Have you ever had difficulty convincing your patient with dementia to brush their teeth? You are not alone!

Working in an in-patient facility, such as an acute or sub-acute rehab setting, or long-term care, you are sure to meet many wonderful patients. Some of these people will also have dementia. Working with a person with dementia can bring its own set of challenges, including communication difficulties, physical limitations, agitation, and emotionality, to name but a few.

Check out this article on improving communication when working with people with dementia!

Why can trying to brush teeth be so important in those with dementia?

The act of trying to brush the teeth of a loved one can be a particular challenge for caregivers of those with dementia, and with good reason. Firstly, poor dentition and poor oral care can come with many of its own issues. If you have a patient with poor dental hygiene, they may be experiencing oral pain- which, especially if they cannot communicate the underlying cause, can lead to agitation, aggressive, depressed mood, and other communication breakdowns. Sub-standard oral care is also linked to aspiration pneumonia in the elderly- which naturally has a massive impact on the health and quality of life. Gum disease has been linked to the development of dementia itself. Periodontal disease can cause infection, increased blood sugar (which may impact the person with diabetes), and other chronic conditions. It is clear that oral health, or disease, has a huge impact on overall health and wellness.

Poor oral health is a major issue among the elderly. According to the CDC, a staggering 96% of adults over 65 years old have a cavity and 1 in 5 have tooth decay. Over 2 in 3 (68%) of over-65s have gum disease, 1 in 5 have lost all their teeth (rising to 26% in over-75s). Oral cancer and chronic disease (such as medications that cause dry mouth, in turn increasing risk of cavities) are also much higher among the older population.

These existing correlations are only magnified in those who also have dementia, as these persons are shown to have greater rates of poor hygiene and oral disease. People with dementia are less likely to engage in thorough, regular oral care and hygiene– placing them at an even higher risk of the complications of poor dental and mouth care.

Depending on the stage and the severity of the dementia, tooth brushing can become difficult to perform- either independently or with assistance from a caregiver. It is well documented that the more cognitively intact a person is, the better their oral care will be. Conversely, decreased cognition is associated with poor clinical oral health status, tooth decay, missing teeth, and a higher rate of gum disease.

The problem of care-resistant behavior

Care-resistant behavior can be a major barrier to helping your person with dementia maintain proper oral care.

Many, if not most, persons with dementia require assistance in some aspects of activities of daily living. This can include oral care, to a greater or lesser degree. Care-resistant behavior can complicate this assistance, however. This are actions that are caused by a caregiving encounter, and involve the person with dementia opposing the actions of the caregiver.

Care-resistant behavior can present as an uncooperative, disruptive, agitated, or even aggressive response to the action initiated. Clearly, this has a huge impact on the care provided to the person. Tooth brushing/oral care are far from the only actions impacted by care-resisted behaviors in the person with dementia- bathing, dressing, taking medications, eating, and many other aspects can, and are, affected.

Agitation during a care event is usually present in those with milder and moderate dementias, and may reduce as the dementia becomes severe. The presence of care-resistant behavior, however, increases proportionally to the worsening of the dementia, and has been reported to be 8 times greater in those with severe dementia. Those who require more assistance are also more likely to exhibit this pattern of behavior.

The ‘vicious cycle’ that presents itself based on the confluence of these two factors, especially in an in-patient setting, is that patients with dementia do not receive the assistance they require. This contributes to an overall worsening of health outcomes, and generally a higher burden of care and a less content person with dementia.

The person with dementia may perceive a higher level of threat during oral care- an invasive procedure, combined with an unfamiliar and not-overly-friendly caregiver presentation is ripe to produce resistance in the person with dementia.

I have always thought that if a patient presents for an in-patient stay, perhaps to recuperate from another injury such as a fall, then we as clinicians have a golden opportunity to intervene in other aspects of care to help and support the family members. This includes oral examinations, working out ways of decreased care-resistant behaviors, and setting caregivers up for success when working with their loved one.

This wonderful article by Jablonksi et al (2011) examined interventions to reduce care-resistant behavior during oral care with people with dementia. They proposed using the MOUTh intervention, which I find to be applicable and incredibly useful for improving oral care. This breaks down the activity itself in terms of threat perception and reduction. I have included some of these strategies below. Try some of these techniques when working with your person with dementia to help in toothbrushing and oral care!

Modify your approach.

Before ever approaching the person with dementia, check in with yourself. Are you in a rush? Irritated? Are you likely to use negative facial expressions and body language with your person- are you feeling the “burden” of care right at this moment? You may have poor associations with this task, especially if you often deal with care resistant behavior. It is vital that your tone of voice, facial expression, and body language does not communicate any negativity to the person. Not only are they less likely to trust you, but they may also sense an active threat. You must overcompensate, by ensuring that your presence is positive, approachable, calm, and unrushed.

Approach the person at eye level and within their visual field- do not look down upon the and try to attempt not to surprise or shock them with your approach. This can startle and upset the person, whose vision or hearing may not be intact.

Be calm and gentle! Using a warm, gentle hand on a non-threatening area (like the forearm or hand) can be reassuring and calming. Make sure you are smiling and relaxed in your interaction with the person throughout the entire time. Even a ‘neutral’ face is not perceived positively, so smiling during all interactions is essential.

Make sure you begin your interaction by establishing an acceptable baseline. Begin by discussing a topic you know the person will respond well to and enjoy- such as something they recognize or an interest they hold. This also helps in presenting you as a non-threatening person, who is conversational and friendly.

Modify the activity demands.

Oral care is a very sensory task, which can be overwhelming to the person. Ensure that you are making this activity as calm as possible, by reducing outside noise and creating a calmer environment.

You may need to break the activity into its components and cue the person– make sure that the cues are one-step, unambiguous commands, delivered in a kind tone of voice. Using infantilizing language should be avoided, as it can trigger care-resistant behavior and is generally disrespectful to the person.

The person with dementia may not understand verbal commands as readily as visual cues, so make sure that you demonstrate the action you require– opening your mouth, baring teeth, brush teeth with toothbrush, sticking out tongue, and so on. Make sure these actions are exaggerated and presented in a friendly way.

Position the person in front of the mirror, so they can see themselves throughout the task. This is more likely to result in mouth opening by the person with dementia, for tooth brushing or flossing.

Modify the task.

Use familiar objects, if available. The person’s own toothbrush, denture cup, rinse cup, towel, etc., can both facilitate a sense of ease with familiarity, as well as trigger implicit or procedural memories that can assist with task completion.

Use hand-over-hand or hand-under-hand motions: this can decrease the feeling of invasiveness, as well as elicit dormant automaticity on the part of the person with dementia.  You may begin the tasks with some hand-under hand activities and then be able to decrease these tactile cues as the person recognizes some of the feelings and may continue with the task more independently.

Use environmental stimuli to prime the task– such as positioning the person in front of a sink, placing a toothbrush in their hand, etc. This can access the procedural pathways of this task as well as including the person in the task at hand. Even a person who requires full assistance to clean their mouth may feel more involved in the task at hand if they are feeling the items used, and thereby be less likely to resist. This may also help remind them that they are engaging in a familiar activity, which can decrease perceived threat level.

While performing oral care, use distraction techniques, such as conversation that you know the person enjoys, verbal ping pong, singing, or playing with/holding a comforting or interesting item.

If all else fails and you wish to avoid an escalation of agitation or care-resistant behavior, make sure to have another carer on hand who can ‘swoop in’ and replace the initial caregiver. If the person with dementia has been very resistant and is not engaging positively at all with one carer, then ‘rescuing’ them with another caregiver can help to de-escalate in the moment and the person with dementia may feel safe and heard.

Providing Oral Care: Tips for a successful interaction

For a caregiver, helping someone with dementia to brush their teeth can be an intimidating task- and it may not even seem worth the conflict that it may cause.

It is true to say that employing these strategies will increase the time you spend during that interaction with the person, but the more that these approaches become second nature, the quicker they can be employed, and with better results. Caregivers are more likely to even enjoy the interaction, when care-resistant behavior is reduced.

Although this article seeks to focus on the much-reported issue of difficulty getting people with dementia to brush their teeth, you can apply the same principles to many areas of your daily communications with your person.

Are you interested in learning how to improve your ability to communicate with people with dementia as a caregiver? Check out our fantastic, action packed short webinar on the subject- ‘Settled and Secure- Addressing ‘challenging’ behaviors associated with dementia. This 1.5 hour CEU course provides you with skills and easy to use communications that can make all of your interactions more satisfying, and enable you to bridge the communication chasm that exists between carers and people with dementia.

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