Good oral hygiene is a basic necessity if we wish to maintain overall health and well being. Neglecting mouth care can lead to serious consequences—from pain, tooth loss and the ability to eat, smile and talk properly to serious disease. It has been estimated that poor mouth care may be responsible for up to half the cases of pneumonia in nursing home residents and other people with physical or mental impairment. When someone has dementia, even a normal daily activity like brushing our teeth, can become quite challenging. And while dementia itself does not cause oral decay or disease, there is a strong chance that problems may develop indirectly due to a person’s loss of awareness of good hygiene practices and/or their inability to communicate difficulties they are experiencing. Medications and certain foods can also create problems, e.g., dry mouth.
If your friend or relative is a resident of a nursing home or long-term care facility, they are most likely continually monitored and assisted with daily mouth care by the nurses and CNAs as necessary. It is also valuable though for you to be knowledgeable about symptoms, potential problems and effective strategies to resolve them. Although there are several oral diseases associated with aging, the three most common are:
- Tooth decay—Dental caries or cavities, caused by dental plaque formed when sugar is consumed
- Periodontal (gum) diseases, specifically periodontitis and gingivitis, which has been associated with diabetes, heart disease and stroke
- Oral cancer
If left untreated, these diseases can cause serious problems, including:
- Difficulty eating and chewing, which can lead to weight loss and anemia
- Unpleasant facial appearance and difficulty talking, increasing social isolation and withdrawal
- Pain and/or temperature sensitivity when eating or brushing teeth
Since dementia increases the perception of threats and decreases the capability to comprehend instructions and communicate, it is no surprise that residents may become uncooperative, agitated or depressed and even resist care by aggression or avoidance.
Some telltale symptoms that may indicate dental problems include: (1) Tugging or frequently feeling the face or mouth, (2) Removing dentures repeatedly, (3) Increased moaning or crying out, (4) Changes in sleep patterns and daily routines, or (5) Refusal to eat (especially hot or cold foods) or loss of appetite
There are constructive steps and procedures, however, that can be pursued to ensure good oral care. If you are a family member or close friend, you can provide important information about the resident’s dental history, practices and attitudes toward dentists and oral treatments. You can also facilitate dental care if the person is more comfortable with your presence during treatments or procedures. Ideally, in the early stages of dementia, your friend or relative will be able to handle routine functions such as brushing teeth and be cooperative and responsive to questions and directions. This would also be a good time to work with their dentist to develop a long-term treatment plan and to provide as much treatment as possible to establish the best possible oral health. In the later stages, the goal will shift to maintaining oral health, alleviating pain and discomfort and avoiding infection.
You can inquire whether the facility uses an Oral Health Assessment Tool (OHAT) for Dental Screening or an Oral Hygiene Care Plan (OHCP), which tracks and rates the status of lips, tongue, gums and tissues, oral cleanliness and pain, as well as any necessary interventions (special devices or assistance) or problems (resistance, swallowing difficulties). And, although improved oral hygiene has resulted in better retention of teeth in older people, proper care and maintenance of dentures is equally important. Dentures should be removed and cleaned each night (not with toothpaste, but placed in a cup with water and cleaning tablets), and ill-fitting dentures should be replaced. They should also be marked with a form of identification in case they are misplaced, as making a new set can be costly and distressing to the person.
Helpful Strategies and Products
Your relative’s nurse and CNA have received special training to make sure that good oral care is maintained and to recognize any physical or cognitive changes. When you visit, speak with them about any issues that may arise. The overall goal is to maintain independence as long as possible, encouraging the resident to perform the steps he or she can manage and assisting with the rest. You might want to review with their caregivers the following techniques which have proven successful:
- Make sure the person is comfortable. If they are mobile, it may help them to stand or sit at the sink in front of a mirror.
- Always approach from the front so they can see you and are not startled.
- Try using gestures or pantomime to demonstrate how to brush teeth or rinse.
- Let them touch the brush or take a taste of the toothpaste before beginning.
- Learn a “hand-over-hand” technique, allowing the person to hold the toothbrush but guiding them with your hand.
- Distract them by putting a familiar item in their hands or lap, such as a doll or pillow.
- Play music they like, maybe using an iPod, hum or sing to relax them during care.
- Determine the best time of day to perform oral care—it’s not essential to brush after every meal, particularly if the person refuses to cooperate, and either have someone else step in or try again at a later time.
- Praise and give positive comments to encourage cooperation.
- Keep lips moist by using Vaseline or lip balm.
In addition to behavioral techniques, there are certain products that can facilitate daily mouth care:
- Soft toothbrushes and fluoridated toothpaste are recommended.
- Saliva substitutes (usually a gel or spray) are used for dry mouth to prevent infections and disease.
- For those resistant to brushing, swabs or cotton-tipped applicators can be applied. Glycerin swabs are not recommended, however, since they contain sugar.
In conclusion, good oral hygiene can certainly be a challenge for those with Alzheimer’s disease and dementia. While independence should be stressed, memory and abilities will change and must be continuously addressed by staff. Good mouth care, however, will reduce discomfort, prevent oral and other more serious diseases and provide a positive impact on the overall quality of life.