Orofacial pain and its potential oral causes in older people with mild cognitive impairment or dementia.

BACKGROUND: The number of people with dementia and natural dentition is growing. As dementia progresses, the degree of self-care decreases and the risk of oral health problems and orofacial pain increases. OBJECTIVES: To examine and compare the presence of orofacial pain and its potential causes in older people with Mild Cognitive Impairment (MCI) or dementia. METHODS: In this cross-sectional observational study, the presence of orofacial pain and its potential causes was studied in 348 participants with MCI or dementia with all levels of cognitive impairment in two outpatient memory clinics and ten nursing homes. RESULTS: Orofacial pain was reported by 25.7% of the 179 participants who were considered to present a reliable pain self-report (Mini-Mental State Examination score ≥14 points), while it could not be determined in people with more severe cognitive impairment. The oral health examination of the 348 participants indicated that potential painful conditions, such as coronal caries, root caries, tooth root remnants or ulcers were present in 50.3%. There was a significant correlation between the level of cognitive impairment and the number of teeth, r = 0.185, P = 0.003, teeth with coronal caries, r = -0.238, P < 0.001, and the number of tooth root remnants, r = -0.229, P = 0.004, after adjusting for age. CONCLUSIONS: This study indicated that orofacial pain and its potential causes were frequently present in participants with MCI or dementia. Therefore, a regular oral examination by (oral) healthcare providers in people with MCI or dementia remains imperative, even if no pain is reported.

Mind your teeth-The relationship between mastication and cognition.

This article explores the multifactorial relationship between mastication and cognition, with a focus on dementia. Older persons, especially those with dementia, are at great risk of suffering from oral health problems such as orofacial pain and loss of natural teeth. A possible explanation could be that the cognitive and motor impairments resulting from dementia cause a decrease in self-care and as such, a worsening of oral health. An alternative explanation is that cognition and oral health influence each other. Animal studies show that a decrease in masticatory activity, for example, due to a soft diet or loss of teeth, causes memory loss and neuronal degeneration. The relationship between mastication and cognition has also been researched in human studies, but a cause-effect relationship has not been proven. It is likely that multiple factors play a role in this relationship, such as self-care, nutrition, stress and pain.

Oral hygiene and oral health in older people with dementia: a comprehensive review with focus on oral soft tissues.

BACKGROUND: The number of older people with dementia and a natural dentition is growing. Recently, a systematic review concerning the oral health of older people with dementia with the focus on diseases of oral hard tissues was published. OBJECTIVE: To provide a comprehensive literature overview following a systematic approach of the level of oral hygiene and oral health status in older people with dementia with focus on oral soft tissues. METHODS: A literature search was conducted in the databases PubMed, CINAHL, and the Cochrane Library. The following search terms were used: dementia and oral health or stomatognathic disease. A critical appraisal of the included studies was performed with the Newcastle-Ottawa scale (NOS) and Delphi list. RESULTS: The searches yielded 549 unique articles, of which 36 were included for critical appraisal and data extraction. The included studies suggest that older people with dementia had high scores for gingival bleeding, periodontitis, plaque, and assistance for oral care. In addition, candidiasis, stomatitis, and reduced salivary flow were frequently present in older people with dementia. CONCLUSIONS: The studies included in the current systematic review suggest that older people with dementia have high levels of plaque and many oral health problems related to oral soft tissues, such as gingival bleeding, periodontal pockets, stomatitis, mucosal lesions, and reduced salivary flow. SCIENTIFIC RATIONALE FOR STUDY: With the aging of the population, a higher prevalence of dementia and an increase in oral health problems can be expected. It is of interest to have an overview of the prevalence of oral problems in people with dementia. PRINCIPAL FINDINGS: Older people with dementia have multiple oral health problems related to oral soft tissues, such as gingival bleeding, periodontal pockets, mucosal lesions, and reduced salivary flow. PRACTICAL IMPLICATIONS: The oral health and hygiene of older people with dementia is not sufficient and could be improved with oral care education of formal and informal caregivers and regular professional dental care to people with dementia.

Oral function of older people with mild cognitive impairment or dementia.

OBJECTIVES: The aim of this study was to examine and compare the oral function of older people with mild cognitive impairment (MCI) or dementia. METHODS: This cross-sectional observational study included participants with MCI or dementia aged 60 years or older. Global cognitive functioning was evaluated with the Mini Mental State Examination (MMSE) and the oral function was evaluated with subjective and objective assessments, including the perceived quality of chewing and swallowing, the function of the prostheses, the number of occluding pairs (OP), the degree of tooth wear and the active and passive maximum mouth opening. RESULTS: The quality of chewing and swallowing was perceived as good in, respectively, 86.0% and 90.9% of the participants. Full or partial prostheses were worn by 63.8% of the participants, and the retention was good in 58.4% of the upper and 50.0% of the lower prostheses. Participants with MCI had a median of 3.0 (Inter Quartile Range [IQR] 0.0-7.5) occluding pairs, while participants with dementia had a median of 0.0 (IQR 0.0-1.0) occluding pairs, U = 3838.50, P < 0.001. There was a weak positive correlation between the number of occluding pairs and the MMSE score, r = 0.267, also when adjusted for age, r = 0.230. The median tooth wear score was 2.0 (IQR 2.0-2.0) in participants with MCI or dementia. The active maximum mouth opening was 45.8 (SD 9.3) mm in participants with dementia, while it was 49.8 (SD 8.1) mm in those with MCI, t(253) = 2.67, P = 0.008. CONCLUSION: For most participants with MCI or dementia, the swallowing ability and chewing ability were perceived as good. In addition, more than half of the prostheses had good retention and occlusion. Participants with more severe cognitive impairment had fewer occluding pairs and a smaller active mouth opening. The degree of tooth wear was less than one-third of the clinical crown in most participants with MCI or dementia.

Psychometric evaluation of the Orofacial Pain Scale for Non-Verbal Individuals as a screening tool for orofacial pain in people with dementia.

OBJECTIVE: The aim of this study was to describe the psychometric evaluation of the Orofacial Pain Scale for Non-Verbal Individuals (OPS-NVI) as a screening tool for orofacial pain in people with dementia. BACKGROUND: The OPS-NVI has recently been developed and needs psychometric evaluation for clinical use in people with dementia. The pain self-report is imperative as a reference standard and can be provided by people with mild-to-moderate cognitive impairment. METHODS: The presence of orofacial pain during rest, drinking, chewing and oral hygiene care was observed in people with mild cognitive impairment (MCI) and dementia using the OPS-NVI. Participants who were considered to present a reliable self-report were asked about pain presence, and in all participants, the oral health was examined by a dentist for the presence of potential painful conditions. After item-reduction, inter-rater reliability and criterion validity were determined. RESULTS: The presence of orofacial pain in this population was low (0%-10%), resulting in an average Positive Agreement of 0%-100%, an average Negative Agreement of 77%-100%, a sensitivity of 0%-100% and a specificity of 66%-100% for the individual items of the OPS-NVI. At the same time, the presence of oral problems, such as ulcers, tooth root remnants and caries was high (64.5%). CONCLUSION: The orofacial pain presence in this MCI and dementia population was low, resulting in low scores for average Positive Agreement and sensitivity and high scores for average Negative Agreement and specificity. Therefore, the OPS-NVI in its current form cannot be recommended as a screening tool for orofacial pain in people with MCI and dementia. However, the inter-rater reliability and criterion validity of the individual items in this study provide more insight for the further adjustment of the OPS-NVI for diagnostic use. Notably, oral health problems were frequently present, although no pain was reported or observed, indicating that oral health problems cannot be used as a new reference standard for orofacial pain, and a regular oral examination by care providers and oral hygiene care professionals remains indispensable.

Oral health and orofacial pain in older people with dementia: a systematic review with focus on dental hard tissues.

OBJECTIVE: The aim of this review was to provide a systematic overview including a quality assessment of studies about oral health and orofacial pain in older people with dementia, compared to older people without dementia. METHODS: A systematic literature search was performed in PubMed, CINAHL, and the Cochrane Library. The following search terms were used: dementia and oral health or stomatognathic disease. The quality assessment of the included articles was performed using the Newcastle-Ottawa Scale (NOS). RESULTS: The search yielded 527 articles, of which 37 were included for the quality assessment and quantitative overview. The median NOS score of the included studies was 5, and the mean was 4.9 (SD 2.2). The heterogeneity between the studies was considered too large to perform a meta-analysis. An equivalent prevalence of orofacial pain, number of teeth present, decayed missing filled teeth index, edentulousness percentage, and denture use was found for both groups. However, the presence of caries and retained roots was higher in older people with dementia than in those without. CONCLUSIONS: Older people with dementia have worse oral health, with more retained roots and coronal and root caries, when compared to older people without dementia. Little research focused on orofacial pain in older people with dementia. CLINICAL RELEVANCE: The current state of oral health in older people with dementia could be improved with oral care education of caretakers and regular professional dental care.

The mouth care item of the MOBID pain scale: secondary analyses of unique video uptakes by dental professionals.

PURPOSE: The Mobilization-Observation-Behaviour-Intensity-Dementia (MOBID) Pain Scale has been developed for the assessment of pain in elderly individuals with severe dementia. From the initial draft of the MOBID, the teeth/mouth care item was removed due to its low correlation with the total score. However, the observation of this item was done by non-dental professionals only. The aim was to revisit the unique teeth/mouth care video uptake fragments with a group of experienced elderly care dentists, as to establish the reliability of this item. MATERIAL AND METHODS: Using the Orofacial MOBID Pain Scale, 11 fragments were assessed by 12 specialists during two sessions with a 4-week interval. The specialists scored whether or not they observed orofacial pain/discomfort-related behaviours (pain noises, facial expressions and/or defence) and/or dementia-related behaviours (anxiety, aggression and/or confusion). The threshold for agreement in scoring was arbitrarily set at 66.6%. As a next step, reliability was quantified using Cohen's kappa. RESULTS: For only two video fragments, substantial agreement was obtained during both sessions, while for three fragments, the agreement was substantial during one session only. In addition, only three observers were able to provide consistent scores. For two of those, the various kappa values could be qualified as moderate to good. Notably, all consistent scores pertained to dementia-related behaviours; not to orofacial pain/disability-related behaviours. CONCLUSION: Teeth/mouth care, as displayed on video uptakes, cannot be interpreted reliably by experienced elderly care dentists in terms of orofacial pain/discomfort-related behaviour or dementia-related behaviour with the Orofacial MOBID Pain Scale.

Pain in dementia: prevalence and associated factors: protocol of a multidisciplinary study.

BACKGROUND: Pain is a common problem in people with dementia, however the exact prevalence of pain in dementia subtypes, e.g. Alzheimer's Disease (AD), Vascular Dementia (VaD), Frontotemporal Dementia (FTD) and dementia with Lewy Bodies (DLB), is unknown, as is the relation between pain and the different subtypes of dementia. In this study, the prevalence of pain in people with dementia will be investigated per dementia subtype and the relationship between the various subtypes of dementia and the presence of specific types of pain (i.e. musculoskeletal pain, neuropathic pain and orofacial pain) will be examined. Secondly, associations between various types of pain, cognitive functioning, neuropsychiatric symptoms and quality of life in people with dementia will be examined. A third purpose is to study the value of the assessment of autonomic responses in assessing pain in people with dementia. Finally, the effect of feedback to the attending physician on the presence of pain, based on examination by investigators with backgrounds in neuropsychology, geriatric dentistry and elderly care medicine, will be evaluated. METHODS/DESIGN: A cross-sectional, partially longitudinal observational study in 400 participants with dementia, aged 60 years and older. Participants will be recruited from an outpatient memory clinic and dementia special care units. All participants will be examined by an elderly care medicine trainee, a dentist with experience in geriatric dentistry, and a neuropsychologist. The primary outcome is presence of pain. Secondary outcomes will include oral health, autonomic responses to pain stimulus, vital sensibility and gnostic sensibility, musculoskeletal examination, cognitive functioning, neuropsychiatric symptoms, and quality of life. DISCUSSION: This study will help to enhance our knowledge regarding the prevalence of different types of pain in different dementia subtypes i.e. AD, VaD, FTD and DLB. This study also aims to contribute to a better understanding of oral health status in people with dementia, the use of autonomic responses in the assessment of pain in people with dementia and the relationships between pain and cognitive symptoms, neuropsychiatric symptoms and quality of life in people with various dementia subtypes and in different stages of the disease.

Chewing Efficiency, Global Cognitive Functioning, and Dentition: A Cross-sectional Observational Study in Older People With Mild Cognitive Impairment or Mild to Moderate Dementia.

Introduction: Previous studies suggest an association between poor mastication and cognitive impairment. The role of chewing efficiency and dentition in this relation is unclear. The aim was to examine global cognitive functioning and dentition as predictors for chewing efficiency, in older people with mild cognitive impairment (MCI) or dementia. Methods: In this observational cross-sectional study, 136 people with MCI or dementia were included. The chewing efficiency was assessed with a two-colored chewing gum and analyzed with the Chewing Efficiency Analysis software. The level of global cognitive functioning was measured with the Mini Mental State Examination (MMSE) by trained clinical staff. An oral examination was performed by a dentist and included the number of present teeth, the number of occluding pairs, and the presence of prostheses. Age, gender, and educational years were derived from the medical records. Univariate and multivariate backward stepwise linear regression analyses were used to evaluate global cognitive functioning and dentition as predictors for chewing efficiency. Results: The mean age of the participants was 82.1 (SD 5.8) years, and 74 (54.4%) were female. The participants had a median MMSE score of 22.4 (IQR 18.0-26.0) and a median Chewing Efficiency Analysis score of 0.46 (IQR 0.14-0.59). The median number of teeth was 13.0 (IQR 0.0-23.0), and the median number of occluding pairs was 0.0 (IQR 0.0-7.0). Sixty-four (47.4%) of the participants wore full prosthesis in the upper jaw. In univariate linear regression analyses, predictive factors for the Chewing Efficiency Analysis score were age, MMSE score, full prosthesis in the upper jaw, number of present teeth, and number of occluding pairs. In the multivariate model, full prosthesis in the upper jaw and number of occluding pairs were significant predictors for the Chewing Efficiency Analysis score. Participants with full prosthesis in the upper jaw had a lower Chewing Efficiency Analysis score than participants with natural dentition in the upper jaw. Conclusion: Better mastication is associated with a higher number of occluding pairs. Full prosthesis in the upper jaw is related to a lower chewing efficiency. Global cognitive functioning is not associated with mastication in older people with MCI or mild-to-moderate dementia. This might be explained by sufficient capacity for compensation of reduced mastication in this group.

Orofacial Pain During Rest and Chewing in Dementia Patients Admitted to Acute Hospital Wards: Validity Testing of the Orofacial Pain Scale for Non-Verbal Individuals.

AIMS: To assess the validity of the resting and chewing components of the recently developed observational diagnostic tool, the Orofacial Pain Scale for Non-Verbal Individuals (OPS-NVI). METHODS: This cross-sectional observational study was carried out in two UK hospitals. A total of 56 participants with dementia who were admitted to the acute hospital were observed for 3 minutes during rest and during chewing, and the OPS-NVI was used to identify orofacial pain. Afterwards, the participants were asked about the presence of orofacial pain using self-report pain scales. The sensitivity, specificity, and area under the receiver operating curve (AUROC) of the OPS-NVI were calculated for each activity. Spearman coefficient was calculated to assess the correlation between the number of positively scored behavior items of the OPS-NVI and the presence of orofacial pain according to self-report. RESULTS: According to the OPS-NVI, orofacial pain was present in 5.4% of participants during rest and in 9.1% during chewing. According to self-report, the prevalence of orofacial pain was 5.4% during rest and 10.7% during chewing. The specificity of the OPS-NVI was 98.1% to 100%, the sensitivity was 66.7% to 83.3%, and the AUROC was 0.824 to 0.917. The predictive validity showed a strong correlation (0.633 to 0.930, P < .001) between the number of positive behavior items and the self-reported presence of orofacial pain. CONCLUSION: The resting and chewing components of the OPS-NVI showed promising concurrent and predictive validity. Nevertheless, further validation is required and highly recommended.

Pain Assessment in Impaired Cognition (PAIC): content validity of the Dutch version of a new and universal tool to measure pain in dementia.

OBJECTIVES: Detection and measurement of pain in persons with dementia by using observational pain measurement tools is essential. However, the evidence for the psychometric properties of existing observational tools remains limited. Therefore, a new meta-tool has been developed: Pain Assessment in Impaired Cognition (PAIC), as a collaborative EU action. The aim is to describe the translation procedure and content validity of the Dutch version of the PAIC. METHODS: Translation of the PAIC into Dutch followed the forward-backward approach of the Guidelines for Establishing Cultural Equivalence of Instruments. A questionnaire survey was administered to clinical nursing home experts (20 physicians and 20 nurses) to determine whether the PAIC items are indicative of pain and whether items are specific for pain or for other disorders (anxiety disorder, delirium, dementia, or depression). To quantify content validity, mean scores per item were calculated. RESULTS: Eleven items were indicative of pain, for example, "frowning," "freezing," and "groaning." Fifteen items were considered to be pain-specific, for example, "frowning," "curling up," and "complaining." There were discrepancies between the notion of pain characteristics according to nurses and physicians, especially in the facial expressions domain. DISCUSSION: Within the body movement domain, PAIC items correspond well with the clinical experience of the physicians and nurses. However, items in the facial expressions and vocalizations domains need further study with respect to item reduction. Also, differences were revealed in the notion of pain characteristics between physicians and nurses, suggesting the need for more interdisciplinary education on pain in dementia.

Orofacial Pain and Mastication in Dementia.

Orofacial pain is a common condition in the general population. It is likely that this is also the case in older persons with a dementia. However, the assessment of (orofacial) pain in non-verbal individuals is hampered by the subjective nature of pain, and their limited communicative abilities. To overcome this drawback, several tools have been developed for the assessment of pain based on observations of pain-specific facial activities, body movements, and vocalizations. Unfortunately, none of the so far developed observational tools have been designed specifically for the assessment of orofacial pain. While the recent psychometric testing of the Orofacial MOBID Pain Scale did not yield reliable outcomes, the subsequently developed Orofacial Pain Scale for Non-Verbal Individuals (OPS-NVI) is currently being evaluated and shows good promise to be reliable and valid. Besides the assessment of orofacial pain, an important application of this instrument will be the investigation of the probable causal association between impaired chewing and cognitive decline, in which orofacial pain plays a mediating role by its negative influence on chewing ability. The identification of this negative influence will urge opinion leaders and policy makers to improve the oral health status in older persons with a dementia. Ultimately, pain-free oral functioning may lead to a higher quality of life and might help stabilizing or improving cognition in this frail and vulnerable patient population.

Orofacial Pain during Mastication in People with Dementia: Reliability Testing of the Orofacial Pain Scale for Non-Verbal Individuals.

Objectives. The aim of this study was to establish the reliability of the "chewing" subscale of the OPS-NVI, a novel tool designed to estimate presence and severity of orofacial pain in nonverbal patients. Methods. The OPS-NVI consists of 16 items for observed behavior, classified into four categories and a subjective estimate of pain. Two observers used the OPS-NVI for 237 video clips of people with dementia in Dutch nursing homes during their meal to observe their behavior and to estimate the intensity of orofacial pain. Six weeks later, the same observers rated the video clips a second time. Results. Bottom and ceiling effects for some items were found. This resulted in exclusion of these items from the statistical analyses. The categories which included the remaining items (n = 6) showed reliability varying between fair-to-good and excellent (interobserver reliability, ICC: 0.40-0.47; intraobserver reliability, ICC: 0.40-0.92). Conclusions. The "chewing" subscale of the OPS-NVI showed a fair-to-good to excellent interobserver and intraobserver reliability in this dementia population. This study contributes to the validation process of the OPS-NVI as a whole and stresses the need for further assessment of the reliability of the OPS-NVI with subjects that might already show signs of orofacial pain.