Expert: Mary Gordon - 1/4/2011

Question
Hi Mary,

I have written you in the past and am seeking advice.  My 95 year old aunt is living in a nursing home and has an attorney making her medical and financial decisions.  The attorney was recently contacted by the nursing home about "my aunt having some dental work done".  Apparently, my aunt's dentures are "broken" and the nursing home was seeking permission to do $1500.00 work of dental work to fix her dentures.  My aunt has not lost weight and does not seem in pain.  T he attorney felt the cost was high and I am  concerned with my aunt's ability of cooperating during the procedure, let alone being traumatized with a dental mold in her mouth.  I would respect your opinion; what would you do?

Answer
Have you spoken to the home about what exactly is wrong with the dentures? With a price tag like that, it sounds like either they are proposing to replace them entirely, or to do related dental work as well as repairs. You need to know exactly what they are proposing to undertake - and more importantly - WHY - to be able to make a decision.

I agree with you about the stress around having a mold taken or any other dental work that requires her cooperation. Since she will not understand what is happening or why, she is likely to be frightened and combative, and may need sedation. It's only worth doing if it's vital to her ability to eat or she has some major dental infection that is going to cause health problems that will involve suffering.  If she is not in pain, and is able to eat without them, you will have to have a long think about this one. The cost is really a minor component of the decision.

By later AD, my mother in law would not wear her dentures at all. I recall one family occasion when we tried to bring her from the AD ward to our home for dinner - at this point, she could still walk with assistance and could talk a little. The staff was able to dress her without too much difficulty, but she had a complete melt down over the dentures. I suspect she just had no idea what the staff were trying to shove in her mouth or why. After much coaxing and her balking and struggling no matter what anyone tried, they gave up, and that was quite literally the end of her wearing them at all for the rest of her life - she came to dinner with no teeth and was happy as a clam.  She did fine with only a couple of her own teeth left - and she was certainly long past being aware of what it looked like! She didn't really start to lose weight until her final spiral, which began when she lost interest in food entirely - an event entirely unrelated to teeth.In other words, teeth had nothing to do with anything in the final equation - no one cared about the cosmetic aspect and they weren't needed for her to eat or feed herself, and she was not at all fussed by the lack of them. We made the decision if they made her miserable or uncomfortable in any way, phhhht, we just weren't going to bother her with them any more.

In point of fact, teeth or no teeth, by later AD, most people with the disease will have a lot of trouble chewing and swallowing, which you told me in November she already has. As discussed, it's called dysphagia, which is caused by coordination problems from the neurological damage. They can no longer handle anything that really needs chewing at all, and because they can't coordinate the movement of food in their mouths, swallowing is a concern - or they just forget to swallow entirely.  Some even start to have trouble with thin liquids or mixed textures like cereal in milk.  They start needing thickened liquids and purees with a smooth, consistent texture, even if they have ALL their own teeth in place - and if I recall correctly, she's into the puree phase at present.

Since your aunt is already off regular solids and eating softer foods there may be absolutely no point to fixing dentures (i.e. she doesn't need to be able to chew to eat). If she is having chewing problems, they are very unlikely to be from the dental situation but from her muscular coordination problems caused by the dementia. You don't mention if she is still able to feed herself at this point - but even this makes no difference. If she can use a spoon on her own, she can eat purees.

I don't know if a truly palliative approach to your aunt's care has been discussed as yet - i.e. you approach all her care with the goal of her comfort and serenity, keeping her out of all pain and distress, and giving her the best possible quality of life. Anything that is taken on for her has to be seen through that filter - what is kindest for her as opposed what would be considered "best" for a healthy person when the perspective is a cure and a long life afterwards. You really do need to talk to the home to find out exactly what issue they are  attempting to "fix" in a 95 year old lady with dementia. You certainly don't need dentures to live, and if they hurt her or are broken, she can stop wearing them.

I'm sure you can hear my bias running through this! Talk to them, and unless they can make a really compelling case that dental intervention is all about her comfort, safety, peace and serenity, and to prevent suffering....I might say goodbye to the dentures if they can't just be fixed without making molds and fittings.

Mary