Strategies to Promote Mouth Care in Persons with Dementia, “C’mon, Mom, brush your teeth”
Posted May 16 2011 9:36am
Another day, another struggle. Trying to get your parent or spouse to cooperate with mouth care is a trial. Hearing the person you love tell you “no,” having him or her heap verbal garbage on you, or even push you away just hurts...
By Rita A. Jablonski Alzheimer's Reading Room
Rita A. Jablonski
I don’t pretend to have all of the answers. I’ve worked with persons with dementia in a variety of settings, initially as a nursing assistant 30 years ago and more recently as a nurse practitioner in a nursing home.
These strategies are a combination of techniques reported by other clinicians, most notably the late Dr. Jane Chalmers from the University of Iowa, and my own trial-and-error experiences.
My team recently tested these strategies in a pilot study funded by the Brookdale Foundation . We were able to provide thorough mouth care to persons with dementia who had reputations of fighting and biting during mouth care. If any of these techniques help just one caregiver, I have done my job.
The first step is to use the environment to your advantage. The wiring in the brain changes with dementia. Think of memories as sidewalks. Some sidewalks never change. Other sidewalks become choked with weeds and crumble from tree routes. Using cues from the environment, you can sort of clear the brush and activate a memory path.
The best place to do mouth care is in front of a sink. It can be the bathroom sink, but if the bathroom is too tight, the kitchen sink works, too. Ideally, have the elder stand in front of the sink. If standing is too difficult, a chair in front of the sink works. Have a mirror hanging at the elder’s eye level. The mirror helps to reinforce self-care memories and provides additional cues.
Changes in the brain associated with dementia result in the elder over-exaggerating potential threats in the environment. He or she may interpret a neutral facial expression as a negative threatening one, such as anger, and may react with resistance. I know this sounds weird, but smile as much as possible when helping with mouth care. Also, lower the pitch of your voice. As everyone ages, we lose the ability to hear higher-pitched sounds. I know this personally. My teens programmed their cell phones with ring tones advertised as “adult proof.” My middle aged ears failed to detect the ringing cell phones…but my dog did and yelped every time a cell phone rang. Busted!!
Anyway, it is important for women, especially, to lower the pitch of their voices. Otherwise, we sound like the adults in the old Charlie Brown cartoons (wha wha wha whaaaaaa) and the elder may act out in frustration if he or she is unable to hear us clearly.
Allow the elder to do as much self-care as possible. It is less threatening to stick one’s own hand in one’s mouth than to allow someone else to do so. If you are concerned that your family member is not doing adequate mouth care, you have a few options.
One is to guide the hand. Another is to grab a toothbrush and pantomime or gesture mouth care—kind of a “monkey see monkey do” technique. Sometimes, one can “prime the pump” by starting the mouth care for the elder -- you put the toothpaste on the toothbrush and hand the toothbrush to the elder, gesturing all the while. Use tepid water to rinse. As people age, the gums recede, exposing more sensitive tooth root. The use of cold water to rinse may cause pain, and the elder may resist mouth care at this point.
If you need to do the mouth care, but your family member is still resisting, you may find the “bridging” technique helpful. Give the elder a toothbrush to hold while you brush his or her teeth. Speaking of toothbrushes, use a soft one. Some elders tolerate electric toothbrushes. Others initially are OK with them, but become fussy as the dementia progresses. Dementia is “moving backwards in time,” so the experience of an electric toothbrush may become erased from a person’s memory as the dementia progresses. Those foam toothettes favored by many hospitals and nursing homes? Toss them. They are worthless.
One mistake I made early in my career, and a mistake I see people new to dementia care make, is using reason and explanation to convince a person with dementia about the need or benefit of mouth care. In the early stages this works, but as the disease progresses, the use of reason and explanation only serves to spark resistance.
Instead, use simple, respectful, one-step commands. Give the elder time to process before repeating. Combine words with gestures and pantomimes. Avoid talking to the elder like a child.
Family caregivers get this, but I am embarrassed on a daily basis when I observe other health care providers speak to older adults the way I talk to my cat—in a sing-song baby talk manner, using plural pronouns.
This type of speech, dubbed “elderspeak”, has been documented by other nurse researchers as a guarantee for care resistance. Here is why: a person with dementia may forget the name of his spouse or the names of her children, but he or she never forgets that he or she is an adult. Elderspeak is a direct assault on the elder’s dignity.
Flossing is doable, and in some cases, it is easier than brushing. The trick is to throw away the string floss and purchase these plastic toothpicks with little spiral brushes on the end. The correct name is “proximal brushes” but some products are also labeled as interdentate sticks.
Some elders will use the brushes like toothpicks. Others will let you go in between the teeth. If the elder is having a bad day and none too thrilled with brushing, an option is to dip the proximal brush into mouthwash and go in between the teeth.
In our study, we had the elders say “EEEEEEEEEE” and we flossed using the proximal brushes. Even if someone clenches his or teeth, the proximal brushes still work well. We also had situations where the elder would not cooperate with tooth brushing but tolerated the flossing. The elder then allowed us to brush her teeth after we flossed. The order really does not matter.
Sometimes, distraction works wonders. One of the ladies in our study would only cooperate with mouth care if we sang. She would sing, and then switch to humming, while we brushed her teeth. Another lady clutched her stuffed dog throughout mouth care. A third resident brightened when we discussed his favorite topic, bowling.
What about dentures? Again, the best strategy is to have the elder remove the dentures by himself. The lower denture is easier to remove first. The upper denture usually gets “stuck,” so have the elder puff his or her cheeks to break the seal. Again, pantomiming works better than explaining.
If the elder is unwilling or unable to remove the dentures, you can do so. If the elder lets you, you can simply remove them. If the elder is resisting, you can place his or her hands over your hands and remove the dentures. For some reason, we encountered less resistance when we had the elder put their hand over ours as we worked to remove the dentures. Another technique is to put your hands over your family member’s hands and guide them to remove the dentures.
To remove the lower denture, place both thumbs along the lower border and your index fingers to the side of the teeth and pull up and out. To remove the upper dentures, try to get the elder to puff his or her cheeks to break the seal. Then, place your thumbs on the biting surface and your index fingers along the upper ridge. Slide the dentures forward and down.
Dentures should never be cleaned with toothpaste. Toothpaste contains abrasive particles that can ruin the acrylic surface of the dentures. Regular dish detergent works, along with commercial cleaners. Make sure you rinse the dentures very well! A hard bristled denture brush will remove more debris and stains than a regular soft toothbrush.
If the elder doesn’t want the dentures back in, or seems to really resist having the dentures removed, check the dentures for any nicks, chips, or rough edges. A seemingly small rough spot can be torture against the roof of the mouth or a sensitive gum. Check roof of the elder’s mouth for any white coating—the elder can have an oral yeast infection that is painful. Dentures need to be out for at least four hours to give the oral tissues a rest. Overnight is ideal.
Finally, have the elder put the denture back on their own in whatever order the elder prefers. If you have to put the dentures back in, put the top in first and bottom in second.
If the elder is really resistant to having the dentures removed, you can try the bridging technique. Have the elder hold a spare pair of dentures or a denture cup while you do the mouth care. Distraction can also work here, as well.
I encountered one lady who absolutely would not open her mouth for mouth care. We finally succeeded by sitting her in a wheelchair and brushing her teeth from behind. As long as she could see herself in the mirror, it was as if we did not exist, and she would open her mouth in response to verbal cues. If anyone tried to do mouth care facing her, she clenched her mouth shut.
We did not have a 100% success rate but we were able to provide mouth care the majority of the time. Sometimes, the elder became resistant because of an infection, like a bladder infection. Once the infection was treated, the elder became more cooperative. Other times, the elder is resistant no matter what strategies we used. The lesson we learned was to keep trying. The more we provided mouth care using these strategies, the easier the mouth care became for us and the elders. The care resistant behavior diminished as the study progressed.
Thank you for reading this article and I hope you find something in here helpful. I wish to acknowledge the Brookdale Foundation , which funded the study from which this information was obtained.
The National Institutes of Health has recently provided me with additional funding to take this research to the next level. As a nurse, I am practical in nature. I truly hope that the results of my research make a positive contribution to the lives of persons with dementia and their caregivers.
Rita A. Jablonski , PhD, CRNP, is an assistant professor at the Pennsylvania State University School of Nursing. Her research involves developing and testing ways to improve the mouth care provided by nursing home staff to persons with dementia. She also maintains an active clinical practice as a nurse practitioner at Centre Volunteers in Medicine.