Elisa Ghezzi, DDS, PhD, joins the podcast to discuss the importance of maintaining oral health throughout one’s life, and especially as one grows older. Discussing the effects of oral health on our systemic health, oral health’s connection to dysphagia, and how caregivers can help dementia patients care for their teeth, Dr. Ghezzi provides insight on how vital it is to care for our oral health as we age.
Guest: Elisa Ghezzi, DDS, PhD, adjunct clinical assistant professor, University of Michigan School of Dentistry, provider, Voiage Portable Dentistry
1:15 - How did you get interested in oral health in older adults?
3:28 - Why isn’t there more training or education in general dentistry for an older population?
4:34 - What are oral diseases, and what are their effects on systemic health?
6:00 - Is there an association between oral disease and cognition or cognitive impairment?
8:50 - IDoes inflammation affect oral health?
10:00 - What can be done to prevent oral conditions?
13:39 - What can we do to help protect our teeth?
16:38 - What should older adults and people who are experiencing dementia do about flossing?
19:05 - For our audience members who might be caring for someone who has dementia,, what recommendations would you offer when the person they are caring for is resistant to the act of having someone brush their teeth?
22:10 - What is the relationship between oral health, oral disease, and dysphagia?
28:20 - What is the most pressing issue facing older adults and their oral health care?
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Dr. Nathaniel Chin: I'm Dr. Nathaniel Chin, and you're listening to Dementia Matters, a podcast about Alzheimer's Disease. Dementia Matters is a production of the Wisconsin Alzheimer's Disease Research Center. Our goal is to educate listeners on the latest news in Alzheimer's Disease research and caregiver strategies. Thanks for joining us.
Today on Dementia Matters, I have with me Dr. Elisa Ghezzi, a dentist and PhD researcher in oral health and aging, as well as an active writer and lecturer on oral health care for older adults and persons with Dementia. She is an adjunct clinical assistant professor at the University of Michigan and has provided dental care for residents of long-term care facilities in Detroit, Michigan. Dr. Ghezzi also served as a past chair of the Coalition for Oral Health for the Aging. In addition to her training in dentistry and obtaining her PhD, she also trained in geriatric dentistry fellowship. Dr. Ghezzi, you have a very unique background and a much needed set of skills in helping people age successfully. Thank you for joining me today on Dementia Matters.
Dr. Elisa Ghezzi: Thank you for inviting me. It's a pleasure to be here
Chin: How did you get interested in oral health in an older adult?
Ghezzi: I think I accidentally fell into it when I was in dental school. I remember one day sitting in a lecture and my mind was wandering and it went to, you know, what was I going to do after dental school and what popped into my mind was the thought of working with the elderly and then realized that I don't think we were going to have any classes on that topic and really hadn't learned anything. And that was most of my dental school experience. Unfortunately in the last 30 years it really hasn't changed. So there really wasn't much experience or training that I received in dental school, especially working — never with a person with dementia. And so I did find out my senior year of dental school that there was an opportunity, that the University of Michigan did have a two-year geriatric fellowship so I was interested in finding out more about that and so I did. It was something that to do that I would need to first do a one-year general practice residency, and so it — actually I had grown up in Ann Arbor and done high school, undergrad, middle school at the University of Michigan so I wanted to take that one year opportunity to leave Ann Arbor. So I ended up going to the VA, the Veterans Administration Medical Center in Minneapolis, Minnesota for doing my one-year residency and decided I would hang out with a bunch of older gentlemen there, and if I didn't like that I would move on to general practice or something else. But I had a wonderful experience there and was able to actually connect with some aging experts in the dental field in Minnesota where there's there's some real experts there, and decided, you know what, I was really still fascinated with this idea and then came back to do the fellowship. So I kind of, I just walk through doors that open and keep walking until I don't find one that I'm interested in and there's another one pretty much that that will follow. It wasn't a real plan but it's where I've ended up and loved every minute of it.
Chin: Why isn't there more training education in general dentistry for an aging population?
Ghezzi: I think in the undergrad educational system there's just so many things that needs to be done. It just gets squeezed out. There's a little bit of an attitude that it's particularly more of expertise and so it's something that is more helpful to be taught more post-graduate, though there are very few — like less than ten programs in the entire country — that exist to do that and it's very hard to find people willing to even do the programs. Unfortunately a lot of that has to do with economic incentive. There really isn't any. And it's there aren't academic positions or really good job opportunities when one finished such training either. So I think there's there's a lot of economics to it.
Chin: I think that can probably be seen in in the medical field too. As a geriatrician, I've had many similar conversations. So in dentistry, obviously, oral disease is a key issue that we need to address, so what are oral diseases and what are their effects on systemic health?
Ghezzi: Well, I appreciate that you actually are asking me about oral diseases as opposed to dental diseases because there is a very big distinction. A dental disease is a tooth problem and an oral disease is a problem in the oral cavity. Obviously dental diseases are all oral diseases, so tooth problems like decay where the tooth structure is getting eaten away. There's diseases around the tooth, which periodontal means around the tooth, so those are periodontal disease is when the tissues are bone around the tooth become infected. And bone does not like infection, so anytime there's an infection the bone its response is to dissolve or disappear, so that's why you have bone loss in periodontal disease. It's a result of the infection going on. Yeah so, for people who are immunocompromised, they can actually have other issues like oral candidiasis where it's a fungal infection of the tissues in the oral cavity, and this is because the body if someone's immunocompromised is not able to kind of maintain the balance of the bacteria and fungus in the mouth and so there's there's kind of an overgrowth. It'll manifest either kind of white patches or red patches on the tissues of the mouth
Chin: And so is there an association between oral disease and cognition or cognitive impairment?
Ghezzi: Yeah, you know, actually I forgot to answer your question on systemic health. So exactly, systemic health, cognition. You know, this has been a challenge throughout my career in trying to — as an epidemiologist we like to find associations, and it's really important to make the distinction between an association and causation. So you know, I always say that my five-year-old knows that their mouth is connected to the body. So you know I think we all instinctively know that what happens with and through the mouth, since it's kind of the entry into the body, is going to impact the rest of the body. The extent to which that occurs and the amount that with our limitations in research we can prove that is a whole other question. I think that has been one of the big challenges of the oral systemic research community. A number of years ago, I was at the University of North Carolina at Chapel Hill and did this study where we had people who had very, very bad decay and periodontal disease and needed to actually have all of their teeth removed. We measured systemic inflammatory markers before that and after that and, you know, the pre-trial hypothesis was that we'd remove all this horrible infection, you'd see this beautiful drop in the inflammatory markers. The answer is that's not what we saw, because these people had many other systemic issues that were going on in their bodies. Many of them had heart disease, diabetes. It's almost impossible to find a candidate who is perfectly healthy but needs all their teeth out. Again, confounding factors exist in all research, and I think is one of the biggest challenges in the oral systemic discussion. And I think, again, that follows through with the oral diseases and cognitive impairment. Are there studies out there that show an association between the two? Sure. Are there any intervention studies that show that if you try to improve cognitive impairment you're going to have an impact on oral disease? No. Do I think there ever will be? No, I don't think you can successfully actually do that research at this point. So we have a lot of associative research out there, but I think— I don't think it's really going to improve much in the next decade or so because I just don't think it is feasible as long as we keep our mouths connected to our body. There's just too many interplays of other diseases and other things going on with us.
Chin: And so with that in mind then, are there proposed mechanisms, because I know the studies can't actually draw that causal relationship, but you mentioned you know inflammation. Do people think that that could be one of the driving forces or do we really not know what that relationship would be?
Ghezzi: That has — the inflammatory hypothesis has been very popular for a number of decades now and I think it's very plausible. Again, I think the problem with inflammatory research is that there's just too many things in our bodies that can cause inflammation, that it's impossible to separate that out, and that the other parts like potentially heart disease or other causes of inflammatory processes have a bigger impact on the inflammatory process than the oral disease does. And so, if you modify the oral disease component, it isn't significant enough to impact the entire insult that the body is having from other inflammatory processes.
Chin: And I suppose in the dental field too, the mantra is still the same, that prevention is key. And so with oral disease, you know, what can be done to prevent the oral conditions?
Ghezzi: To me, this is my favorite topic. Having worked with people with Dementia throughout my career, this is where I have found the biggest impact on saving teeth, keeping people healthy, and being able to have interventions that really make an impact and that anybody can implement. But the biggest issue, I think, is the education and empowering of people to actually do that. In my practice with people with Dementia, most of them are dealing with decay issues because these are people who have maintained their teeth through a lifetime. To be 85, 90, 95 and have your teeth you most likely did not suffer from periodontal disease during your lifetime. If you did, you probably have already lost a number of teeth. And so, to get into your late 80s, 90s with teeth, you did not do that by accident, you really wanted to keep your teeth, and you knew what you needed to do to keep them. And so, to me that's huge. Especially in our dementia treatment because one of the big keys to treating someone with dementia is to make sure you treat them as they always wanted to be treated. The mouth speaks volumes. I can look in someone's mouth and know exactly what their oral health priority has been throughout their lifetime. Sometimes I'd have to describe some people that they look like they're kind of put together with duct tape, you know, they're kind of surviving but they only did the bare minimum of what needed to happen to kind of keep going. Other people, you know, obviously have invested quite a significant amount over a lifetime and I'd have to bet that they did not want, when they were no longer able to take care of themselves, to just have that investment be lost. And so, to me, that is key, and especially in an environment when again working with other caregivers who are telling me, you know, they don't want to brush their teeth, that needs to be taken with a caveat. That yes, currently they're confused about the brushing of their teeth but, I think, had you asked them ten years ago that if they were really no longer able to cooperate and they just said “No I don't feel like doing that”, then we should just let their teeth rot. So there's kind of this balance between, I think autonomy and appropriate medical care that needs to be discussed and addressed within the context of care for people with Dementia. And again, I think if somebody comes in that it's clear that oral health was never really a priority for them, then, you know what, I'm a little bit more ‘lax on pushing them to make sure that they save every tooth, but if somebody comes in clearly with 28 teeth, beautifully restored - again we can tell how much money you've invested in your mouth, we can count crowns and implants and other things that somebody who has invested three, five, ten, twenty thousand dollars into their mouth - I don't think they would want to just lose it just because they can't take care of their teeth.
Chin: So, what can we do to help protect our teeth?
Ghezzi: One of the things that is critical is the daily oral care. It's actually the most critical, that honestly you don't even need to see a dentist if you actually have impeccable daily oral care, which is you need to have your teeth brushed twice a day in the morning, after breakfast, get that food out of your mouth and make sure you brush before you go to bed because what is causing the decay is the food is sitting on the teeth. The bacteria in the mouth take that food, break it down, create acid, and it's the acid that dissolves the teeth. We understand this. We've understood this for decades. It hasn't changed. It's what goes on. It's very simple. You leave the food, the bacteria are going to use it to create acid, you're going to just lose the teeth. It's that simple. And so you need to get it off. The other thing is we have some great adjunctive therapies, such as fluorides. All of my patients, I put on not only using a fluoride toothpaste to be brushing their teeth but then also given a little bit more fluoride before they go to bed, where it's kind of sitting on their mouth. And the teeth have to be cleaned to do that. So again when you're working with long-term care facilities, a lot of them don't appreciate orders for oral care. You really — what I’ve developed is an oral care plan. They have care plans for everything so I've developed a form that's an oral care plan, but I actually do put in an order to brush teeth but it's not the order to brush the teeth. It's the order for the prescription fluoride gel to be applied and although sometimes you can buy it over the counter, I like to write the prescription because then I can write in the prescription of the order for this to be applied, the teeth first have to be brushed, so it allows the ability for in order for both tooth brushing and application of gel to occur, and that it requires documentation, that daily this has been done. And so accountability is the key to prevention in persons with dementia. So getting the teeth cleaned and getting the fluoride gel is the most important piece and if you do that in my opinion, it's about 80% of what needs to be done. The other 20% is that it would be good for me to come in and just kind of debride the mouth at some point. There's going to be stuff most people are on a six-month cleaning schedule. I'd say the majority of my patients are on three, and families will say, “You know, do we really”. I said, you know, you can do whatever you want but if you'd like to save the teeth you do. So again everyone has their ability to make the decisions they want to make, but if you want to save teeth it's three month recall, brushing twice a day, and fluoride application are the three things that will keep a person with Dementia keeping their teeth for a lifetime.
Chin: I didn't hear you mention flossing. What should older adults and people who are experiencing Dementia do about flossing?
Ghezzi: That is always the question I get from somebody astute, listening to what I say. Yes, what about flossing. And my response to that is the secret to getting something done with a person with Dementia is to keep instructions simple and to focus on what really is going to have the biggest impact. Is flossing helpful? Sure! Is it required to keep your teeth in someone with Dementia? Actually, no. If you do the other two things, I don't think it's worth the time and energy. I do have family members who really are adamant about doing it and do it amazingly, and if they want to do it I definitely cheerlead and encourage. That's great, but I find that there's a certain point with instructions that people's eyes kind of get a little glassed over, you've given them too much and they don't even know where to take the first step forward. I find flossing is very good at causing that reaction and I just don't find it helpful. That said, when I'm cleaning somebody's teeth, I always can kind of predict where the decay is going to occur next because it is where the plaque is or the food impaction. And so probably the biggest cause of decay in a person with Dementia, because they aren't able to react to this, is where they're getting food caught between teeth. If you and I have food caught between our teeth, we are so irritated, we are gonna go find the floss. Unfortunately, for someone who isn't really able to localize what's going on that will just sit there until maybe the next time I come and visit them. And so, any big spaces between teeth, and so this is where, again, if you're like the 50 to 70 years what should we be doing — if you have an open contact where food is getting caught, you want to have a crown placed on that tooth to make sure that that contact the crown can be designed to close that contact, that that is really critical and important and worth the investment. Actually, it's something I did last year because of an issue. So, for those of us who are getting, you know, into that ‘the prepare for growing older’ phase while you have some discretionary funds, those are the things that you need to be thinking about.
Chin: And for our audience members that may be caregivers or family members of someone who has Dementia but that person is resistant or at least struggles with the act of having someone brush their teeth, what kind of recommendations would you give to help that family member successfully help that person with Dementia?
Ghezzi: So that's a great question, and there's a website called Mouth Care Without a Battle that has a video that really addresses this issue so I would encourage anyone who is really struggling with this to obtain that video and watch it to get some really good, practical advice. Some of the recommendations that I have are that teeth have multiple sides. The inside of the mouth, actually, for the most part our tongue cleans pretty well and when people are struggling with brushing someone's teeth, often what they're referring to is I can't get into their mouth or I think they're going to bite me. And so in those cases, especially for people who if I’m going to see them, I'm going to recommend some Ativan or other sort of oral sedative just to clean their teeth. You know I have some understanding of the challenge they have and my expectations are a little bit different for those people. So what I say to them is that where the decay actually occurs most of the time is along the gum line between the teeth and the cheek because there's a lot of food being pocketed that just gets held there. Any food pocketed is a huge problem, so if you know of someone who's doing that again, after each meal someone needs to get in with some gauze and just kind of pull that out because any food sitting there you will have that going on and that's where I will know that it's happening when I see decay all on the upper right teeth and nothing anywhere else. I can tell you, that's where they're pocketing food. So what really needs to be done is that. If they're clenching, let them clench and just clean between the teeth and the cheeks then the lips - that's what needs to be the priority. And so oftentimes when I give that advice, it lessens the anxiety and the expectation of what needs to be accomplished. That again 75% of what needs to happen is that. If you're just doing that, you're going to be good enough for me to come in in three months to do the rest and we'll be — the goal is maintenance and stability. When I have a new patient, there may be issues I need to deal with but as long as you're in my care you're not going to have progressive disease and that is maintainable in persons with Dementia. And so are we looking for perfection? Absolutely not. We're looking for adequate and adequate means every time I see you, you look the same as you did before and as long as you're maintaining, that is success
Chin: Very real expectations, I appreciate that. And in people with Dementia as their disease, their underlying disease progresses, many will develop dysphagia or the difficulty with swallowing. So what is the relationship between oral health, oral disease, and dysphagia?
Ghezzi: So dysphagia is the difficulty swallowing. When you have difficulty swallowing, the challenges you can aspirate. You can aspirate saliva that's just in your mouth you can ask for it obviously the food. So it's important that food be chewed well, and so it is important that one has what we call a functional dentition — enough teeth to be able to chew food adequately. That does not mean you need a full complement of teeth but it does mean that you do need typically at least ten on the top and bottom that do actually match. So that's a challenge. We can have some people who have lost teeth on the lower and on the left side and on the upper on the right side, and although they have a number of back teeth, none of the teeth actually match. so those are things that do matter, that a dentist is going to assess. Kind of how functional are the teeth? How many teeth come together and do you have that are able to chew? That's an important assessment and sometimes, you know, you may need a partial. In terms of working with people with Dementia, I don't think I've made a partial for someone with Dementia for kind of two reasons. One: it's a skill to learn how to use any sort of prosthesis; complete denture which replaces all of the teeth on an arch, a partial denture which replaces some of the teeth on an arch. There's a huge learning curve to being able to use one of those and most people do not have the ability once they develop Dementia to do that. Again, these are things to think about that if someone's going to need that, you want to start earlier in getting that so it's already becoming routine and you know how to use it. The other issue, obviously, with people with dementia is they will take things out. So even if they've had a partial for years, they could start taking it out, leaving it wherever they are. One of my caveats in remaking something if that's lost is that if you're not making any change in the situation for how it was lost in the first place, to make another one is a two thousand dollar experiment that I can tell you is going to probably have the same end and isn't really something I'm interested in being involved in. So those are things to assess. People do not need partials to eat, even if they've had them previously. That — again, we need to get back to this functional dentition. Do they have enough that they're chewing their teeth and able to eat with it? So for someone with dysphagia, they definitely need an analysis of what's going on and so, the relationship with the oral cavity is kind of adjunct I'd say. Again it's creating the food to be able to be swallowed safely, but as I said you can aspirate saliva. So there's — even if we thicken liquids, we can't thicken your saliva so there's always going to be this risk that exists because there's substances in the oral cavity that are going to go down the airway or the esophagus and potentially into the airway and that's that's the issue. So the other piece that people get kind of hung up on is providing oral care because you know, God forbid, we brush somebody's teeth and then, you know, they aspirate maybe the toothpaste, that sort of thing. I think there's a bit too much fear in that regard that more inhibits needed oral care then prevents unwanted aspiration. Again, when you're dealing with someone with Dementia, there's a number of issues you have to deal with. Like we typically will take water, swish, and spit the toothpaste out. Whether someone has dysphagia or not, that's an issue with someone with Dementia, that some of them can't follow that instruction, they're gonna swallow it. So again, it may not be good if someone has dysphagia and they're going to try to swallow it if you hand them a glass of water to swish and spit. You may want to put toothpaste on a toothbrush, brush the teeth, and more use a kind of a wet gauze to remove the excess that's there. Swishing and spitting is not a necessary component. It definitely makes it effective to clean the mouth out but there are other ways to accomplish that if you're going to be concerned about aspiration. So I think the big issue is do not skimp on oral care, but adapt it, because the mouth is full of bacteria and to not do the oral care is to have the number of bacteria increase. Again, they're going to be aspirating if they're aspirating, and you want whatever that is that's being aspirated to be as clean as possible. The only way you're going to do that is if you're cleaning the oral cavity, so oral care is critical for someone like this. And yes, you will have to do some modification but fear resulting in discontinuing or limiting oral care I think is the bigger problem that I see out there than people providing oral care and someone asked — I have never actually heard of an aspiration complication from excessive oral care.
Chin: So stick with the fundamentals of addressing and cleaning your oral cavity?
Chin: So I guess to end, Dr. Ghezzi, what is the most pressing issue facing older adults and their oral health care?
Ghezzi: Unfortunately, I think back to where we started. I think the answer is economics. I think people have a decent amount of discretionary income in their 50s to 70s and that's really a time when people need to be talking with their dentist and preparing for the future. If you have a tooth that's got a lot of big fillings, is it time to put a crown on that tooth? Because when you're 85 that's probably not something you're going to want to invest in, and at that point you may lose the tooth which, had you done the crown when you were 65, you probably would still be able to keep it. So I think there's a lot that needs to be done in the earlier years at preparing for aging, and preparing for the fact that most likely your oral hygiene is going to decline when you get into your later years and preparing for that decline. I think there's a real lack of education that currently goes on and discussion that dentists have with patients that really needs to occur. Then, again, the discretionary income partly is because a lot of them have dental insurance at that point. Currently dental care is not covered by medicare; that's been a discussion throughout my career. I think in the next decade we will probably see some sort of incorporation, what that will look like to the extent, what it will cover. Definitely I think there's a lot of push for at least the preventive services. And this is an issue, you know. So whenever someone in my practice passes away, I always take a minute to contemplate how would I have treated that person differently had I known that they would be leaving me at this point? And I'd have to say, never the answer is more dentistry, and it's really pushed me toward just being so focused on prevention because that is what everybody needs. Again, if a piece of legislation goes through to add dental into medicare, at least if it has a decent preventive component it'll be huge. And again, if we can put ourselves back together and, as I said, once you meet me my idea is to keep you and maintain you. If we do the dentistry in the 50s and 60s and hit you with prevention in the 80s and 90s, the majority of the people are going to be in good shape, but that currently is not our model. I think it’s one really worth considering
Chin: Well, thank you for your time on Dementia Matters, Dr. Ghezzi.
Ghezzi: Thank you for having me!
Chin: Dementia Matters is brought to you by the Wisconsin Alzheimer's Disease Research Center. The Wisconsin Alzheimer's Disease Research Center combines academic, clinical, and research expertise from the University of Wisconsin School of Medicine and Public Health and the Geriatric Research Education and Clinical Center of the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin. It receives funding from private university, state, and national sources, including a grant from the National Institutes of Health for Alzheimer's Disease Centers. This episode was produced by Rebecca Wasieleski and edited by Bashir Aden. Our musical jingle is "Cases to Rest" by Blue Dot Sessions. Check out our website at adrc.wisc.edu. You can also follow us on Twitter and Facebook. If you have any questions or comments email us at firstname.lastname@example.org. Thanks for listening.