dental plaque,
gingival bleeding and supra- or
54 JADA, Vol. 123, January 1992
subgingival calculus. The
distance from the free gingival
m argin to th e cementoenamel
junction and the distance from
the FGM to the bottom of the
sulcus or pocket was m easured
w ith an NIDR color-coded
periodontal probe. Later, the
percentage of tooth surfaces for
each subject w ith dental plaque,
gingival bleeding and calculus
was calculated and the am ounts
of gingival recession, pocketing
and attach m en t loss were
recorded.
All intraoral structures were
assessed w ith a modified
mucosal ratin g scale.31 Normal
Patients with Alzheimer’s
had significantly more
sites with gingival
plaque, bleeding and
calculus, compared with
controls
mucosal or mild changes (dry,
pale or glossy m ucosa and
alterations in mucosal
topography) were rated zero,
and m oderate or severe changes
(erythem ic or leukoplakic
lesions, ulcerations and
erosions) were rated one.32 Oral
candidal lesions (atrophic,
pseudom em branous and
denture stom atitis) were
clinically diagnosed and
grouped together.33
■■ S tatistical analysis. The
d ata were analyzed for
differences betw een Alzheim er’s
p atients and control subjects,
and betw een m en and women
w ithin each group. A S tudent’s
¿-test was used when m ean
values had a norm al
distribution, and a Mann-
W hitney U procedure was used
for non-param etric values. Chi-
square and two-way F isher’s
exact tests were performed for
prevalence data.
C orrelation analyses were
performed on patients with
Alzheim er’s to determ ine if a
relation existed betw een level of
dem entia (as determ ined from
the MMSE score) and an
individual oral health
param eter. One-way ANOVA
tests were performed on the
Alzheim er’s population to
m easure any possible
association between diagnosis
(definite, probable and possible
Alzheim er’s) and any of th e oral
health clinical m easurem ents.
D ata were analyzed using the
RS3 software package (BBN
Software Products Corp.) A
criterion of P<0.05 was accepted
for significance in all statistical
tests.
R ESU LTS
As no gender differences were
observed for any of the clinical
param eters, analyses were
performed w ith m en and
women combined. P atients with
Alzheim er’s had significantly
more sites w ith gingival plaque,
bleeding and calculus,
com pared w ith controls (Figure
l).To determ ine the severity of
gingival disease, the num ber of
study subjects w ith dental
plaque, gingival bleeding and
calculus on 75 percent or more
of all dental sites surveyed was
analyzed.
Forty-four percent of the
patients (17 of 39; two patients
were edentulous) had dental
plaque on a t least 75 percent of
all surveyed tooth sites, which
was statistically greater th an
the 11 percent (five of 49) found
in th e controls. Sim ilar analyses
for gingival bleeding and
calculus showed no statistical
differences between study
groups.
 No statistically significant
differences for any of th e three
periodontal param eters were
observed (Figure 2). W hen an
analysis was perform ed to
determ ine if any correlations
existed betw een MMSE scores
and gingival and periodontal
param eters in patients, a
significant correlation was
found for periodontal pocketing.
Increased periodontal pocketing
was associated w ith a
decreasing MMSE score. B ut no
other correlation was
statistically significant.
There were no statistical
differences am ong the three
p atien t types (definite,
probable, possible) for any of
the gingival and periodontal
m easures, except gingival
bleeding. Definite (n=2) and
probable (n=32) Alzheim er’s
subjects had a greater
percentage of sites w ith gingival
bleeding th an the possible
group (n=5). Two probable
subjects were edentulous.
The total rem aining teeth,
num bers of teeth w ith decayed
TA BLE 1
DENIAL PARAMETERS IN PATIENTS WITH ALZHEIMER'S DISEASE AND CONTROLS*
DENTAL ALZHEIMER'S
PARAMETER (n=41)
No. teeth 21.1 ± 1.2
DMFT 21.1 ± 0.6
No. teeth with
coronal caries 0.8 ± 0.3
No. teeth with
cervical caries 0.6 ± 0.2
No. teeth with
coronal
restorations 13.8 ± 1.0
No. teeth with
cervical
restorations 2.2 ±0.4
* Results expressed a t M ± SEM.
t NS = not significant.
t S tu d en t’s i-test.
§ M ann-W hitney test.
coronal and cervical surfaces
and coronal restorations were
not statistically different
between groups (Table 1).
A lternatively, DMFT and the
num ber of teeth w ith cervical
restorations were greater
am ong patients with
Alzheim er’s compared w ith
controls. Significant negative
correlations were found
betw een th e MMSE score and
num ber of teeth w ith coronal
caries and cervical caries. No
other statistically significant
correlations were identified for
the dental param eters.
Intraoral mucosal
exam ination showed no
significant differences betw een
groups. There was a
statistically significant greater
prevalence of dry and cracked
lips among patients with
Alzheim er’s (13 of 41) compared
w ith controls (five of 49). There
were no differences in the
presence of oral candidiasis
among the two groups.
Twelve patients and 12
controls were w earing a t least
CONTROLS DIFFERENCE
(n=49)
22.2 ± 1.1 NS f
18.5 ± 0.8 P = 0.02$
0.4 ± 0.1 NS
0.6 + 0.2 NS
12.3 ± 0.9 NS
1.8 ± 0.4 P = 0.03§
one removable prosthesis
(complete or partial). Analyzing
the prevalence of denture
stom atitis, erythem a or
ulceration showed no
differences betw een these two
prosthesis groups, although
about 50 percent of both
populations had some form of
denture stom atitis (six of 12
Alzheim er’s, five of 12 controls).
No correlations were identified
between MMSE scores and any
of the oral mucosal param eters
investigated in th e Alzheim er’s
patients.
D IS C U S S IO N
Studying th e oral health of
unm edicated patien ts w ith
Alzheim er’s disease revealed
few yet significant differences
in comparison w ith healthy,
unm edicated control subjects.
Since th is is th e first available
general oral h ealth exam ination
of p atients w ith Alzheim er's
disease, no comparisons can be
made w ith other populations of
patients w ith Alzheim er’s.
P atien ts in this study were
carefully screened for
Alzheim er’s disease.19To isolate
the effects of Alzheim er’s
disease on oral health and to
elim inate the influence of other
disorders or medical tre a tm e n t
as potential confounding
variables, only community-
dwelling patients who were not
being tre a te d for any other
systemic disease and did not
take m edications were included.
Alzheim er’s p atients had
dim inished gingival health.
There were greater gingival
plaque, bleeding and calculus in
patients compared with
controls. For alm ost h alf (44
percent) of the patients, 75
percent or more of their
surveyed tooth surfaces were
covered w ith dental plaque. The
JADA, Vol. 123, January 1992 55
FIGURE 1
evidence th a t dental decay had
80
increased recently in patients
w ith Alzheim er’s. P atients had
Ul 70 22 percent more teeth w ith
I/)
cervical restorations th an did
«
z 60
controls. Although the tim e of
< caries development in the study
III
population was unknown, it is
I 30
known th a t cervical decay
V)
Ul increases w ith age.28As the
I- patients were 48 years or older,
35 cervical restorations were likely
IL
0 30 placed later in life.
h These findings suggest a
Z different disease p a tte rn in
111
2 0
0 Alzheim er’s patients compared
cc w ith controls. P atients w ith the
Ul
tL i o disease m ay be susceptible to
cervical decay. Salivary gland
hypofunction is associated with
PLAQUE GINGIVAL BLEEDING CALCULUS cervical decay,39 and decreased
salivary output was previously
CONTROL SUBJECTS
identified in unm edicated
Alzheim er’s patients.5
PATIENTS WITH ALZHEIMER'S DISEASE
The num ber of teeth with
coronal and cervical caries
increased w ith increasing
Gingival parameters in 41 unmedicated patients with Alzheimer’s
disease and 49 healthy controls. Results are expressed as percent of
dem entia severity (determ ined
sites with plaque, gingival bleeding, or calculus (M ± SEM). Columns by decreasing MMSE scores24).
that share a common subscript are significantly different at #»<0.0001
Except for periodontal
(a), PcO.OI (b), P<0.04 (c).
pocketing, there were no other
correlations of oral health
greater prevalence of plaque m easured adequately). param eters and level of
accum ulations found in patients The periodontal health of cognitive function. There were
partially accounts for the patients was statistically indis­ no additional associations
increased gingival bleeding and tinguishable from th a t of betw een Alzheim er’s diagnosis
calculus compared with controls. This finding is (definite, probable and possible)
controls. surprising, since tradition and any oral health
Since cognitive im pairm ent, dictates th a t periodontitis is m easurem ents except gingival
m otor restlessness and apraxia preceded by gingivitis.34 bleeding.
are common in Alzheim er’s, it is Relatively recent findings, However, none of these
not surprising th a t patients in however, report th a t gingivitis significant correlations or
this study had more gingivitis may not be a harbinger of associations was statistically
th a n controls. Satisfactory oral im pending periodontal strong in patients w ith
hygiene requires cognitive and destruction.35'38 Possibly for Alzheim er’s. It is not known if
voluntary m otor skills. Alzheim er’s patients in this dental caries, gingival bleeding
Im pairm ent of these skills m ay study, gingivitis has not been and periodontal pocketing will
resu lt in poor dental plaque present long enough to resu lt in advance in a patient with
removal. Decline in memory, periodontal disease. progressive degenerative
prom inent among Alzheim er’s In the two groups, no differ­ dem entia. But given the
patients, m ay cause infrequent ences were detected in the presence of salivary gland
or irreg u lar oral hygiene (unfor­ num bers of teeth with coronal dysfunction and gingivitis, the
tunately, this cannot be or cervical decay. B ut th ere was incidence of dental caries,

56 JADA, Vol. 123, January 1992

gingival and periodontal disease
probably will increase w ith the
dem entia’s progression.
The oral m ucosal condition of
Alzheim er’s patien ts was
sim ilar to th a t of controls, but
more p atients had dry, chapped
lips. D im inished saliva
secretion has been associated
w ith changes in th e appearance
of labial m ucosa.40 Although we
found a high prevalence (about
50 percent) of denture
stom atitis, erythem a or
ulceration in the Alzheim er’s
patients, the control group had
sim ilar problems.
Because of th e im portance of
salivary gland function in these
patients, u n stim ulated and 2
percent citrate-stim ulated
parotid and subm andibular
salivary gland flow rate s were
collected from p atients and
FIGURE 2
3
2.5
2
Ul
ID 2
4
1
z
< M anual or m echanical
H
I 1.5
0.5
POCKETS
RECESSION
CONTROL SU BJECTS
PATIENTS WITH ALZHEIM ER'S DISEASE
Periodontal parameters in 41 unmedicated patients with Alzheimer’s
disease and 49 healthy controls. Results are expressed in millimeters
(M ± SEM).
controls, according to
established techniques.4142
The findings were sim ilar to
those reported earlier using 23
of 41 subjects. Briefly, parotid
output was u n altered by
Alzheim er’s disease in these
patients, b u t subm andibular
flow rate s were decidedly
diminished. Several hypotheses
for these findings were
suggested,5 including
neurological deficiencies and
dehydration.
Salivary gland dysfunction
m ay be im plicated in altered
gingival h ealth and increased
cervical restorations in
Alzheim er’s patients. Saliva is
essential to m ain tain oral
health.43 It protects the m outh,
upper airw ay and digestive
tra c t and facilitates m any
sensorim otor phenomena.
ATTACHMENT LOSS
Saliva’s flushing action clears
plaque and bacteria from dental
and oral mucosal surfaces. If
salivary output is diminished,
patients m ay be more likely to
develop gingivitis and cervical
caries. The lack of saliva m ay
also partially account for the
increased prevalence of dry
labial mucosa am ong these
patients.
The findings from this study
have fu rth e r im plications for
the clinical care of Alzheim er’s
patients since all study subjects
were unm edicated. The
psychotropic drugs used to tre a t
Alzheim er’s patien ts for mood
disorders1and for reversing
cognitive losses44 are frequently
associated w ith salivary gland
hypofunction.16 W hen these
medications are given to people
w ith Alzheim er’s, they m ay
develop fu rth e r alterations in
salivary fluid output,
subsequently leading to
dim inished oral health.
CONCLUSIONS
From th is study’s findings,
several oral h ealth care
m easures for Alzheim er’s
patients are recommended.
toothbrushing and flossing,
ideally after each m eal, will
help prevent gingival and
dental disease. Chlorhexidine
sprays have proved efficacious
as an adjunct to oral hygiene in
physically handicapped adults.45
P atien ts need help w ith th eir
oral hygiene. W hen friends and
relatives participated in
p atients’ plaque control
program s, plaque and gingivitis
levels were reduced.46 F requent
toothbrushing and regular
dental check-ups lowered root
caries rate s.47 Fluoridated
dentifrices,48 fluoridated w ater
supplies49 and topical fluoride
JADA, Vol. 123, January 1992 57
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